Hernia Surgery 9783132405516, 9783132406896

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Hernia Surgery Volker Schumpelick, MD Professor Emeritus Former President European Hernia Society (EHS) Hamburg, Germany Georg Arlt, MD Associate Professor Department of General, Visceral, and Minimally Invasive Surgery Park-Klinik Weissensee Berlin, Germany Joachim Conze, MD Associate Professor UM Hernia Center Dr. Conze Munich, Germany Karsten Junge, MD Professor Department of General, Visceral, and Minimally Invasive Surgery Rhein-Maas Klinikum Würselen, Germany

512 illustrations

Thieme Stuttgart · New York · Delhi · Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher. This book is an authorized translation of the 5th German edition published and copyrighted 2015 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Hernien Translator: Geraldine O’Sullivan, Dublin, Ireland Illustrator: Gisela Tambour, Göttingen, Germany; Andrea Schnitzler, Innsbruck, Austria Licenses: 1st English edition 1990

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Contents 1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

1.1 Anatomy of the Anterior Abdominal Wall. . . . . . . . . . . . . . . . . . . . Andreas Prescher and Werner Lierse (†) 1.1.1



Muscles of the Abdominal Wall. . . . . . . . . . . The Rectus Abdominis Muscle . . . . . . . . . . . . . The External Oblique Muscle. . . . . . . . . . . . . .  The Internal Oblique Muscle. . . . . . . . . . . . . . . The Transversus Abdominis Muscle. . . . . . . . .

1.1.2

Fasciae and Fascial Structures. . . . . . . . . . . .



Subcutaneous (Camper) Fascia or Fatty Layer







of the Abdomen. . . . . . . . . . . . . . . . . . . . . . . . . .

2 2 2 4 6 7 8 8

Superficial Abdominal Fascia (Scarpa fascia) or

Membranous Layer of the Abdomen . . . . . . . . The Rectus Sheath. . . . . . . . . . . . . . . . . . . . . . . . The Linea Alba. . . . . . . . . . . . . . . . . . . . . . . . . . . The Transversalis Fascia. . . . . . . . . . . . . . . . . . .

8



Inguinal Ligament. . . . . . . . . . . . . . . . . . . . . . . . Inguinal Falx (Conjoint Tendon) . . . . . . . . . . . .



Interfoveolar Ligament (of Hesselbach). . . . . .

1.1.3

Anatomical Regions and Hernial



Inguinal Canal with Superficial and Deep

Orifices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Inguinal Rings . . . . . . . . . . . . . . . . . . . . . . . . . . .

15 15 15 18

23

1.2.1

Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

24

1.3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . Son Truong Ngoc and Marcel Binnebösel 1.3.1 1.3.2 1.3.3 1.3.4



History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Differential Diagnosis. . . . . . . . . . . . . . . . . . . . .  Investigations. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Plain X-Ray of the Abdomen . . . . . . . . . . . . . . .



Ultrasonographic Hernia Criteria. . . . . . . . . . .



Ultrasonographic Differential Diagnosis of



Pathological Findings in the Abdominal Wall



and Groin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.3.6

Doppler Ultrasonography, Duplex

32 32

35

Ultrasonography. . . . . . . . . . . . . . . . . . . . . . . . . . 

36



37

39

15

24

Hernia Location. . . . . . . . . . . . . . . . . . . . . . . . . . . 

32

37



Incarceration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Equipment and Examination Technique . . . . .

Conservative Treatment. . . . . . . . . . . . . . . . . . . 

Definition and Terminology. . . . . . . . . . Volker Schumpelick

1.2.5

31

Ultrasonography. . . . . . . . . . . . . . . . . . . . . . . . . . 

1.4.2

14

1.2

1.2.4



Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . .

Definition, Anatomy, and

The Inguinofemoral Region . . . . . . . . . . . . . .18

Hernia Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . 



1.3.5

31

Pathogenesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 



Structure of a Hernia. . . . . . . . . . . . . . . . . . . . . . 

Computed Tomography, Magnetic

1.4.1

Muscular Lacuna. . . . . . . . . . . . . . . . . . . . . . . . .

1.2.3



31

10

Vascular Lacuna and Femoral Ring. . . . . . . .18

1.2.2

Herniography (Peritoneography). . . . . . . . . . .

The History of Hernia Surgery. . . . . . . . Volker Schumpelick



Laparoscopic Anatomy . . . . . . . . . . . . . . . . . . . . 

Water-Soluble Contrast Agent. . . . . . . . . . . . . .



1.4



1.1.4

Gastrointestinal or Colon Imaging with

9

9

Peritoneum. . . . . . . . . . . . . . . . . . . . . . . . . . . . .13



2

24 24 26 26 30 30 30

1.4.3

Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

1.5

Repair Principles and Materials. . . . . . . Uwe Klinge and Matthias Pross

1.5.1

1.5.2 1.5.3



Choice of Procedure. . . . . . . . . . . . . . . . . . . . . . . 

The Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hernia Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Operation Techniques. . . . . . . . . . . . . . . . . . . . .

Principles for Choice of Procedure. . . . . . . . . .  Basic Hernia Repair Procedures. . . . . . . . . . . . 

Inguinal Hernias . . . . . . . . . . . . . . . . . . . . . . . . . Abdominal Wall. . . . . . . . . . . . . . . . . . . . . . . . . .

1.5.4

Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 



Uwe Klinge and Bernd Klosterhalfen

1.6

Hernia Biomechanics . . . . . . . . . . . . . . . Christian Hollinsky

1.6.1



Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Muscle Forces in the Abdominal Wall . . . . . . .

46 46 46 46 47 47 48 48 48 52 54 54 54



Linea Alba. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.6.2

Mechanics of Hernia Surgery with Mesh

Reinforcement. . . . . . . . . . . . . . . . . . . . . . . . . . . .  Material Properties of Hernia Meshes. . . . . . .

55



55



Prosthesis Overlapping. . . . . . . . . . . . . . . . . . . .

31

Bulging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31



Fixation of Plastics. . . . . . . . . . . . . . . . . . . . . . . 

31

39

55

55 57 58

v

 1.7

Biological Meshes . . . . . . . . . . . . . . . . . . Dirk Weyhe



58

1.7.1

Introduction and Basic Principles. . . . . . . . . . 

58

1.7.2

Biomechanical Principle of Mesh

Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

1.7.3

Biological Materials . . . . . . . . . . . . . . . . . . . . . . . 

58 58



Biological Cross-Linked and Non-Cross-Linked



Membranes (Collagenase Resistance) . . . . . . .

1.7.4

Indications and Complications of Biological

58

Membranes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

59



60

1.8 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . Ekkehard Schippers 1.8.1 1.8.2 1.8.3

General Anesthesia. . . . . . . . . . . . . . . . . . . . . . . .  Epidural and Spinal Anesthesia . . . . . . . . . . . .  Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . 

60 60 60

Pediatric Hernia. . . . . . . . . . . . . . . . . . . . Gerhard Steinau



65

1.9.1

Indication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

65

1.9.2 1.9.3 1.9.4 1.9.5 1.9.6 1.9.7 1.9.8 1.9.9 1.9.10 1.9.11

Preparation for Operation . . . . . . . . . . . . . . . . .  Special Risks and Informed Consent. . . . . . . .  Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Relevant Anatomy, Dangers, and Tricks. . . . .  Management of Special Complications. . . . .  Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . .  Operation Techniques. . . . . . . . . . . . . . . . . . . . . 

Inguinal Hernia Operation in Boys . . . . . . . . . 

86 86

Choice of Procedure . . . . . . . . . . . . . . . . . . . . . .

2.2

Open Suture Techniques . . . . . . . . . . . .



87

2.2.1

Approach and Dissection. . . . . . . . . . . . . . . . . . 

87



Volker Schumpelick



Indication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.2.2

Operation Preparation . . . . . . . . . . . . . . . . . . . . Special Risks, Informed Consent. . . . . . . . . . . . Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relevant Anatomy, Dangers, and Tricks. . . . . . Management of Special Complications . . . . . . Postoperative Management. . . . . . . . . . . . . . . . Operation Techniques. . . . . . . . . . . . . . . . . . . . .

Hernia Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 



Bassini Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . .



Volker Schumpelick

65 65 65 65 65 65

Laparoscopy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

70 77

61





65

73

Adult Inguinal Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

65

Inguinal Testis . . . . . . . . . . . . . . . . . . . . . . . . . . .

Inguinal Hernia Surgery in Girls. . . . . . . . . . . .

2

2.1.1

65

70

Local Anesthesia Technique. . . . . . . . . . . . . . . .



65

Hydrocele. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



2.1 Indications and Choice of Procedure . . . Volker Schumpelick

86

86



Lotheissen/McVay Repair. . . . . . . . . . . . . . . . . . 114



Karsten Junge

2.3

Open Mesh Techniques. . . . . . . . . . . . . .

2.3.1

Lichtenstein Repair. . . . . . . . . . . . . . . . . . . . . . . .  117



Georg Arlt



Repair Principle. . . . . . . . . . . . . . . . . . . . . . . . . . 117





117

Indication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Operation Techniques. . . . . . . . . . . . . . . . . . . . . 118

87



87

2.3.2

Transinguinal Preperitoneal Patch. . . . . . . . . .  121

87



Volker Schumpelick, Ralph Lorenz, and Andreas Koch



Repair Principle. . . . . . . . . . . . . . . . . . . . . . . . . . 121

87 87 87 87 87



Indication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Operation Techniques. . . . . . . . . . . . . . . . . . . . . 121

2.3.3

Nyhus Repair with Mesh . . . . . . . . . . . . . . . . . .  127



Georg Arlt

96



Repair Principle. . . . . . . . . . . . . . . . . . . . . . . . . . 127

96



87 87



The Zimmerman Repair. . . . . . . . . . . . . . . . . . . 101



Karsten Junge



Minimal Repair Technique. . . . . . . . . . . . . . . . . 104

Ulrike Muschaweck and Christoph Peter Schuhmacher

vi

1.9



Shouldice Repair . . . . . . . . . . . . . . . . . . . . . . . . . 107



Volker Schumpelick and Andreas Tittel



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Operation Techniques. . . . . . . . . . . . . . . . . . . . . 127

2.3.4

The Stoppa/Wantz Procedure. . . . . . . . . . . . . .  132



Volker Schumpelick



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133



Contraindications . . . . . . . . . . . . . . . . . . . . . . . . 133 Material. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

 2.3.5

Postoperative Care. . . . . . . . . . . . . . . . . . . . . . .  133 Operation Techniques. . . . . . . . . . . . . . . . . . . . . 133

Three-dimensional Mesh Procedures. . . . . . .  144



Tim Tollens and Ralph Lorenz



Introduction and History: The Gilbert



Technique with the Prolene Hernia System/



Ultrapro Hernia System . . . . . . . . . . . . . . . . . . . 144

2.3.6

Plug and Patch. . . . . . . . . . . . . . . . . . . . . . . . . . . .  147



Friedrich-Eckart Isemer

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Operative Principle. . . . . . . . . . . . . . . . . . . . . . . 148 Operation Techniques. . . . . . . . . . . . . . . . . . . . . 148



150

2.4

Laparoscopic Techniques. . . . . . . . . . . .

2.4.1

Transabdominal Preperitoneal Mesh. . . . . . .  150



Reinhard Bittner and Jochen Schwarz



Historical Development. . . . . . . . . . . . . . . . . . . 150





Operation Techniques. . . . . . . . . . . . . . . . . . . . . 144













Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151



2.4.2

3.1 3.1.1 3.1.2

3.2.2

History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  174 Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  175 Clinical Examination. . . . . . . . . . . . . . . . . . . . . . 175



Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . . . 175



Magnetic Resonance Imaging and Computed

Tomography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

3.2.3

Herniography. . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  176

3.2.4

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  176

3.3

Sliding Hernia. . . . . . . . . . . . . . . . . . . . . . Volker Schumpelick

 

177 180

3.4

Recurrent Hernia. . . . . . . . . . . . . . . . . . . Karsten Junge

3.4.1

General Remarks/Epidemiology . . . . . . . . . . .  180

3.4.2

Patient and Operator Position. . . . . . . . . . . . . . 152 Trocar Choice and Position. . . . . . . . . . . . . . . .  152 Pneumoperitoneum Creation . . . . . . . . . . . . . . 152 Operation Techniques. . . . . . . . . . . . . . . . . . . . . 153 Learning Curve Results with Simple and

Difficult Hernias . . . . . . . . . . . . . . . . . . . . . . . . . 156 Comparison of TAPP with TEP. . . . . . . . . . . . . . 157

Totally Extraperitoneal Mesh

Repair (TEP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  157



Andreas Kuthe



Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157



Operation Techniques. . . . . . . . . . . . . . . . . . . . . 157 Special Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 TEP: Indications and Contraindications. . . . . . 164

2.4.3

Minitechnique. . . . . . . . . . . . . . . . . . . . . . . . . . . .  165



Henning Niebuhr



Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165



Instruments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Operation techniques. . . . . . . . . . . . . . . . . . . . . 165

Special Hernias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  3.4.3 Female Hernias. . . . . . . . . . . . . . . . . . . . .  172 Forms and Location. . . . . . . . . . . . . . . . . . . . . . .  3.4.4 Georg Arlt Choice of Procedure. . . . . . . . . . . . . . . . . . . . . . .  3.4.5 Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Operation Tactics. . . . . . . . . . . . . . . . . . . . . . . . 172 3.4.6 Dissection and Repair . . . . . . . . . . . . . . . . . . . . .  Operation Techniques . . . . . . . . . . . . . . . . . . . 172 3.4.7 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Sportsman’s Groin. . . . . . . . . . . . . . . . . .  174 3.5 Umbilical Hernia . . . . . . . . . . . . . . . . . . . 

3.2 Ulrike Muschaweck and Christoph Peter Schuhmacher 3.2.1

Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152





3

Informed Consent, Preoperative Preparation,

Perioperative Management. . . . . . . . . . . . . . . . 151

Risk Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  180

172 181 184 185 186 186 187



Ulla Volmer and Georg Arlt

3.5.1

Epidemiology and Pathogenesis. . . . . . . . . . .  187

3.5.2 3.5.3 3.5.4 3.5.5

Diagnosis and Classification . . . . . . . . . . . . . . .  187 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  187 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .  187 Operation Technique. . . . . . . . . . . . . . . . . . . . . .  187



Spitzy Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189



Preperitoneal Umbilical Mesh

3.6

Femoral Hernia . . . . . . . . . . . . . . . . . . . . Volker Schumpelick

3.6.1

Basic Principles . . . . . . . . . . . . . . . . . . . . . . . . . . .  192

Plasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

3.6.2



192

General Remarks. . . . . . . . . . . . . . . . . . . . . . . . . 192 The Hernial Orifice . . . . . . . . . . . . . . . . . . . . . . . 192 Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  193

Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  193

vii

 3.6.3 3.6.4 3.6.5 3.6.6

Preparation, Anesthesia, and Positioning. . . .  193 Operation Tactics. . . . . . . . . . . . . . . . . . . . . . . . . .  193 Forms of Repair. . . . . . . . . . . . . . . . . . . . . . . . . . .  194 Crural Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Inguinal Access . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Preperitoneal Access. . . . . . . . . . . . . . . . . . . . . . 197

Operation Techniques. . . . . . . . . . . . . . . . . . . . .  197 Crural Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Inguinal Access . . . . . . . . . . . . . . . . . . . . . . . . . . 201



Alloplastic Repair . . . . . . . . . . . . . . . . . . . . . . . . 208

3.7

Rare Hernias. . . . . . . . . . . . . . . . . . . . . . . Christian Peiper and Ralph Lorenz

3.7.1

Lumbar Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . .  208

3.7.2



208

Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Operation Techniques. . . . . . . . . . . . . . . . . . . . . 208

Supravesical Hernia. . . . . . . . . . . . . . . . . . . . . . .  209 Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

Perineal Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . .  213

Location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213 Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .213 3.7.6

Operation Techniques. . . . . . . . . . . . . . . . . . . . .215 Interparietal Hernias. . . . . . . . . . . . . . . . . . . . . .  215

Location. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215 Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215

Operation Techniques . . . . . . . . . . . . . . . . . . .215

3.8

Spigelian Hernia. . . . . . . . . . . . . . . . . . . . Marc Miserez

3.8.1

Definition, Anatomy, and Incidence. . . . . . . .  217

3.8.2 3.8.3



Results and Complications. . . . . . . . . . . . . . . . .  217

3.8.4

Operation Techniques. . . . . . . . . . . . . . . . . . . . .  217

3.9

Internal Hernias. . . . . . . . . . . . . . . . . . . . Volker Schumpelick and Uwe Klinge

3.9.1

Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  223



Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

3.9.4

Operation Techniques. . . . . . . . . . . . . . . . . . . . . 212

3.9.6

Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212

3.9.8



Operation Techniques. . . . . . . . . . . . . . . . . . . . . 213

3.9.10

4

Incisional Hernias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

4.1

General Principles. . . . . . . . . . . . . . . . . . . Joachim Conze

3.7.4

4.1.1

Obturator Hernia. . . . . . . . . . . . . . . . . . . . . . . . . .  210

3.9.3

Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210

3.9.5

Sciatic Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  212

3.9.7

Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212

3.9.9



234



Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234



223

Incidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  223

Operation Techniques. . . . . . . . . . . . . . . . . . . . . 210

3.7.3

217

Diagnosis and Choice of Procedure. . . . . . . . .  217

3.9.2



Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  223 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  229 Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  229 Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  229 Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  229 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .  229 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  229 Operation Techniques. . . . . . . . . . . . . . . . . . . . .  229 234

Operation Techniques. . . . . . . . . . . . . . . . . . . . . 236 Relevant Anatomy, Dangers, and Tricks. . . . . . 243 Management of Special Complications . . . . . . 243



Postoperative Care. . . . . . . . . . . . . . . . . . . . . . .  243

4.2.2

Open Onlay (Epifascial Mesh



Joachim Conze



Operation Techniques . . . . . . . . . . . . . . . . . . .243

Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234



Relevant Anatomy, Dangers, and Tricks. . . .246

Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234



Management of Special Complications. . . .246

Operation Tactics. . . . . . . . . . . . . . . . . . . . . . . . 234



Postoperative Care . . . . . . . . . . . . . . . . . . . . . .246

4.1.9

Perioperative Management . . . . . . . . . . . . . . 235

4.2.3

Open Intraperitoneal Onlay Mesh

4.2

Open Technique. . . . . . . . . . . . . . . . . . . .



Frank P. Müller

4.2.1

Open Sublay (Retromuscular



Joachim Conze

4.1.2 4.1.3

Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

4.1.4

Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  234

4.1.5

Preoperative Preparation and Informed

Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

4.1.6 4.1.7 4.1.8



235

Augmentation). . . . . . . . . . . . . . . . . . . . . . . . . . .  235

viii

3.7.5

Augmentation). . . . . . . . . . . . . . . . . . . . . . . . . . . .  243

Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  246 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . .246

Operation Techniques . . . . . . . . . . . . . . . . . . .247



Advantages and Disadvantages. . . . . . . . . . .251

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251

4.3 Laparoscopic Repair of Incisional Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . .



252

4.3.1

General Principles . . . . . . . . . . . . . . . . . . . . . . .  252



Dieter Berger



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253



Contraindications . . . . . . . . . . . . . . . . . . . . . . . . 253 Operation Techniques. . . . . . . . . . . . . . . . . . . . . 253 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . .  258 Unanswered Questions. . . . . . . . . . . . . . . . . . . . 258



Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

4.3.2

Endoscopic Totally Extraperitoneal



Transhernial Sublay Ventral Hernia Repair



using the Single-Port Technique. . . . . . . . . .  258



Wolfgang Reinpold



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259



Operation Preparation . . . . . . . . . . . . . . . . . . . . 259 Special Risks, Informed Consent. . . . . . . . . . . . 259 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Relevant Anatomy, Dangers, and Tricks. . . . . . 259 Management of Special Complications . . . . . . 259 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . .  259 Operation Techniques. . . . . . . . . . . . . . . . . . . . . 259

4.3.3

Laparoscopic Repair of Parastomal Hernias. . .  261



Dieter Berger



Keyhole Technique . . . . . . . . . . . . . . . . . . . . . . . 261



Sugarbaker Technique. . . . . . . . . . . . . . . . . . . . . 262 Sandwich Technique. . . . . . . . . . . . . . . . . . . . . . 262 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . .  264 Limits of the Laparoscopic Technique . . . . . . . 264 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

4.3.4

Open Repair of Parastomal Hernias . . . . . .  264



Ulrich Andreas Dietz



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Operation Preparation . . . . . . . . . . . . . . . . . . . . 265 Special Risks, Informed Consent. . . . . . . . . . . . 265 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265



Positioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265



Operation Technique 1: Retromuscular



Mesh Position . . . . . . . . . . . . . . . . . . . . . . . . . . . 265



The Sugarbaker Intraperitoneal Mesh





Operation Technique. . . . . . . . . . . . . . . . . . . . . . 269 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . .  272

4.3.5

Preoperative Progressive



Stefan Willis



Physiological Basis . . . . . . . . . . . . . . . . . . . . . . . 272

Pneumoperitoneum. . . . . . . . . . . . . . . . . . . . . .  272



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . 272

Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275



Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

4.3.6

Giant Incisional Hernia. . . . . . . . . . . . . . . . . . .  275



Joachim Conze and Volker Schumpelick



Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  275



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275



Preoperative Preparation and Informed



Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276

Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276



Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276 Operation Tactics. . . . . . . . . . . . . . . . . . . . . . . . . 276 Perioperative Management. . . . . . . . . . . . . . . . 277 Repair Techniques. . . . . . . . . . . . . . . . . . . . . . . . 277



Postoperative Care. . . . . . . . . . . . . . . . . . . . . . .  281

4.3.7

Posterior Component Separation



According to Rosen. . . . . . . . . . . . . . . . . . . . . . .  281



Wolfgang Reinpold



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

4.3.8

Diagnosis and Operation Preparation . . . . . . . 282 Special Risks, Informed Consent. . . . . . . . . . . . 282 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 Operation Steps. . . . . . . . . . . . . . . . . . . . . . . . . . 282 Relevant Anatomy, Dangers, and Tricks. . . . . . 283 Management of Special Complications . . . . . . 283 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . .  284 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

Anterior Component Separation



According to Ramirez . . . . . . . . . . . . . . . . . . . .  285



Michael Stumpf



Basis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285



Operation Techniques. . . . . . . . . . . . . . . . . . . . . 285

4.3.9

Endoscopic Component Separation . . . . . .  287



Wolfgang Reinpold



Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287



Diagnosis and Operation Preparation . . . . . . . 287

ix



Special Risks, Informed Consent. . . . . . . . . . . . 287

Pathological Diagnosis . . . . . . . . . . . . . . . . . . . . 293

4.4.4

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  294

Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288



Surgical. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

Position. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288 Operation Steps. . . . . . . . . . . . . . . . . . . . . . . . . . 288

Conservative. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  294

Adjuvant Therapy . . . . . . . . . . . . . . . . . . . . . . . . 295

Relevant Anatomy, Dangers, Tricks. . . . . . . . . . 290

4.4.5

Prognosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  295



Postoperative Care. . . . . . . . . . . . . . . . . . . . . . .  290

Prevention of Incisional Hernias. . . . . . René H. Fortelny

4.3.10

Laparostomy Hernias . . . . . . . . . . . . . . . . . . . .  290

4.5



Joachim Conze

4.5.1

Abdominal Wall Closure



Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290



Dissection of the Linea Alba . . . . . . . . . . . . . . . 296





Management of Special Complications . . . . . . 290

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292



292

4.4

Abdominal Wall Tumors. . . . . . . . . . . . . Filip Muysoms and Joachim Conze

4.4.1

Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . 292

4.4.2 4.4.3

Clinical Symptoms. . . . . . . . . . . . . . . . . . . . . . . 292 Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Diagnostic Imaging. . . . . . . . . . . . . . . . . . . . . . 293





Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296

4.5.2

Indications for Prophylactic Mesh

Reinforcement. . . . . . . . . . . . . . . . . . . . . . . . . . . .  298

4.5.3

Prophylactic Mesh Reinforcement

Operation Procedure. . . . . . . . . . . . . . . . . . . . . .  299 Initial Dissection of the Linea Alba. . . . . . . . . . 299 Operation Procedure: Onlay Mesh. . . . . . . . . . 299 Operation Procedure: Sublay Mesh . . . . . . . . . 299

Differential Diagnosis. . . . . . . . . . . . . . . . . . . . . 293

5

Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

5.1.1 5.1.2 5.1.3 5.1.4

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Infections in Inguinal Hernia Surgery. . . . . 307 Infections in Incisional Hernia Surgery. . . . 307

5.1.5

Prevention of Wound Infections. . . . . . . . . . 308

5.1.6

Treatment of Wound and Mesh



Infections in Hernia Surgery . . . . . . . . . . . . . 308

5.2 Incarceration . . . . . . . . . . . . . . . . . . . . . . Bernd Stechemesser 5.2.1 5.2.2



310

Etiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310 Clinical Features. . . . . . . . . . . . . . . . . . . . . . . .  310

4.5.4

5.2.4

Postoperative Management. . . . . . . . . . . . . . . .  299

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

Incarceration Rates and Risk . . . . . . . . . . . . . 311

5.3

Postoperative Pain . . . . . . . . . . . . . . . . . Georg Arlt

5.3.1

Acute Postoperative Pain. . . . . . . . . . . . . . . . . 311

5.3.2

Chronic Postoperative Pain after Inguinal



and Femoral Hernia Operation . . . . . . . . . . . 312

5.4

Triple Neurectomy. . . . . . . . . . . . . . . . . . Georg Arlt

5.4.1

Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  314

5.4.2 5.4.3 5.4.4



Operation Techniques. . . . . . . . . . . . . . . . . . . . .  316 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  316

Miscellaneous. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

6.1

Training in Hernia Surgery: Hernia Compact—Young Surgery as a 3-Day Further Education Course. . . . . . . Ralph Lorenz, Bernd Stechemesser, and Wolfgang Reinpold Hernia Register: Outcome Research in Hernia Surgery. . . . . . . . . . . . . . . . . . . . . Ferdinand Köckerling, Dietmar Jacob, Christine Schug-Paß

6.2.1



320



314

Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  316

6

6.2

311



Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

320

306

5.2.5

5.2.3



295

Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  296



5.1 Infection. . . . . . . . . . . . . . . . . . . . . . . . . . .  306 Bernhard J. Lammers

x



Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

320

Patient Data and Methodology . . . . . . . . . . . 321 Project. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Informed Consent. . . . . . . . . . . . . . . . . . . . . . . . 321 Recording of Clinical Data . . . . . . . . . . . . . . . . . 321 Data Protection . . . . . . . . . . . . . . . . . . . . . . . . . . 322 Data Retrieval. . . . . . . . . . . . . . . . . . . . . . . . . . . . 323 Follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323



Preface First published in German over 25 years ago, Hernien represented the first modern work on surgical technique and is now in its fifth edition. This standard work is now being published in English by Thieme. The cautious beginnings and definitions in what was over 25 years ago a rather marginal branch of “real surgery” have now become a stable pillar of routine surgical practice. Hernia surgery, with its great variety of methods, now accounts for 10–15% of surgical procedures and is also the subject of national and international conferences, with its own specialist societies. Hernia management, formerly a little-regarded stepchild, has now become an important branch of general surgery, with a major research impetus and a deluge of medical devices. Compared with other branches of surgery, patients are usually younger and have longer life expectancy. In the 1980s and 1990s, the development of hernia surgery experienced something of a gold-rush mentality; what had been left to the youngest trainee surgeons now became the focus of attention thanks to new methods, modern materials, and revised scientific ideas. Even the opinion leaders of the surgical associations were now interested in hernia surgery and visited and chaired conferences

on this topic. Not least due to their influence, new methods, new materials, new companies, new concepts, new “pioneers”, and new questions shot up like mushrooms. Hardly any conference dared to omit hernia as a leading topic and even today, the announcement of a hernia session regularly attracts hundreds of interested surgeons. After the success story of the last quarter century, the initiators may be permitted to look back at what they accomplished and define what has been tried and tested. The history of hernia surgery will continue to develop steadily in future but nevertheless this manual, which makes recommendations for routine surgical practice, appears justified. What was a delicate shoot has now become a strong, important, and pioneering branch of surgery with numerous sturdy side-branches. The authors hope that this English edition will attract as much attention as the first edition 25 years ago. Volker Schumpelick, Hamburg Georg Arlt, Berlin Joachim Conze, Munich Karsten Junge, Würselen

xi



Editors Volker Schumpelick, MD Professor Emeritus Former President European Hernia   Society (EHS) Hamburg, Germany Georg Arlt, MD Associate Professor Department of General, Visceral, and Minimally   Invasive Surgery Park-Klinik Weissensee Berlin, Germany Joachim Conze, MD Associate Professor UM Hernia Center Dr. Conze Munich, Germany Karsten Junge, MD Professor Department of General, Visceral, and Minimally   Invasive Surgery Rhein-Maas Klinikum Würselen, Germany

Contributors Georg Arlt, MD Associate Professor Department of General, Visceral, and Minimally   Invasive Surgery Park-Klinik Weissensee Berlin, Germany Dieter Berger, MD Professor Private Hospital Lindberg Winterthur, Switzerland Marcel Binnebösel, MD Professor Department of General, Visceral, and   Transplant Surgery University Hospital Aachen Aachen, Germany Reinhard Bittner, MD, FRCS Professor Emeritus Stuttgart, Germany Joachim Conze, MD Associate Professor UM Hernia Center Dr. Conze Munich, Germany

xii

Ulrich Andreas Dietz, MD, MSc Professor Department of Surgery Buergerspital Solothurn Solothurn, Switzerland René H. Fortelny, MD Professor Department of General, Visceral, and Tumor Surgery Wilhelminenspital Vienna, Austria Christian Hollinsky, MD Associate Professor Department of Surgery Social Medicine Center Floridsdorf Vienna, Austria Friedrich-Eckart Isemer, MD Professor Hernia Center DKD HELIOS Hospital Wiesbaden Wiesbaden, Germany Dietmar Jacob, MD, MBA Associate Professor COPV (Surgical Orthopedic Group Practice) Berlin, Germany Karsten Junge, MD Professor Department of General, Visceral, and Minimally Invasive Surgery Rhein-Maas Klinikum Würselen, Germany Uwe Klinge, MD Professor Department of General, Visceral, and Transplant Surgery University Hospital Aachen Aachen, Germany Bernd Klosterhalfen, MD Professor Pathology Institute and Group Practice Düren Hospital Düren, Germany Andreas Koch, MD Surgical Practice TKC Medical Center Cottbus, Germany Ferdinand Köckerling, MD Professor Department of Surgery and Vascular Surgery Vivantes Hospital Spandau Berlin, Germany

 Andreas Kuthe, MD Surgical Department DRK Hospital Clementinenhaus Hanover, Germany

Wolfgang Reinpold, MD Department of Surgery Wilhelmsburg Hospital Gross-Sand Hamburg, Germany

Bernhard Lammers, MD Surgical Department I Municipal Hospital Neuss Lukas Hospital Neuss, Germany

Ekkehard Schippers, MD Professor Surgical Department Juliusspital Würzburg, Germany

Ralph Lorenz, MD 3+ Chirurgen, Surgical Group Practice Berlin, Germany Marc Miserez, MD. PhD. FRCS (Glasg.) Department of Abdominal Surgery University Hospital Gasthuisberg Leuven, Belgium Ulrike Muschaweck, MD MediCenter Starnberg Starnberg, Germany Frank P. Mueller, MD Department of General and Visceral Surgery Sankt Marien-Hospital Buer Gelsenkirchen, Germany Filip Muysoms, MD Associate Professor A.Z. Maria Middelares Gent, Belgium Henning Niebuhr, MD Professor Hanse Hernia Center Hamburg Hamburg, Germany Christian Peiper, MD Professor Department of General and   Visceral Surgery Evangelisches Krankenhaus Hamm Hamm, Germany Andreas Prescher, MD Professor Molecular and Cellular Anatomy   Institute of RWTH Aachen Aachen, Germany Matthias Pross, MD Professor Department of Surgery DRK Hospital Berlin-Köpenick Berlin, Germany

Christine Schug-Paß, MD Associate Professor KRH Hospital Siloah Garbsen, Germany Christoph Schuhmacher, MD Professor European Clinical Research Infrastructure Network (ECRIN) Paris Biopark Paris, France Volker Schumpelick, MD Professor Emeritus Former President European Hernia Society (EHS) Hamburg, Germany Jochen Schwarz Winghofer Medicum Hernia Center Rottenburg am Neckar Rottenburg am Neckar, Germany Bernd Stechemesser, MD Cologne Hernia Center Cologne, Germany Gerhard Steinau, MD Professor Department of General, Visceral, and Transplant Surgery University Hospital Aachen Aachen, Germany Michael Stumpf, MD Professor Department of General and Visceral Surgery HELIOS Hospital Pforzheim Pforzheim, Germany Andreas Tittel, MD Associate Professor Department for General, Visceral, and Thoracic Surgery Evangelisches Krankenhaus Bethesda Mönchengladbach, Germany

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 Tim Tollens, MD Imelda Hospital Bonheiden, Belgium Son Truong Ngoc, MD Professor Emeritus Aachen, Germany Ulla Volmer, MD Department of General, Visceral, and Minimally Invasive Surgery Park-Klinik Weissensee Berlin, Germany

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Dirk Weyhe, MD Associate Professor University Department of Visceral Surgery Pius-Hospital Oldenburg Oldenburg, Germany Stefan Willis, MD Professor Department of Surgery Hospital Ludwigshafen Ludwigshafen, Germany



Synonyms of Anatomical Names This collection of synonyms makes no claim to be complete and has been kept brief deliberately. It is intended to provide guidance to the interested reader due to the confusing nomenclature. The current terms in the most recent Terminologia Anatomica (1998) [211] are printed in bold. It should be noted,

however, that some official terms are inadequate and some structures are not even included. The classic names are included in these cases. Eponyms are also emphasized, as these terms are still used frequently in the surgical and clinical literature.

Adminiculum lineae albae  or triangular ligament

Medial inguinal fossa  or internal inguinal fossa or me-

Superficial inguinal ring  or subcutaneous or medial or external inguinal ring Deep inguinal ring  or preperitoneal or lateral or internal or abdominal inguinal ring Aponeurotic arch of the transverse muscle  or transversus abdominis arch Iliopectineal arch  or iliopectineal ligament or inter-

dial inguinal fovea Saphenous opening  or fossa ovalis Tendinous intersections  or tendinous inscriptions Parietal layer of the tunica vaginalis of the testis or periorchium or parietal peritoneum of the testis Visceral layer of the tunica vaginalis of the testis or epiorchium or visceral peritoneum of the testis

lacunar ligament or iliopubic ligament or interpubic

Inguinal ligament  (Poupart) or fallopian ligament

ligament

Interfoveolar ligament  (Hesselbach) or interfoveolar

Cremasteric artery  or external spermatic artery Artery to ductus deferens  or artery to vas deferens Inferior epigastric artery  or caudal epigastric artery Testicular artery  or spermatic artery or internal spermatic artery Lateral crus  or inferior crus or lateral column or inferior column Medial crus  or superior crus or medial column or superior column Ductus deferens  or vas deferens Inguinal falx  or conjoint tendon or Henle’s ligament (belongs to the transversus abdominis muscle) External spermatic fascia  or Cooper’s cremasteric fas-

muscle (of Hesselbach) or pubotransversalis muscle Lacunar ligament  (Gimbernat) Caution: Different usage in Eisler [62], Braus and Elze [30], and in the present text Pectineal ligament  or pubic ligament or Cooper’s ligament. This does not mean the superior pubic ligament Reflected ligament  (Colles) or reflected inguinal ligament Caution: Different usage in Eisler [62], Braus and Elze [30], and in the present text Ligamentum teres of the uterus  or round ligament of the uterus Arcuate line  (Douglas) or semicircular line

cia (outermost layer of the spermatic cord originating

Falciform margin  or Burn’s ligament

from the superficial abdominal fascia)

Cremaster muscle  (Riolan) or testicular muscle or

Internal spermatic fascia  or tunica vaginalis of the testis and spermatic cord (continuation of the transversalis fascia onto the spermatic cord) Subcutaneous abdominal fascia  or Camper fascia or external subcutaneous fibrous tunic Transversalis fascia  or fascia of the transversus abdominis muscle Endoabdominal fascia of Luschka  or intra-abdominal

suspensory muscle External oblique muscle of the abdomen  or descending oblique Internal oblique muscle of the abdomen  or ascending oblique Transversus abdominis muscle  or transverse abdominal Fatty layer of the abdomen  or subcutaneous fascia (Camper)

fascia or internal abdominal fascia or subperitoneal

Iliac part of the iliopsoas fascia  or iliac fascia

connective tissue layer or preperitoneal connective

Psoas part of the iliopsoas fascia  or psoas fascia

tissue layer

Lateral umbilical fold  or epigastric fold or inferior

Intercrural fibers  or aponeurotic intercrural fibers or intercolumnar fibers or collateral fibers Lateral inguinal fossa  or external inguinal fossa or lateral inguinal fovea

epigastric artery fold Medial umbilical fold  or lateral vesicoumbilical fold (contains the medial umbilical ligament or lateral umbilical ligament or cord of the umbilical artery)

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 Median umbilical fold  or middle umbilical fold or

by Skandalakis [202]. Although this would be histori-

middle vesicoumbilical fold (contains the median um-

cally more correct, it would lead to confusion with the

bilical ligament or cord of the urachus) Processus vaginalis of the transversalis fascia  or infundibuliform fascia or Nuhn fascial funnel Genital branch of the genitofemoral nerve  or external spermatic nerve Femoral septum  (Cloquet) or femoral ring septum Membranous layer of the abdomen  or superficial abdominal fascia (Scarpa) Iliopubic tract  (Thomson) or Thomson’s ligament or deep crural arch; Hesselbach ligament was suggested

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interfoveolar (Hesselbach) ligament. Transversalis loop  or Henle loop or Henle’s ligament or falciform ligament of Henle Femoral trigone  or Scarpa triangle Tunica vaginalis testis  or tunica vaginalis propria testis Vestige of processus vaginalis  or vaginal ligament or remnant of the processus vaginalis (Haller)

1

Chapter 1 Introduction

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1 1.1

Anatomy of the Anterior Abdominal Wall

1.2

Definition and Terminology

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1.3

Diagnosis

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1.4

The History of Hernia Surgery

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1.5

Repair Principles and Materials

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1.6

Hernia Biomechanics

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1.7

Biological Meshes

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1.8

Anesthesia

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1.9

Pediatric Hernia

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Introduction

1  Introduction 1.1  Anatomy of the Anterior Abdominal Wall Andreas Prescher and Werner Lierse (†) A large gap exists in the human skeleton between the lower border of the thorax and the upper border of the bony pelvis. This extensive gap is closed by the multilayered abdominal wall, which consists of broad muscles, fasciae, aponeuroses, and peritoneum. The soft abdominal wall allows the thorax and entire trunk to move freely. It provides less protection to the intra-abdominal organs than the bony skeleton, but this is compensated by pronounced abdominal muscle reflexes. The muscle layers of the abdominal wall consist of intrinsic muscles, namely the external oblique, internal oblique, and transversus abdominis laterally and the rectus abdominis and pyramidalis anteriorly. These muscles are fixed within the bony frame formed by the thorax, pelvis, and costal processes of the lumbar vertebrae and are completed by characteristic fasciae and connective tissue systems. At certain typical sites, the abdominal wall contains no muscle and consists only of connective tissue. These anatomical sites of lower resistance are the hernial orifices that warrant surgical attention.

1.1.1  Muscles of the Abdominal Wall Refer to22, 30 and78 for related literature.

The Rectus Abdominis Muscle ▶ Origin. It originates by three slips from the anterior surface of the fifth to seventh costal cartilage. Near the midline, it forms the entire thickness of the anterior abdominal wall with the insignificant pyramidalis anterior to its lower end. The lateral slip is the widest and arises from the anterior surface of the fifth costal cartilage as far as the osteochondral junction. In many cases, the fibers of this muscle slip pass obliquely in an inferomedial direction. The intermediate slip originates from the anterior surface of the sixth costal cartilage, and the medial slip from the anterior surface of the seventh costal cartilage and anterior surface of the xiphoid process. Furthermore, the medial slip extends around the ascending border of the seventh costal cartilage to attach to its posterior surface. The fibers of the intermediate and medial slips pass in purely longitudinal direction as far as the first tendinous intersection.

▶ Insertion. The rectus abdominis muscle is inserted by a strong flat tendon on the upper border of the pubic symphysis and adjacent parts of the superior pubic ramus. The lateral and medial parts of the tendon are quite different: the average length of the tendon is 4 to 5 cm laterally but only 2 to 3 cm medially. The junction does not form a continuous line from lateral to medial but occurs abruptly at one point (▶Fig. 1.1). Lateral to this point, the rectus sheath is inserted on the anterior border of the superior pubic ramus, while medially the tendon is inserted on the medial surface of the pubic tubercle and extends onto the anterior surface of the pubic symphysis. Some of the fibers cross the midline to the contralateral pubic tubercle, where they mingle and cross at an acute angle. A few aberrant fibers pass to the suspensory ligament of the penis. In addition to extending between fixed cranial and caudal bony points, the medial border of the rectus abdominis is also inserted in the linea alba. This “medial insertion” is particularly prominent below the umbilicus; it becomes stronger inferiorly, forming the adminiculum lineae albae. The firm attachment of the rectus abdominis to the linea alba prevents the two rectus muscles from diverging, a condition known as diastasis of the recti. ▶ Tendinous intersections. The entire rectus abdominis structure is intersected by tendinous bands, resulting in a muscle with four bellies. The tendinous intersections are true tendons with longitudinal fibers, which are firmly adherent to the anterior layer of the rectus sheath but are mobile over the posterior layer. The anterior adhesions prevent the muscle from moving as a whole within the rectus sheath, while allowing the individual sections to move in isolation. On average, there are four intersections at the following positions: •• First intersection: at the level of the tip of the eighth rib. •• Second intersection: at the level of the lower border of the 10th rib. •• Third intersection: at the level of the umbilicus. •• Fourth intersection: inconstant, at the level of the arcuate line. The tendinous intersections are up to 1 cm wide, have a zigzag or oblique course, and are firmly adherent medially to the linea alba and anteriorly to the anterior layer of the rectus sheath. ▶ Neurovascular supply. The arterial supply to the rectus abdominis muscle is from the superior and inferior epigastric arteries. These vessels lie in an obvious groove on the posterior surface of the muscle and extend lengthwise on the muscle. A continuous large-lumen

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Fig. 1.1  Rectus abdominis and transversus abdominis (R5 = fifth rib). 1 Rectus abdominis. 2 Tendinous intersection. 3 Linea alba: broad part. 4 Linea alba: narrow part. 5 Posterior layer of the rectus sheath with arcuate line (of Douglas). 6 Transversus abdominis. 7 Linea semilunaris (Spieghel line). 8 Suspensory ligament of the penis.

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Introduction connection between the two arteries, as shown in many atlases of anatomy, does not usually exist. The nerve supply is through the anterior rami of T7 to T12, often supplemented by accessory branches from T6 and L1.62 The muscular branches enter the lateral border and posterior surface of the muscle in 12 to 25 separate branches. Because of this position, the innervation is destroyed by a lateral incision.30

The External Oblique Muscle ▶ Origin. The external oblique muscle arises from the 5th to the 12th rib, forming a characteristic line that runs from the costochondral junction of the 5th rib to the rudimentary cartilage of the 12th rib. The muscle origin consists of slips that interdigitate superiorly with serratus anterior and inferiorly with latissimus dorsi. The

resulting jagged line, which is clearly visible in the living, is called Gerdy’s line (Pierre Nicolas Gerdy, 1797–1856, anatomy and physiology prosector and later professor of surgery in Paris). The dentations of the external oblique muscle increase in size from above as far as the 8th rib and then become smaller but thicker. The slips of the muscle’s origin overlap like roof tiles. The anterior boundary is smooth superiorly but often wavy inferiorly (▶Fig. 1.2). At about the level of the anterior superior iliac spine, it turns at a right angle to become the muscle’s inferior border, which follows the iliac crest, thereby forming the Gaupp muscle corner (Ernst Gaupp, 1865–1916, professor of anatomy in Freiburg, Königsberg and Breslau; ▶Fig. 1.2, ▶Fig. 1.3), which will be discussed further in connection with the inguinal canal. Fig. 1.2  External oblique muscle. 1 External oblique muscle. 2 Serratus anterior. 3 Latissimus dorsi. 4 Gaupp muscle corner. 5 Gerdy’s line. 6 Intercrural fibers. 7 Pectoralis major.

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Fig. 1.3  Anatomy of the lower abdominal wall in the plane of the external oblique. 1 Medial crus. 2 Lateral crus. 3 Intercrural fibers. 4 Superficial inguinal ring. 5 External oblique muscle (Gaupp muscle corner). 6 Lacunar (Gimbernat) ligament. 7 Suspensory ligament of the penis.

▶ Insertion. The external oblique muscle is inserted on the outer lip of the iliac crest, pubic tubercle, and linea alba. It inserts in the iliac crest through a short strong tendon. Anteriorly, the muscle is continuous with its extensive aponeurosis, the inferior border of which forms the inguinal ligament. This ligament extends from the anterior superior iliac spine to the pubic tubercle, becoming wider from lateral to medial portion (▶Fig. 1.11).

▶ Direction of fibers. In the upper part of the muscle, the fibers run almost horizontally but slant increasingly downward in the inferior portion. This fiber direction (▶Fig. 1.2) continues in the connective tissue fibers of the aponeurosis. These aponeurotic fibers cross the midline and interlace with the contralateral fibers. In the inferior part of the linea alba, they form two layers on the opposite side: the superficial layer radiates into the

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Introduction fascia lata through the adductor longus muscle, whereas the deep layer is inserted on the pubic tubercle, forming the reflected inguinal ligament (Colles’ ligament; after Abraham Colles, 1773–1843, professor of anatomy and surgery in Dublin; see also inguinal canal and inguinal ligament). The fibers that pass in the inferior muscle border from the anterior superior iliac spine to the muscle corner merit attention as they form the inguinal ligament (Poupart ligament; after François Poupart, 1616–1708, surgeon in Reims and Paris). Above the iliopsoas muscle, this ligament constitutes a stronger band within the iliac fascia, because of which it cannot be separated from the iliopsoas muscle fascia (see inguinal ligament).

▶ Neurovascular supply. The muscle is innervated by anterior branches of T5 to T12 and sometimes also L1. The blood supply comes from the deep circumflex iliac artery, the inferior and superior epigastric arteries, the musculophrenic artery, and the lateral thoracic artery.

The Internal Oblique Muscle ▶ Origin. The internal oblique muscle arises from the intermediate line of the iliac crest, from the superficial layer of the thoracolumbar fascia, and from the lateral part of the inguinal ligament. The muscle can be described as a five-sided curved sheet (▶Fig. 1.4). The origin is typically S-shaped with its main bend at the anterior superior iliac spine. Fig. 1.4  Internal oblique muscle with its five borders. 1 Internal oblique muscle. A S-shaped origin. B Inferior border with diverging fibers. C Vertically ascending posterior border. D Stepped superior border. E Medial border with inferior dentations. 2 Rectus abdominis muscle.

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1.1  Anatomy of the Anterior Abdominal Wall The inferior or inferomedial border of the muscle is the shortest and is subject to numerous variations. Fibers may diverge from this often poorly demarcated border and combine with fibers from the transversus abdominis to form the cremaster muscle on the spermatic cord. The cremaster fibers are located in the lateral and posterior segments of the spermatic cord. If they are present in increased numbers, they may expose a medial portion of the spermatic cord. The posterior border passes vertically upward from the iliac crest to the superior border, where it is inserted. ▶ Insertion. The internal oblique muscle is inserted superiorly and anteriorly: •• The superior border extends from the tip of the 10th costal cartilage to the tip of the 12th costal cartilage and has a variable course depending on the shape of the ribs (▶Fig. 1.4). •• The anterior border forms the longest side of the muscle and describes a line that extends from the pubic tubercle to the tip of the 10th rib. In its inferior part, it typically has small dentations, the lowest of which projects furthest medially (▶Fig. 1.4). ▶ Direction of fibers. This varies between the individual parts of the muscle. The fibers that originate between the anterior superior iliac spine and the gluteal tubercle diverge greatly. The fibers of the adjacent inferior part of the muscle have a parallel course, whereas the fibers arising from the lateral inguinal ligament run almost horizontally but possibly irregularly. The insertion of the internal oblique muscle is through a short flat tendon. The anterior border merges with the broad aponeurosis of the internal oblique muscle. It is important to note that the collagen fibers of the aponeurosis maintain the direction of the muscle fibers and therefore have three sections, like the muscle. At the lateral border of the rectus abdominis the aponeurosis forms the rectus sheath, which will be described in more detail in section The Rectus Sheath (page 9). The internal oblique muscle is enclosed between a thin superficial fascia and a thick, feltlike, deep fascia. The superficial fascia is clearly distinct from the muscle and can also be separated from the deep fascia of the external oblique. The deep fascia of the internal oblique is very difficult to distinguish as a separate layer and merges with the superficial fascia of the transversus abdominis muscle. Sometimes, the two layers can be separated close to the inguinal canal. The superficial internal oblique fascia forms the middle spermatic fascia. When the inguinal part of the internal oblique muscle is particularly bulky, these fibers are forced apart when a hernia is present. Some of these fibers then extend inferiorly on the hernial sac. ▶ Neurovascular supply. The segmental nerves (T8–L1) and vessels (especially branches of the deep circumflex iliac artery and vein) run in the deep and thick connective

tissue layer. This structural arrangement is altered in the inguinal part, where the segmental nerves and vessels perforate the internal oblique muscle and run on its surface in inferomedial direction. According to Eisler,62 the internal oblique is supplied by T10–L2. The nerves enter the muscle from its underside.

1

The Transversus Abdominis Muscle ▶ Origin. The transversus abdominis muscle originates from the six lower ribs as well as from the deep layer of the thoracolumbar fascia, the inner lip of the iliac crest, and the psoas fascia. It also regularly extends to the lateral part of the inguinal ligament. ▶ Insertion. The transversus abdominis is inserted in the linea alba, the xiphoid process, the cranial border of the pubic symphysis, and the adjacent medial part of the pecten pubis. The transversus abdominis can be regarded as a direct inferior continuation of the transversus thoracis muscle. It is therefore not surprising that variations in the origin of the transversus abdominis are closely linked with variations in the prominence of the transversus thoracis. When the inferior part of the transversus thoracis is less developed, the origin of the transversus abdominis is correspondingly higher and vice versa. ▶ Direction of fibers. The fibers run parallelly and horizontally, with the anterior segments curving downward in the inferior region. According to Eisler,62 the overall shape of the transversus abdominis can be compared with a crescent moon, with its concavity facing anteriorly. At this muscle border, the transversus abdominis is continuous with its aponeurosis, which forms part of the rectus sheath, discussed in section The Rectus Sheath (page 9). The junction between the muscle and its connective tissue aponeurosis is called the semilunar (spigelian) line (after Adriaan van den Spieghel, Spigelius in Latin, 1578–1625, professor of anatomy in Venice and Padua; see ▶Fig. 1.1). It is important to note that the horizontal direction of the muscle fibers continues in the horizontal fibers of the aponeurosis. Cranially, the aponeurosis crosses the anterior surface of the xiphoid process to which it is partly adherent, but also passes to the contralateral side, leading to the interlacing of the fibers. Another group of fibers is inserted anterior to the transversus thoracis on the lateral segments of the root of the xiphoid process. The inferior muscle fibers that pass downward continue into the corresponding tendon fibers that pass almost parallel to the lateral border of the rectus abdominis behind the reflected inguinal (Colles) ligament to the pecten pubis. According to Eisler,62 three layers of fibers can be detected in this region of the transversus abdominis: •• Superficial layer: passes anteriorly over the rectus abdominis and pyramidalis and is inserted in the linea alba and pubic symphysis.

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Introduction •• Middle layer: between pyramidalis and rectus abdominis. •• Deep layer: passes with its fibers beside the rectus abdominis to the pecten pubis. The outer surface of the muscle is covered by its fascia and by a thick connective tissue layer, and the inner surface is covered by its posterior muscle fascia and the strong transversalis fascia. ▶ Neurovascular supply. The transversus abdominis is innervated by the branches of T530 with an occasional contribution from the iliohypogastric and ilioinguinal nerves. The nerves supplying the muscle are on its outer surface initially and form looping anastomoses during their intramuscular course. The blood supply is provided by the deep circumflex iliac artery, the inferior and superior epigastric arteries, and by the musculophrenic artery.

1.1.2  Fasciae and Fascial Structures The division, in the older nomenclature, of the superficial abdominal fascia into a superficial layer (subcutaneous fascia or Camper fascia, after Peter Camper, 1722–1789, professor of anatomy, surgery and medicine in Amsterdam and Groningen) and a deep layer, the actual superficial abdominal fascia (or Scarpa fascia, after Antonio Scarpa, 1747–1832, professor of anatomy and surgery in Modena and Padua), will continue to be used here, although it is no longer given in the new Terminologia Anatomica.221 The terms “fatty layer of the abdomen” and “membranous layer of the abdomen,” introduced in place of the previous names for the fascial structures, have not yet entered the clinical parlance and are rather confusing. “Fatty layer of the abdomen” does not at all reflect the obvious structure of the connective tissue framework of the subcutaneous fat layer. This is not a simple fat pad; moreover, in quadrupeds this structural layer forms a thick elastic fascia (“yellow abdominal skin”). So comparative anatomy also argues for the retention of the term “fascia.”

Subcutaneous (Camper) Fascia or Fatty Layer of the Abdomen Below the umbilicus in the aponeurotic region of the anterior abdominal wall and on the rectus sheath, there is a dense structure of elastic tissue, perforated like a honeycomb, which becomes visible only when the fat within it is expressed.180 This formation, part of the subcutaneous tissue, is called the subcutaneous fascia (Camper) or fatty layer of the abdomen. Cranially, this fascia is gradually dissipated and disappears. Laterally, it is firmly connected to the fascia of the external oblique muscle and terminates in this. Inferiorly, by contrast, it splits into a superficial and a deep layer. These layers behave differently: the superficial layer

merges with the fascia lata and the deep layer terminates in the inguinal ligament. The structure is also noteworthy medially, where again the fascia splits into several layers. The deep layers become adherent with the linea alba while the superficial layers cross to the contralateral side and connect to the skin, which appears retracted along the midline, especially in obese persons. In front of the pubic symphysis, the subcutaneous fascia forms the elastic fundiform ligament of the penis or clitoris. An important topographical feature of this ligament is its presence in front of the linea alba, the insertion of the rectus muscles, and the suspensory ligament of the penis.

Superficial Abdominal Fascia (Scarpa fascia) or Membranous Layer of the Abdomen The superficial abdominal fascia is the name given to the tough connective tissue layer containing numerous elastic fibers that lies on the external oblique muscle. This fascia continues on the aponeurosis but here it becomes thin and nonmobile. Typical fiber directions can be identified within the abdominal fascia. Fibers coming from the anterior superior iliac spine run concentrically around the corner of the external oblique muscle, pass upward parallel to the border of the rectus, and then turn medially to terminate on the rectus sheath.8,9,10,11,12,50,78,145,222,235 At the costal margin, strong fiber systems form, which pass over the xiphoid process to terminate on the contralateral side. The fibers arising from the lateral part of the inguinal ligament constitute a system that fans out over the slit formed by the inferior and superior crura and terminates on the rectus sheath. These fibers are termed intercrural fibers. These are usually very poorly developed in women and are otherwise very variable. The intercrural fibers are not involved in forming the superficial inguinal ring. Rather, this is closed laterally by fascial fibers arising from the medial part of the inguinal ligament. It is important to note that the superficial abdominal fascia continues as a thin layer on the spermatic cord, thus forming the external spermatic fascia (cremasteric fascia, Cooper fascia, after Sir Astley Paston Cooper, 1768–1841, professor of anatomy and surgery in London). Below the inguinal ligament, the superficial abdominal fascia is continuous with the fascia lata. The fascia lata divides into two layers over the femoral vessels, which lie in the iliopectineal fossa. The deeper layer corresponds to the iliopectineal fascia on the lateral side of the (superficial) femoral artery. The superficial layer forms the lateral, curved border of the fossa ovalis through which the great saphenous vein passes (falciform margin with superior and inferior horns). Because of the doubling of the fascia lata, the superficial layer forms the cranial limb and the inferior curved margin of the fossa ovalis and is inserted with the deep layer on

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1.1  Anatomy of the Anterior Abdominal Wall the pectineal fascia and pecten pubis. This deep portion of the fascia lata helps strengthen the medial wall of the femoral canal. In the author’s opinion, there is no need or anatomical justification for distinguishing another connective tissue layer from the superficial abdominal (Scarpa) fascia, named the Gallaudet fascia.73,180,209

The Rectus Sheath The rectus sheath is a flat connective tissue tube containing the rectus abdominis muscle. This sheath consists of anterior and posterior laminae that are adherent with one another medially and laterally (see ▶Fig. 1.6, ▶Fig. 1.10).62 The posterior layer is absent superiorly, where the rectus abdominis lies on the thorax. As far as the ninth costal cartilage, the posterior layer consists essentially of the aponeurosis of the transversus abdominis as the posterior layer of the internal oblique aponeurosis is extremely thin. The typical structure of the posterior layer only forms below the level of the ninth costal cartilage, where the rectus sheath consists of the posterior layer of the internal oblique aponeurosis, the transversus abdominis aponeurosis, and the transversalis fascia. The posterior lamina occupies the upper two-thirds of the rectus sheath and then undergoes a major transformation: roughly 4 to 6 cm below the umbilicus, the posterior layer of the internal oblique aponeurosis and the transversus abdominis aponeurosis pass into the anterior lamina of the sheath. The transition area is marked by the inferior concave border of the aponeurosis where it passes forward and is known as the arcuate line or semicircular line of Douglas (after James Douglas, 1675–1742, anatomist and gynecologist in London). The arcuate line is classically described as situated 4 to 5 cm inferior to the umbilicus but it may be encountered as far as 9 cm below it. The aponeurotic fibers often do not switch abruptly from posterior to anterior but form a transitional zone so the arcuate line can also be regarded as an area. Spigelian hernias are found where the arcuate line crosses the semilunar (Spieghel) line. Below the arcuate line, the posterior lamina consists only of transversalis fascia and is therefore very thin and delicate. It should also be noted that the inferior part, consisting only of transversalis fascia, is firmly adherent to the linea alba and therefore continues onto the posterior surface of the adminiculum lineae albae, finally inserting in the pubic bone. Because of this, the posterior lamina is approximately 1 cm from the posterior surface of the rectus abdominis inferiorly, with development of a fat-filled submuscular space (the Charpy retromuscular fossa, after Adrien Charpy, 1848–1911, professor of anatomy in Toulouse). The anterior lamina of the rectus sheath comprises two segments with differing structure. As far as the arcuate line the anterior lamina consists of the external oblique aponeurosis and the anterior layer of the internal

oblique aponeurosis. Below the arcuate line, it is joined by the posterior layer of the internal oblique aponeurosis and the aponeurosis of the transversus abdominis. It is noteworthy that the external oblique aponeurosis does not merge with the anterior layer of the internal oblique aponeurosis immediately at the lateral border of the rectus sheath, but this fusion takes place more medially on the rectus sheath. The area where they merge moves more medially in inferior direction and finally almost coincides with the linea alba. The space within the rectus sheath is divided into anterior and posterior parts. The anterior part is in front of the rectus abdominis and is further divided by adhesion of the tendinous intersections to the anterior lamina. The anterior space does not communicate with the space behind the muscle at the lateral border of the rectus muscle as connective tissue fibers from the lateral border of the muscle attach firmly to the lateral area where the anterior and posterior laminae fuse, thereby completing the separation. This subdivision of the space within the rectus sheath is important for the spread of pathological processes and effusions.

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The Linea Alba The linea alba (see ▶Fig. 1.1) is a connective tissue raphe formed by the aponeuroses of the abdominal muscles where they meet in the midline. It is approximately 35 to 40 cm in length. The linea alba starts on the anterior surface of the xiphoid process with the interlacing of the cranial fibers of the transversus abdominis and local fascia. Inferiorly, the linea alba is inserted on the pubic tubercle and many of its fibers merge with the adductor fascia. Two large segments of differing texture can be distinguished in the linea alba:62 •• The cranial part, extending to about 4 to 5 cm below the umbilicus, consists of a very thin band, roughly 1 to 2.5 cm wide, where the aponeurotic fibers interlace in both sagittal and frontal direction. •• The inferior part, which extends to the symphysis, is characterized by an absence of the sagittal fiber component. So, it appears as a very narrow but thick band. The adminiculum lineae albae is at the lower end of the linea alba. This structure begins at the arcuate line and becomes wider inferiorly, resulting in a triangular lamella, formerly termed the triangular ligament. The adminiculum lineae albae is posterior to the rectus abdominis muscles and is attached to the superior ramus of the pubic bone posterior to the rectus tendons. The anteromedial ridge of the adminiculum lineae albae passes between the two rectus muscles and is connected to the visible anterior band of the linea alba. The broad superior part of the linea alba contains the umbilicus and accessory openings may also be present. These openings arise due to divergence of the fibers, with the small rectangular openings become rounded owing to

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Introduction the circular extension of the fibers. The accessory openings, found only above the umbilicus, contain a fat plug which is connected to the subperitoneal fat tissue. These accessory gaps and the umbilicus are potential sites for linea alba and umbilical hernias. The complex architecture of the linea alba fibers can be divided into three distinct layers, from anterior to posterior:13,14 •• Oblique fibers. •• Transverse fibers. •• Irregular fibers. Unlike previous researchers, the authors have not found any separate areas of interlacing of fibers. It is also interesting that sexual dimorphism is found in the fibrous architecture of the linea alba:14 there are considerably more transverse fibers in the infraumbilical region in women than in men. This can probably be regarded as a functional adaptation. The topography of the superior linea alba insertion on the xiphoid process is of particular surgical importance. Incision of the posterior lamina of the rectus sheath beside the xiphoid provides access to the retroxiphoid space. This space contains loose, delicate preperitoneal fat limited superiorly by the diaphragm, which can be readily extended by blunt dissection to enable combined retromuscular and retroxiphoid positioning of a sublay mesh.46 When the posterior layer of the rectus sheath is opened more inferiorly directly beside the linea alba, the preperitoneal fat space is reached. This space appears as a fatfilled triangular area described by Conze et al47 as the fatty triangle. The fatty triangle likewise allows retromuscular mesh positioning with adequate overlapping areas.

The Transversalis Fascia The transversalis or endoabdominal fascia (of Luschka, after Hubert von Luschka, 1820–1875, initially an apothecary, then a general physician, and finally professor of anatomy in Tübingen), which covers the entire inner surface of the anterior abdominal wall, is an important structure in the abdominal wall and inguinal and femoral regions (▶Fig. 1.5). In the inguinal region, it consists of a series of arches that extend up to the arcuate line and are bounded inferiorly by the femoral vessels. The transversalis fascia is a connective tissue layer of greatly variable thickness, which is difficult to demonstrate by dissection. The transversalis fascia is firmly adherent to the subserous connective tissue of the peritoneum and lies on the transversus muscle and its aponeurosis. (Note: the transversalis fascia is not the same as the transversus aponeurosis.) A little above the umbilicus, the transversalis fascia forms the thicker, stronger, and denser umbilical fascia.166 The umbilical fascia is thus a special part of the

transversalis fascia, where the fibers run horizontally. The umbilical fascia disappears gradually superiorly, whereas its inferior margin often has a sharp curved margin that is concave inferiorly. The peritoneum is immovable on the umbilical fascia. The inferior part of the transversalis fascia has special relations. It is reinforced here by the iliopubic tract and attaches to the entire posterior surface of the inguinal ligament, where it helps to form the posterior wall of the inguinal canal, the deep inguinal ring, and the femoral ring. The position where the spermatic cord enters the inguinal canal, the transversalis fascia is continuous with the delicate spermatic fascia, thereby forming the processus vaginalis of the transversalis fascia. The medial border of this fascial funnel is usually sharp, whereas the superolateral margin is more rounded and concave. The sharp medial border is also called the Krause semilunar fold of the transversalis fascia (after Wilhelm Johann Friedrich Krause, 1833–1910, professor of anatomy in Göttingen and Berlin). On the lateral third of the inguinal ligament, the transversalis fascia is continuous with the iliac part of the iliopsoas fascia. It is generally accepted that only the transversalis fascia separates the dorsum of the rectus muscles from the peritoneum. The transversalis fascia is variously described as: •• Aponeurosis. •• Membrane. •• Thickened fat layer. •• Extraperitoneal boundary layer. The transversalis fascia is the deep layer that forms the boundary with the peritoneum and also covers the abdominal surface of the transversus abdominis and its aponeurosis. It lies on the fascia of the rectus abdominis, quadratus lumborum, and iliopsoas muscles and of the diaphragm. With these muscle fasciae, it forms a large sac that completely underlies the peritoneum. Close to the kidneys, this fascial tissue contains abundant perirenal fat. Within the pelvis, it is called the paracolpium, paraproctium, paracystium, and parametrium.84 There is very little fat around the umbilicus and on the diaphragm; the fascia is loose and vascular in the inguinal canal, where it contains the blood vessels and nerves lying on the internal spermatic fascia. Since the structure of the transversalis fascia differs greatly in different regions, the abdominal wall and inguinal regions are discussed separately below.

Transversalis Fascia on the Abdominal Wall The transversalis fascia varies in firmness and thickness both inter- and intra-individually. In general, the transversalis fascia is particularly thin in the upper abdomen and particularly thick on the lateral abdominal wall. However, it is most pronounced in the inguinal region. According to Velpeau, two layers can be distinguished in

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1.1  Anatomy of the Anterior Abdominal Wall

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Fig. 1.5  Anatomy of the lower abdominal wall in the transversalis fascia plane. The Hesselbach triangle between 1, 2 and 3 has a lattice-like structure. 1 Henle loop. 2 Interfoveolar (Hesselbach) ligament. 3 Curved rectus margin. 4 Semilunar line.

the transversalis fascia. The deep layer corresponds to the peritoneal lamella and the superficial layer to the transversus fascia, which cannot always be demonstrated. The superficial layer is “soldered” to the transversus abdominis aponeurosis and passes with this in front of the rectus abdominis. Here, it further divides into two layers to enclose the pyramidalis muscle. The deep layer (Velpeau lamina propria, after Alfred Armand Louis Marie Velpeau, 1795–1867, renowned French surgeon) of the transversalis fascia

constitutes a mobile layer between the pure muscle fascia and the (peritoneal) fascia. This layer (the peritoneal lamella) remains behind the rectus abdominis and forms the posterior lamella of the rectus sheath (▶Fig. 1.5). Medially, the interfoveolar ligament of Hesselbach (after Franz Kaspar Hesselbach, 1759–1816, prosector at the Juliusspital in Würzburg) provides an obvious boundary to the Velpeau lamina propria. Medial to this ligament, it is no longer possible to dissect any continuous fascia.

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Introduction

Transversalis Fascia in the Inguinal Region The transversalis fascia forms a posterior lining for the entire inguinal region.8,9,10,12,34,50,78,145,222 At the deep inguinal ring, it continues on the spermatic cord as the internal spermatic fascia. Certain transversalis fascia structures are distinguished in the inguinal region: •• The transversalis fascia loops at the deep inguinal ring (Henle loop, after Friedrich Gustav Jakob Henle, 1809–1885, professor of anatomy in Zürich, Heidelberg, and Göttingen). •• Internal spermatic fascia, the continuation on the spermatic cord. •• The vascular sheath of the inferior epigastric artery and vein. •• The area in the linea alba where it is interlaced with fibers from the contralateral side. •• The iliopubic tract (Thomson ligament, after Allen Thomson, 1809–1884, professor of anatomy in Aberdeen and Glasgow, and for a time professor of physiology in Edinburgh). The spermatic cord or round ligament of the uterus passes through the abdominal wall lateral to the interfoveolar (Hesselbach) ligament. These structures are enclosed by a U-shaped loop that opens superiorly (the transversalis loop; ▶Fig. 1.5, ▶Fig. 1.6). Curved fibers pass laterally and medially from this transversalis loop. Contraction of the transversalis loop is believed to close the deep inguinal ring. This contraction depends on the

functional status of the musculature. Paralysis or insufficiency, e.g., following trauma or surgery, opens the deep inguinal ring and fosters hernia development. The loop is continuous superiorly with an upper limb and inferiorly with a lower limb, which lies above the iliopubic tract. The iliopubic tract (Thomson ligament) only becomes visible from the front following division of the inguinal ligament. Its fibers run parallel to those of the inguinal ligament initially and then continue inferiorly into the femoral vascular sheath. The transversalis fascia extends upward from the inguinal region in four groups of fibers (columns): •• First column: The connective tissue fibers cross in the linea alba and attach to the pubic symphysis at the adminiculum lineae albae. Fibers branch off from the linea alba to form arches in the posterior layer of the rectus sheath, passing in convex curves from this column into the rectus sheath. It is clear from these fibers that the transversalis fascia, and not the transversus abdominis aponeurosis, is involved (▶Fig. 1.5). •• Second column: This is at the lateral border of the rectus abdominis. Curved fibers pass laterally and medially, thereby forming a mesh between adjacent vertical columns. •• Third column: This sometimes contains the epigastric vessels. Curved bundles of fibers also branch off from it, passing laterally and medially and forming a vaulted lattice.

Fig. 1.6  Anatomy of the inguinal and femoral regions from behind including potential hernial orifices, the vertical columns, and the Hesselbach triangle.   1 Henle loop at the spermatic cord and deep inguinal ring.   2  Interfoveolar (Hesselbach) ligament.   3  Inguinal (Poupart) ligament.   4  Inguinal falx and rectus border.   5  Linea alba and medial umbilical fold.   6  Iliopsoas muscle.   7  Femoral nerve.   8  Inferior epigastric vessels.   9  Lateral umbilical fold. 10  Transversus border, the “white line.” 11  The Hesselbach triangle.

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Fig. 1.7  a and b. a Anatomical location of a direct (= medial) inguinal hernia in the Hesselbach triangle. 1 Henle loop. 2 Vas deferens. 3 Interfoveolar ligament. 4 Inguinal ligament. 5 Transversus border. 6 Hesselbach triangle. 7 Inguinal falx and rectus margin. 8 Iliopsoas muscle. 9 Femoral nerve. b Diagram of the Hesselbach triangle. 1 Linea alba. 2 Lateral rectus margin, inguinal falx. 3 Epigastric vessels. 4 Interfoveolar ligament. 5 Henle loop. 6 The Hesselbach triangle. 7 Inguinal ligament. 8 Vas deferens. 9 Transversus muscle border.

•• Fourth column: This contains the Henle (transversalis) loop at the deep inguinal ring. The second and third columns are the boundaries of the Hesselbach triangle (▶Fig. 1.6, ▶Fig. 1.7, and section ▶1.1.3.1).

Peritoneum The peritoneum is a serous membrane. Its parietal layer lines the entire abdominal and pelvic cavity, while the visceral layer is reflected over the surface of the intraperitoneal organs. The peritoneum consists of three layers: •• Mesothelium: This consists of a single layer of transformed connective tissue cells that behave like epithelium (with desmosomes, basal membrane, and microvilli). The mesothelium has fibrinolytic properties240 that can prevent the formation of

peritoneal adhesions. Traumatized mesothelial cells lose their fibrinolytic activity; so, the feared postoperative adhesions cannot be effectively prevented. •• Lamina propria (or serosa): It contains collagenous and reticular connective tissue, along with numerous blood vessels, lymphatic capillaries, mechanoreceptors, and free nerve endings. •• Subserosa (preperitoneal connective tissue or preperitoneal fat tissue; see ▶Fig. 1.3): Subserosa contains many elastic fibers, can contain variable quantities of fat, and varies greatly in its orientation, firmness, and fiber content. The subserosa is separated from the firm or loose connective tissue of the abdominal wall fascia or retroperitoneal tissue by the transversalis fascia. The subserous layer confers mobility on the peritoneum.

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Introduction The peritoneal relations in the inguinal canal region are of practical importance. In the seventh month of pregnancy, the testis and epididymis pass through the inguinal canal, which is a wide tunnel during development. This descent is guided by the processus vaginalis, an outpouching of the peritoneum. When descent is complete, the proximal part is obliterated while the distal part persists to form the tunica vaginalis of the testis, consisting of the following: •• Parietal layer (periorchium). •• Visceral layer (epiorchium): covers all parts of the testis apart from the posterior surface and is inseparable from the tunica albuginea. Between these two layers is the serous cavity of the scrotum, which surrounds the front and sides of the testis and contains small amounts of fluid. The connection between the scrotal and the peritoneal cavities is generally lost; so, the abdominal cavity is closed at the entrance to the inguinal canal. Persistence of the processus vaginalis can be manifested variously as: •• Congenital inguinal hernia: The hernia contents slide into the patent persistent processus vaginalis and are separated from the testis only by the visceral layer (epiorchium). •• Hydrocele of the spermatic cord: Part of the processus vaginalis persists within the spermatic cord. The secretory activity of the persistent mesothelium then results in a fluid-filled cyst. The small physiological thimble-shaped outpouching of peritoneum into the female inguinal canal is called the canal or diverticulum of Nuck (after Anton Nuck, 1650–1692, professor of anatomy in Leiden), while the equivalent outpouching in the male fetus, which represents the start of processus vaginalis development, is called the Seiler pouch (after Burkhard Wilhelm Seiler, 1779–1843, professor of anatomy and surgery in Wittenberg).

Inguinal Ligament Background

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The nomenclature used here is guided by the precise studies of this region by Eisler62 and it was also used by Braus and Elze.30 It differs from the Terminologia Anatomica. Unfortunately, the nomenclature of many anatomical and surgical descriptions now varies greatly and is sometimes incorrect due to misunderstandings and redefinitions. So clear communication between researchers of this region encounters considerable difficulties, making further misunderstanding inevitable. To provide clarity at this point, ▶Table 1.1 contains a synopsis of the terms used.

Hardly any anatomical structure has been treated as variously and contradictorily in the literature as the inguinal (Poupart) ligament (see ▶Fig. 1.11). Strictly speaking, this connective tissue structure is not a ligament, but a complex entity consisting of different components. The ligament is the inferior border of the external oblique aponeurosis and is in the same plane. It has an oblique course that varies between 35 and 40° to the horizontal axis of the abdomen. It is 12 to 14 cm long. Two distinct sections can be identified: •• Lateral one-third: This is formed by particularly dense parts of the iliopsoas fascia such that this part of the ligament is generally inseparable from the iliopsoas fascia. The fibers do not run directly medially but run more vertically and obliquely down to the iliopectineal fascia. In addition, the lateral one-third contains aponeurotic fibers from the internal oblique and transversus abdominis. •• Medial two-thirds: This is formed by the lower border of the external oblique aponeurosis, which is folded backward. The bone fixation points are lateral to the anterior superior iliac spine (ASIS) and medial to the pubic tubercle. Spatial understanding of the “folded border” is essential, as this arises from the architecture of the lateral crus of the superficial inguinal ring: the superior fibers of the lateral crus are attached anteriorly to the pubic tubercle while the inferior fibers are shifted posteriorly. Since these fibers do not end on bone but pass briefly on and in the periosteum before separating from this, a groove open superiorly is formed. The fibers that pass cranially from the bone form the lacunar (Gimbernat) ligament (after Antonio Don de Gimbernat, 1734–1816, professor of anatomy in Barcelona and later professor of surgery in Madrid) or reflected (Colles) ligament. The inguinal ligament is reinforced and stabilized by anterior and posterior groups of fibers: •• Anteriorly by the Scarpa fascia and its inferior continuation, the fascia lata. •• Posteriorly by the iliopubic tract (a reinforcement of the transversalis fascia, see section The Transversalis Fascia (page 10)), which extends from the ASIS to the pubic bone. The fibers of the external oblique aponeurosis do not run strictly parallel to the inguinal ligament. The angle between them is often 10 to 20°. Every oblique fiber that enters the ligament passes medially and runs longitudinally within the ligament. Close to the ASIS, the aponeurotic fibers continue directly into the fascia lata. In the rest of the ligament, the fibers pass medially to the pubic tubercle. Reinforced fibers from the iliopsoas fascia on the medial surface of the iliopsoas muscle leave the lateral one-third of the inguinal ligament and pass in a laterally concave curve to the iliopubic eminence. This band of fascia is called the iliopectineal arch; it separates the muscular from the vascular lacuna.

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1.1  Anatomy of the Anterior Abdominal Wall Table 1.1  Nomenclature of the ligaments in the inguinal ligament region Structure

Eisler nomenclature62

Terminologia Anatomica221

Ipsilateral fibers diverging cranially from the inguinal ligament

Lacunar ligament (Gimbernat ligament)

Reflected ligament (Colles ligament)

Fibers of the contralateral external oblique aponeurosis

Reflected ligament (Colles ligament)

No name assigned

Fibers diverging caudally from the inguinal ligament and forming the medial boundary of the vascular compartment

Falciform lacunar process

Lacunar ligament (Gimbernat ligament)

The formation of the superficial inguinal ring is closely linked to the anatomy of the inguinal ligament. The fibers of the external oblique aponeurosis coming from the Gaupp muscle corner form two bands that diverge from one another inferomedially (see ▶Fig. 1.3). The inferior band is called the lateral crus and the superior band is the medial crus. The fibers of the lateral crus were described above; those of the medial crus terminate at the pubic tubercle. It is important to note that the bony insertion of the lacunar ligament includes fibers from the contralateral external oblique, some of which enter the lacunar ligament, forming a groove in which the spermatic cord is embedded. The contralateral fibers are known as the reflected (Colles) ligament. In many nomenclatures, including the Terminologia Anatomica, no distinction is made between the ipsilateral and contralateral groups of fibers and the entire band of fibers is called the reflected ligament. Since this is a reduction of the anatomical situation as confirmed by dissection, the Eisler nomenclature will be followed at this point. From the inferomedial end of the inguinal ligament, fibers pass caudally, forming a small connective tissue plate with a laterally concave border. Because of its half-moon shape, this structure is very accurately termed the falciform process of the lacunar ligament; it continues on the upper surface of the superior ramus of the pubis. The lacunar falciform process rounds the medial border of the vascular lacuna (or femoral ring). The lacunar falciform process is part of the inguinal ligament and therefore part of the external oblique aponeurosis. It is attached to the iliopectineal line. According to some authors,145 the lacunar falciform process (or lacunar ligament) does not form the medial border of the femoral ring. In this interpretation, the anterior border of the femoral ring is formed by the anterior layer of the fascia lata and not by the inguinal ligament.

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and inserts widely on the inguinal ligament at its base. This insertion continues over the pectineal (Cooper) ligament onto the surface of the superior ramus of the pubis. According to Eisler’s studies, the term “ligament of Henle” introduced by K. M. Douglas59 designates an aberrant, tendinous strip of the transversus muscle that is inserted on the pecten pubis. The term should therefore not be used when referring to the inguinal falx.

Interfoveolar Ligament (of Hesselbach) The interfoveolar (Hesselbach) ligament is a fibrous sheet that branches off the posterior surface of the transversus abdominis aponeurosis in the arcuate region, passes caudally and inserts in the inguinal ligament at the pecten pubis and on the lacunar ligament. The interfoveolar ligament separates the laterally situated deep inguinal ring from the medial inguinal fossa. The inferior epigastric vessels lie on the posterior surface. When well developed, fibers of the interfoveolar ligament can continue into the posterior rectus sheath. The development of the interfoveolar ligament is linked with that of the inguinal falx and the iliopubic tract. When these two structures are very strongly established, they replace the interfoveolar ligament and vice versa. Both the inguinal falx and the interfoveolar ligament can be regarded as the pelvic insertion of the transversus abdominis. So it is not surprising that variable amounts of striated muscle fibers can be present within these structures. If muscle is visible macroscopically in the interfoveolar ligament, it is also referred to as the interfoveolar (Hesselbach) muscle.

1.1.3  Anatomical Regions and Hernial Orifices

Inguinal Falx (Conjoint Tendon)

Inguinal Canal with Superficial and Deep Inguinal Rings

Removal of the transversalis fascia reveals two highly variable structures, which are treated very differently and superficially in the literature. These are the inguinal falx and the interfoveolar (Hesselbach) ligament, which are discussed below. The inguinal falx is part of the transversus abdominis aponeurosis and lies on the posterior surface of the aponeurosis, which is thereby strengthened. The inguinal falx is a triangular gusset of connective tissue with a sickle-shaped lateral border, which fuses medially with the lateral border of the rectus sheath

The topographical connections between the structures described systematically and separately above will be discussed below. The inguinal canal, located above the inguinal ligament, is an artificial product of dissection created by removal of the spermatic cord or the round ligament of the uterus. It is a typical site of lower resistance in the abdominal wall. The inguinal canal is 4 to 5 cm long (somewhat longer in women than in men) and crosses the abdominal wall obliquely from behind and above in front and below, at an

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Introduction angle of about 15° to the inguinal ligament. The “canal” starts inside at the deep inguinal ring and opens at the superficial inguinal ring (see ▶Fig. 1.3, ▶Fig. 1.6, ▶Fig. 1.8, ▶Fig. 1.13). Four walls are described in the inguinal canal: •• The broad, thick anterior wall is formed by the external oblique aponeurosis with the lateral crus and medial crus. •• The broad but thin posterior wall is provided exclusively by the transversalis fascia. The variable inguinal falx and interfoveolar ligament may be involved in strengthening the posterior wall. •• The narrow superior wall is formed by the lowest fibers of the internal oblique and transversus abdominis, often replaced by connective tissue. •• The narrow inferior wall is formed by the curved border of the external oblique aponeurosis, the lacunar ligament, and the reflected ligament in the form of a connective tissue groove. The inner opening of the inguinal canal is about 1 cm above the middle of the inguinal ligament in the lateral inguinal fossa, which is lateral to the epigastric fold. As a result, the inferior epigastric vessels and the interfoveolar ligament form the medial boundary of the deep inguinal ring. The oval slit of the deep inguinal ring only becomes visible after removal of the peritoneum and division of the Nuhn fascial funnel of the transversalis fascia, which continues on the spermatic cord as the internal spermatic fascia. The superficial inguinal ring lies ca. 1 to 1.5 cm above the pubic tubercle and is bounded by the medial (or superior) crus and the lateral (or inferior) crus, but not by the intercrural fibers. The superficial abdominal fascia is attached

to the fascial margins of the superficial inguinal ring and continues in a funnel shape on the spermatic cord as the external spermatic fascia. The superficial inguinal ring only becomes visible after sharp dissection of this fascia. The spermatic cord passes through the inguinal canal in men and the round ligament of the uterus in women. The complicated layers of the spermatic cord arise because all layers of the abdominal wall are borne along with passage of the peritoneal processus vaginalis and testis, like fingers of a glove. ▶Table 1.2 lists the layers of the abdominal wall against their derivatives in the spermatic cord. The nerves that pass through the inguinal canal are also important surgically: These include the ilioinguinal nerve and genital branch of the genitofemoral nerve (or external spermatic nerve). The ilioinguinal nerve enters the inguinal canal through the deep inguinal ring, often runs below the spermatic cord and leaves the inguinal canal in the medial angle of the superficial inguinal ring or through a separate opening in the medial crus. It then crosses the spermatic cord or round ligament in lateral direction and divides into its scrotal or labial branches. Less often, the ilioinguinal nerve passes through the lateral angle of the superficial inguinal ring, and in some cases, it does not pass through the superficial inguinal ring at all but exits cranial to this. The course of the nerve is outside the coverings of the testis. The ilioinguinal nerve provides the sensory innervation of the skin at the root of the penis and scrotum or of the labia majora and adjacent parts of the inner thigh. The mixed genital branch of the genitofemoral nerve lies on the spermatic cord or round ligament and provides motor Fig. 1.8  Anatomical location of the indirect (lateral) inguinal hernia orifice (at the deep inguinal ring). 1 Inguinal ligament. 2 Iliopsoas muscle. 3 Inferior epigastric artery and vein. 4 Lacunar falciform process. 5 Femoral nerve. 6 Transversus border, the “white line.”

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1.1  Anatomy of the Anterior Abdominal Wall Table 1.2  Layers of the spermatic cord (from within outward) Layers of the abdominal wall

Layers of the spermatic cord

Peritoneum

Tunica vaginalis testis and vaginal ligament

Extraperitoneal fat Transversalis fascia

Internal spermatic fascia (tunica vaginalis communis)

Transversus abdominis Internal oblique

Cremaster

Internal oblique fascia

Middle spermatic fascia

External oblique fascia

External spermatic fascia (Cooper cremasteric fascia)

Camper fascia

Dartos tunic

Abdominal skin

Scrotal skin

innervation to the cremaster muscle and sensory innervation to the skin of the scrotum or labia majora. In addition, it supplies the skin on the upper medial side of the thigh next to the scrotum. It regularly emerges through the superficial inguinal ring on the medial side of the spermatic cord.

Anterior Abdominal Wall Relief The topography of the inner surface of the anterior abdominal wall is important for understanding direct hernias, in particular. The relief of the inside of the abdominal wall is dominated by three cord-like structures (see ▶Fig. 1.6): •• Medial umbilical fold: It passes from the dome of the bladder to the umbilicus in the midline. It contains the obliterated urachus. •• Lateral umbilical fold: This is more lateral and contains the obliterated umbilical artery. •• Epigastric fold: This is even further laterally and contains the inferior epigastric vessels. The nomenclature of these structures is not uniform and is summarized in ▶Table 1.3. Since “lateral umbilical fold,” the Terminologia Anatomica221 term for the fold raised by the epigastric vessels has nothing to do with the umbilicus, Thiel’s example224 is followed and the old term “epigastric fold” is retained, as this has the advantage of indicating the reason for its existence. There are three more or less obvious depressions between the folds: •• Supravesical fossa between the middle umbilical fold and the lateral umbilical fold above the dome of the bladder. •• Medial inguinal fossa between the lateral umbilical fold and the epigastric fold. •• Lateral inguinal fossa lateral to the epigastric fold. This has already been mentioned as the location of the deep inguinal ring. Since indirect hernias enter the inguinal canal, it is clear that these hernias are lateral to the inferior epigastric vessels. The medial inguinal fossa merits closer attention as it is the weakest part of the anterior abdominal wall. This weakness arises on the one hand because this site is muscle free but also because the external oblique aponeurosis outside it diverges in the form of the medial and lateral crus to form the superficial inguinal ring.

1

Table 1.3  Summary of umbilical fold nomenclature Terminologia Anatomica 1998221

Older nomenclature

Median umbilical fold

Middle umbilical fold (unpaired)

Medial umbilical fold

Lateral umbilical fold (paired)

Lateral umbilical fold

Epigastric fold (paired)

This weak area above the inguinal ligament becomes a round to oval region with the addition of the weak vascular lacuna below the ligament, known in the literature as the myopectineal orifice of Fruchaud. Strengthening of this important site of lower resistance can be achieved by the inguinal falx or interfoveolar ligament. The medial inguinal fossa is the internal orifice of direct hernias that appear externally at the superficial inguinal ring and are medial to the inferior epigastric vessels. The Hesselbach triangle (Hesselbach or inguinal trigone, after Franz Kaspar Hesselbach, 1759–1816, anatomist and surgeon in Würzburg), which is a key structure in understanding inguinal hernias and their surgical repair (▶Fig. 1.6, ▶Fig. 1.7), is within the medial inguinal fossa. The Hesselbach triangle is bounded: •• Superiorly by the lower border of the transversus, which is often tendinous and thickened, forming the arch of the transversus aponeurosis, the surgeon’s “white line”.202 •• Medially by the lateral border of the rectus abdominis (second vertical pillar). •• Laterally by the vascular sheath of the inferior epigastric artery and vein (third vertical pillar). •• Inferiorly by the inguinal ligament (▶Fig. 1.7). The apex of the triangle faces medially. The triangle is more obvious in men than in women, who have hardly any triangle on account of their shallow pelvis. This explains why direct inguinal hernias occur rarely in women. Indirect hernias pass through the abdominal wall lateral to the epigastric vessels. Direct hernias pass through it medially in the center of the Hesselbach triangle. The aim of surgical repair is reconstruction of the lost fascial reinforcement of the posterior abdominal wall (▶Fig. 1.8).

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Introduction

Muscular Lacuna Unlike the inguinal canal, which lies above the inguinal ligament, the two orifices described below, the muscular and vascular lacunae, are present below the inguinal ligament. The triangular space below the inguinal ligament but above the superior ramus of the pubis is divided into two segments by the iliopectineal arch (or ligament), which branches off the inguinal ligament and is inserted on the iliopubic ramus. The lateral segment is called the muscular lacuna and the medial is the vascular lacuna. The iliopectineal arch is a strip of the iliopsoas fascia, which must be demonstrated artificially; it may be reinforced by tendinous fibers of the inconstant psoas minor. The iliopsoas muscle passes through the muscular lacuna to the thigh together with the femoral nerve, which lies on the medial border of the iliopsoas. The lateral cutaneous femoral nerve is in the upper lateral corner of the muscular lacuna. Since the iliopsoas fascia is firmly adherent to the inguinal ligament or is a separate component of the ligament, this means that the abdominal cavity is closed extremely strongly from the thigh at the muscular lacuna. Therefore, this orifice is rarely a site of hernia (e.g., the rare lateral Hesselbach femoral hernia, ▶Fig. 1.9).

Vascular Lacuna and Femoral Ring The osteofibrous canal located medial to the iliopectineal arch below the inguinal ligament is called the femoral vascular lacuna (see ▶Fig. 1.6, ▶Fig. 1.13). The vascular lacuna is bounded superiorly and anteriorly by the inguinal ligament, inferoposteriorly by the pubic bone, and laterally by the iliopectineal arch. In the medial sharp angle between the insertion of the inguinal ligament on the pubic tubercle and the superior ramus of the pubis, the space is rounded off by the firm connective tissue lacunar falciform process. This structure is often termed the lacunar ligament of Gimbernat (▶Fig. 1.10) but, as explained above, this should be reserved for a completely different structure. The lacunar falciform process has a laterally concave border and is associated both with the fascia of the pectineus muscle and the pectineal ligament (Cooper liga­ment). This ligament, described by Sir Astley Paston Cooper in 1804,48 is an extremely firm band of fibers on the cranial surface of the superior ramus of the pubic bone, which runs parallel to the pecten pubis and is undermined anteriorly by the pectineus muscle. The true nature of this fibrous band remains uncertain, which has led to numerous interpretations. The following important opinions may be mentioned: •• It is the lateral continuation of the lacunar falciform process (or lacunar ligament of Gimbernat).97 •• It is a three-layered structure, with the superficial layer consisting of pectineal fascia, the middle layer of the pectineus, and the deep layer consisting of thickened periosteum.157 •• It is a fusion of the periosteum with the transversalis fascia and the iliopubic tract.164

The author is convinced that the three layers of the pectineal ligament can be dissected without difficulty; so, this view should be preferred. Even though an understanding of the development of the pectineal ligament is currently lacking, it is nevertheless important to be aware of its topographical relations. According to Skandalakis, the following relations are important: •• The iliopubic tract inserts superiorly on the pectineal ligament. •• The tendon of pectineus arises inferiorly from the pectineal ligament. •• Medially, the pectineal ligament meets the lacunar falciform process. The external iliac artery and vein emerge from the abdominal cavity into the vascular lacuna, where these become the femoral artery and vein, respectively. In the lacuna, the femoral vein is always medial and the femoral artery lateral. A gap remains between the falciform process and the femoral vein, which is closed by the soft and flexible femoral septum (of Cloquet, after Jules Germain Cloquet, 1790–1883, professor of anatomy and surgery in Paris). This septum is attached both to the free border of the falciform process and to the femoral vein. The resistance of the femoral septum is considerably weakened as it is perforated like a sieve to allow passage of lymphatics. Because of these numerous lymphatics, the passage between the falciform process and femoral vein is also called the lymphatic lacuna. A large lymph node is regularly found on the outside of the femoral septum, known as Rosenmüller lymph node (after Johann Christian Rosenmüller, 1771–1820, professor of anatomy and surgery in Leipzig) or Cloquet lymph node. In many cases, this lymph node also extends through the femoral septum; so, the node is both external and internal. Since the lymphatic lacuna is the weak site where femoral hernias emerge, it has become known in surgery as the femoral ring. The femoral ring is the internal femoral hernial orifice, while the external orifice is at the saphenous opening. Under normal anatomical conditions, a connecting “femoral canal” does not exist but only expands when a femoral hernia passes through it.

The Inguinofemoral Region Although this region overlaps with the areas below the inguinal ligament described above, it is discussed separately as the surgically important junction with the lower extremity is located here.11,45,50,78,125,145,208,222 In applied anatomy, the region below the inguinal ligament is significant in two situations: •• Femoral hernia. •• Recurrent inguinal and femoral hernia (▶Fig. 1.11). The region has the following boundaries (▶Fig. 1.12): •• The inguinal ligament superiorly. •• The pectineus muscle medially. •• Tensor fasciae latae laterally.

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1.1  Anatomy of the Anterior Abdominal Wall

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Fig. 1.9  Anatomy of the lower abdominal wall in the plane of the transversus abdominis showing the Hesselbach triangle. 1 Spermatic cord with cremaster muscle. 2 Rectus sheath, external oblique aponeurosis. 3 Rectus sheath, internal oblique aponeurosis. 4 Transversus border forming the upper boundary of the Hesselbach triangle. 5 Hesselbach triangle with transversalis fascia. 6 Rectus sheath, posterior layer of the internal oblique aponeurosis. 7 Linea semilunaris (Spieghel).

The femoral trigone (Scarpa triangle), a possible access route, is present in this region. It is limited: •• By the inguinal ligament superiorly. •• By adductor longus medially. •• By sartorius laterally. The main superficial structures are the fibers of the fascia lata and the fossa ovalis with the saphenofemoral junction.

Caution



Varicosities of the great saphenous vein can be mistaken for a femoral hernia or can make surgery of a femoral hernia difficult. The fossa ovalis contains the saphenofemoral junction, which is formed by the following superficial veins (▶Fig. 1.12):

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Introduction

Fig. 1.10  Anatomy of the lower abdominal wall in the internal oblique plane. 1 Lacunar ligament. 2 Spermatic cord. 3 Cremaster muscle. 4 Inguinal ligament. 5 External oblique aponeurosis.

•• Great saphenous vein with the saphenofemoral junction. •• External pudendal veins. •• Superficial epigastric vein. •• Superficial circumflex iliac vein. These veins are very variable and can drain either into the great saphenous vein or else directly into the femoral vein. A series of arteries, of variable caliber, arise in this region from the external iliac artery and its continuation, the femoral artery: •• The inferior epigastric artery arises from the external iliac artery just before it enters the vascular lacuna.

•• The superficial epigastric artery arises from the femoral artery and passes superiorly in front of the inguinal ligament into the abdominal subcutaneous tissue. •• The deep circumflex iliac artery arises from the external iliac artery and runs upward parallel to the lateral part of the inguinal ligament. The vessel lies between the internal oblique and the transversus abdominis. •• The superficial circumflex iliac artery runs in lateral direction about 2 cm below and parallel to the inguinal ligament; its clinical significance is that it supplies the inguinal flap.

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1.1  Anatomy of the Anterior Abdominal Wall Fig. 1.11  Anatomic layers of the inguinofemoral region from front. 1 Epigastric vessels. 2 Inguinal ligament. 3 Transversus abdominis. 4 Internal oblique. 5 External oblique. 6 Transversus border, the “white line.” 7 Transversalis fascia.

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Fig. 1.12  Anatomy of the fossa ovalis. 1 Femoral vein, artery, and nerve (from medial). 2 Great saphenous vein. 3 External pudendal vein. 4 Superficial epigastric artery and vein. 5 Superficial circumflex iliac vein. 6 Iliopsoas muscle. 7 Pectineus. 8 Falciform margin with superior and inferior horns.

•• The external pudendal arteries (usually two) pass medially to the scrotum and spermatic cord or to the labia. In addition, there are two groups of lymphatics and lymph nodes in this region: •• The superficial lymph nodes are present beside the great saphenous vein.

•• The deep lymph nodes are present beside the femoral vein so they are below the fascia lata. The Rosenmüller (or Cloquet) lymph node is a particularly large one located medial to the femoral vein on the femoral septum. It can also extend inward through the septum in an hourglass shape.

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Introduction The superficial layer of the vascular compartment is formed by the lamina cribrosa, a thin layer of fascia that covers the fossa ovalis. Division of the deeper layer of the fascia lata exposes the vessels and nerves of the inguinofemoral region. The femoral vessels and nerve and the iliopsoas muscle pass through the vascular or muscular lacuna below the inguinal ligament. The vascular lacuna is separated from the muscle lacuna by a thickened band of fascia, known as the iliopectineal arch. The femoral sheath starts here (▶Fig. 1.12). The anterior femoral sheath is the inferior continuation of the transversalis fascia onto the thigh; the iliac part

of the iliopsoas fascia and the pectineal fascia constitute the posterior wall of the sheath. The femoral sheath ends inferiorly at the origin of the deep femoral artery and merges with the adventitia of the vessels. Septa within the sheath divide it into an arterial and a venous compartment. When a femoral hernia is present, it enters the vascular lacuna medial to the femoral vein and artery through the femoral ring (▶Fig. 1.13). The following topographical relations are important at the femoral ring: •• The anterior border is formed by the superficial part of the femoral sheath (derived from the transversalis fascia). Fig. 1.13  Oblique anatomical crosssection through the inguinofemoral region.   1  Iliopsoas muscle.   2  Spermatic cord.   3  Henle loop.   4  Epigastric vessels.   5  Femoral artery and vein.   6  Pubic ramus.   7  Pectineal ligament.   8  Inguinal ligament.   9  Falciform process. 10  Pectineus muscle.

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1.1  Anatomy of the Anterior Abdominal Wall •• The posterior wall of the ring is bounded by pectineus with its fascia, the Cooper ligament, and the superior ramus of the pubic bone. •• The femoral vein and its adventitia form the lateral margin of the ring. •• The medial margin of the femoral ring consists of the border of the transversus abdominis insertion on the Cooper ligament. •• The inguinal ligament is more superficial than the transversalis fascia boundary of the femoral ring. •• The preperitoneal connective tissue (transversalis fascia) is attached to the adventitia of the femoral vein and constitutes the femoral septum, which lies in front of the femoral canal. •• The pectineal (Cooper) ligament on the superior ramus of the pubic bone consists of dense connective tissue fibers, the direction of which roughly follows that of the bone.

1.1.4  Laparoscopic Anatomy The following four readily visible vertical lines provide orientation for laparoscopic hernia exploration: •• The linea alba. •• The lateral border of rectus abdominis crossed by the lateral umbilical fold. •• The vascular sheath of the epigastric vessels. •• The transversalis loop at the deep inguinal ring (▶Fig. 1.7, ▶Fig. 1.14).

The lateral umbilical fold and the epigastric fold can be seen directly. The testicular vessels and vas deferens are often less visible behind the intact peritoneum. The genitofemoral nerve and the testicular vessels lie beneath the parietal peritoneum. The genital branch of the genitofemoral nerve and the vas deferens enter the spermatic cord in the vicinity of the deep inguinal ring. The pubic branch, a communication between the epigastric vessels and the obturator vessels, is found on the medial part of the pectineal ligament. It crosses the periosteum on the inside of the superior pubic ramus, where it is at extreme risk of injury (the “corona mortis”). In 22% of cases, the obturator artery arises from the inferior epigastric artery129 and passes into the obturator canal over the back of the superior pubic ramus. The lateral cutaneous femoral nerve with one or two sensory branches and the femoral branch of the genitofemoral nerve are located in the fat between the iliopsoas muscle and the parietal peritoneum. The ilioinguinal nerve enters the abdominal muscle lateral to this and the femoral nerve is medial to it, lying between iliacus and psoas major and protected only by the iliopsoas fascia. The nerve thus lies deep in the center of the operation region (▶Fig. 1.14). In general, when sutures or staples are used to fix mesh laparoscopically, vessels and nerves are safe only when the fixation is above the iliopubic tract. Lateral branches of the lateral cutaneous femoral nerve are an exception, as they can also run above the iliopubic tract. Below the iliopubic tract, the iliopectineal ligament

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Fig. 1.14  Laparoscopic anatomy of the inguinofemoral region showing the safe areas (cross-hatched) for sutured or stapled mesh fixation.

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Introduction is the only suitable fixation site provided there are no vascular connections to the obturator vessels and small side branches. Blind fixation without prior dissection must be avoided.

1.2  Definition and Terminology Volker Schumpelick

1.2.1 Hernia Definition

[ ]

The term hernia is derived from the Greek word έ̔ ρνος meaning a young shoot. It denotes the protrusion of the parietal peritoneum through a preformed or secondary gap. An external hernia passes through the abdominal wall to become visible on the surface of the body, while an internal hernia results from protrusion into a peritoneal pocket. Interparietal hernias of the abdominal wall occupy an intermediate position. Intra- and retroperitoneal organs can be displaced constantly or intermittently with the hernia. Complete and incomplete (partial or Richter) hernias are distinguished, depending on the content of the sac (▶Fig. 1.15).10,44,119,121,162,236,245 Complete hernias are distinguished from sliding hernias depending on the completeness of the peritoneal covering. Sliding hernias contain retroperitoneal viscera (e.g., ascending or descending colon, bladder, cecum) and therefore the hernial sac is not completely covered by peritoneum. Thus, parts of retroperitoneal organs (e.g., bladder, cecum) sometimes form the wall of the hernial sac. These are easily injured if the actual anatomy is not recognized.205 As regards the time of origin, congenital hernias (e.g., umbilical hernia, indirect inguinal hernia due to patent processus vaginalis) are distinguished from acquired forms (e.g., direct inguinal hernia, femoral hernia).158 A further differentiation is between primary (pre-existing orifices) and secondary (orifices developing later).

1.2.2  Structure of a Hernia The most important components of a hernia surgically are:77,121 •• The hernial orifice. •• The hernial sac. •• The hernial contents. •• The hernial coverings. ▶ Hernial orifice. This is formed by the layers of the abdominal wall, i.e., muscle, tendon, aponeurosis, and

scar tissue. In the pelvis, periosteum and bone can also be involved in the formation of hernial orifice (e.g., obturator hernia). The name of the hernia comes from the location of its orifice (e.g., inguinal, femoral, lumbar, or incisional hernia). ▶ Hernial sac. This is a pouch of varying size that contains the hernia. It is divided topographically into the neck, body, and fundus and is usually lined with reflected peritoneum. With inflammation or necrosis, the sac can adhere to the hernia contents so the contents are fixed within the sac. ▶ Hernial contents. This can comprise any of the abdominal contents, though the omentum and small bowel are most often involved. A giant hernia can contain large amounts of abdominal contents such that its reduction can be difficult due to lack of space within the abdomen. The hernial contents are normally bathed in a transudate and therefore can slide freely, but this can be lost during inflammation, incarceration, or necrosis when blood, bowel content, or pus can lead to adhesions or abscesses. ▶ Hernial coverings. These are the layers of tissue surrounding the hernial sac. Depending on hernia size, duration, and location, they can consist of either two layers (e.g., umbilical hernia, incisional hernia) or multiple layers (e.g., inguinal hernia). The number of layers is determined by the anatomical relations and the mechanism of development. For instance, an inguinal hernia has a five-layered structure consisting of peritoneum, preperitoneal fat, transversalis or cremasteric fascia, superficial abdominal fascia, and subcutaneous tissue and epidermis (see section ▶1.1).

1.2.3  Hernia Disease The pathological significance of a hernia depends on how it affects the patient physically and psychologically after it is diagnosed. This ranges from subjective awareness of the hernia with consequent life-long avoidance of exertion on account of a “weak groin” to concealment of sometimes gigantic scrotal hernias. Objectively, hernias can have a direct effect, for instance, due to disability and ulceration with giant hernias, impairment of joint mobility, recurrent omental incarceration in small hernias, and for cosmetic reasons. Hernia disease is more often caused by changes in the hernial contents. These may include: •• Interference with the blood supply of the bowel and omentum (incarceration, strangulation). •• Interference with intestinal passage (complete or incomplete obstruction). •• Complications of these disturbances. Hernias are classified as reducible, irreducible, and incarcerated. ▶ Reducible hernia. A hernia in which the contents are freely mobile in the hernial sac and ring is termed

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1.2  Definition and Terminology

1

D

E

F Fig. 1.15  Forms of hernia. a Complete hernia. b Sliding hernia. c Incomplete (partial or Richter) hernia, sometimes incorrectly called a Littré hernia.

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Introduction reducible hernia. The hernia contents can return to the abdomen spontaneously or by manual reduction (taxis). ▶ Irreducible hernia. A hernia is irreducible when the contents are fixed in the hernial sac and ring. Hernias are irreducible when incarcerated (see below), when there are adhesions between the sac and its contents, or when the hernia is so large that the contents no longer fit back in the abdomen. A non-incarcerated irreducible hernia is usually present for many years, causes little or no pain, and generally has not been reduced for a long time. ▶ Incarcerated hernia. Incarceration is associated with severe local pain and intestinal obstruction when loops of small bowel are involved (see following section). Attempts at reduction are extremely painful and are rarely successful without analgesia and muscle relaxation.19,48 Hernias may complicate another abdominal disorder, whether causally or not.144 The hernia symptoms may predominate over those of the other disorders, which can therefore be easily overlooked. Associated conditions can include appendicitis, cholecystitis, perforated ulcer, internal hernias, bowel obstruction due to adhesions, small bowel volvulus, extrauterine pregnancy, etc.144 This should be distinguished from symptomatic hernia caused, for example, by peritoneal carcinomatosis, colon cancer, and ascites. In these cases, the hernia is a symptom of disease causing an increase in intra-abdominal pressure.144

1.2.4 Incarceration Incarceration is the most dangerous complication of a hernia. Congestion or strangulation at the hernial ring interferes with the blood supply of the hernial contents. This can involve the omentum and bowel equally. As a result, edema develops with an increase in the incarceration and vascular congestion. Simple incarceration progresses to strangulation due to obstruction of the blood vessels. Without prompt reduction, this vicious circle leads to necrosis of the incarcerated organ(s). The most dangerous condition is intestinal necrosis with subsequent peritonitis, which, if left untreated, has a mortality of 70%. Reduction of an incarcerated hernia is always indicated. This can be conservative in many cases but surgery is essential if this is unsuccessful. A basic rule is that the sun should not rise or set on an incarcerated hernia.239 ▶ Forms of incarceration. Incarceration can be categorized as direct prograde incarceration, partial incarceration (Richter hernia, incorrectly called a Littré hernia, ▶Fig. 1.15c), coprostasis, and retrograde incarceration (▶Fig. 1.16). Partial and retrograde incarcerations are dangerous, because these often do not get recognized. With retrograde incarceration, the strangulated or underperfused loop of small bowel is within the abdomen and evades diagnosis. Similarly, the relatively small swelling associated with an incomplete Richter hernia leads to only mild local symptoms while bowel motility

is preserved. It is only perforation with peritonitis that points to the correct diagnosis. Manual reduction aims to return the bowel to the abdomen without trauma. Complete resolution of the incarceration sparing the hernial contents is necessary. Reduction en bloc (▶Fig. 1.17) tearing the hernial ring must be avoided as the incarceration persists within the abdomen. Pseudoreduction, i.e., movement of the incarceration to beneath the abdominal wall, incomplete reduction, for example of a retrograde incarceration, and reduction of necrotic bowel are real dangers. In addition, every manual reduction using excessive force harbors the risk of rupturing the previously damaged bowel.

1.2.5  Hernia Location The groin is the most frequent site of hernias in adults and children. A distinction is made between indirect  (lateral) and direct (medial) inguinal hernias10,48,158 depending on whether these are located lateral or medial to the epigastric vessels (▶Fig. 1.18). A scrotal hernia is present if the hernial sac extends into the scrotum. This usually originates from an indirect inguinal hernia and only very rarely from a large direct inguinal or femoral hernia. The interparietal hernia, which passes into different layers of the abdominal wall, is a special form. Femoral hernias are located below the inguinal ligament, usually medial to the femoral vein in the vascular lacuna (▶Fig. 1.19).77,92,133,162 Rarer sites of femoral hernia (▶Fig. 1.20) are prevascular, i.e., in front of the vessels, lateral to the vessels, and iliopectineal ligament; lacunar ligament hernia with its orifice in the lacunar ligament; pectineal hernia with its orifice in the pectineal fascia; and finally, the retrovascular hernia extending behind the vessels (see section ▶3.6). Hernias of the bladder region, which are classified as internal and external supravesical hernias, are located in close proximity to inguinal hernias. Internal supravesical hernias, which have a tendency to extend retropubically in the space of Retzius, are particularly dangerous as they are often missed. The Richter hernia, that is, herniation of part of the bowel wall, is often incorrectly called a Littré hernia.189 In Littré’s original article, the hernia contains a Meckel diverticulum. This entity is very rare in view of the low absolute incidence of Meckel diverticulum between 1 and 4.5% and the incidence of hernia, which affects approximately 10% of the population. This explains the low statistical probability of encountering a Littré hernia. Other rare hernias located in the lower abdomen are the spigelian hernia through the linea semilunaris, pelvic hernias, which include obturator hernias, sciatic hernias, and perineal hernias, and lumbar hernias in the posterior abdominal wall. These account for less than 1% of abdominal hernias.

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1.2  Definition and Terminology

1

Fig. 1.16  Forms of incarceration. a Direct prograde incarceration. b Elastic incarceration. c Retrograde incarceration.

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Introduction

Fig. 1.17  Forms of reduction. a Complete reduction. b Pseudoreduction. c Reduction en bloc.

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1.2  Definition and Terminology Fig. 1.18  Anatomy of the anterior abdominal wall showing the hernial orifices (numbers) and canals (arrows). 1 Indirect inguinal hernia. 2 Direct inguinal hernia. 3 Femoral hernia.

1

Fig. 1.19  Anatomical illustration of the abdominal wall. Internal view of the orifices of the indirect and direct inguinal hernia, femoral hernia, and supravesical hernia (X1–X4).   a   Inguinal falx.   b  Inguinal ligament.   c   Iliopubic tract.   d  Pectineal ligament. X1  Indirect hernia. X2  Direct hernia. X3  Femoral hernia. X4  Supravesical = suprapubic hernia.

Incisional hernias are the most frequent hernias of the anterior abdominal wall. They can occur in all forms of scar, most commonly from a surgical incision, but scarring as a result of trauma or other forms of tissue destruction, such as chemical necrosis, predisposes

one to incisional hernia. Recurrent hernias following surgery of primary hernias (e.g., recurrent inguinal hernias) are therefore incisional hernias by definition and should be treated as such. The most common incisional hernias are found after midline laparotomy but are

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Introduction Fig. 1.20  Femoral hernia locations. 1 Typical femoral hernia. 2 Prevascular hernia. 3 External (lateral) hernia. 4 Lacunar ligament hernia. 5 Pectineal hernia. 6 Retrovascular hernia.

known to occur in all other locations. Other hernias of the anterior abdominal wall include epigastric hernias in the supraumbilical linea alba, umbilical hernias, and paraumbilical hernias. Rectus diastasis with broad dehiscence of the linea alba and without a hernial orifice, abdominal wall relaxation, e.g., due to a lumbar incision with nerve damage, and trocar hernias following laparoscopic surgery must be distinguished from these abdominal wall hernias. They are very rarely true hernias, that is, hernial sacs lined with hernial coverings, but usually consist of protruding abdominal organs covered with non-parietal peritoneum and lacking a hernial sac. The pathogenesis lies in rupture of the abdominal wall with the need for immediate management because unlike hernia, the peritoneal cavity is opened, thereby increasing the risk of abdominal infection. By contrast, incisional hernia is usually an elective indication; rectus diastasis rarely requires correction and is indicated, if at all, only by the patient’s wishes, aesthetic sensibility, physical activity, and lifestyle.

1.3 Diagnosis Son Truong Ngoc and Marcel Binnebösel

1.3.1 History The history of hernia involves swelling and a bulge in the groin that often resolves spontaneously. When incarceration is present, the swelling persists and is associated with pain80. If the hernia is reducible and not tender to pressure, but pain persists with a general reaction, other

causes, such as a ruptured aortic aneurysm, ureteric colic, lymphadenitis, or a gravitational abscess, should be considered.135

1.3.2 Examination In addition to a general physical examination, local examination is performed with the patient standing and lying and with and without a Valsalva maneuver. ▶ Inspection. Inspection involves looking for swelling and asymmetry. ▶ Palpation. The index finger follows the inguinal canal by invaginating the scrotum (or the skin of the groin in women) at the superficial inguinal ring. The palpating finger in the inguinal canal is bounded superiorly by the fibers of the internal oblique and transversus abdominis, anteriorly by the external oblique aponeurosis, and inferiorly by the inguinal ligament (▶Fig. 1.21). With an indirect inguinal hernia, the deep ring is lateral to the palpable epigastric vessels, whereas it is posteromedial to the epigastric vessels with a direct inguinal hernia.174 ▶ Complete hernia. The criterion for a hernia is bulging of the peritoneal sac above the level of the transversalis fascia. ▶ Incipient hernia. The peritoneal sac meets the examiner’s finger when the patient coughs or strains. ▶ Soft groin. Wide deep inguinal ring and slack posterior wall of the inguinal canal (transversalis fascia). ▶ Femoral hernia. The femoral hernia is inferior to the inguinal ligament and medial to the vessels (differential diagnosis: varicosity of the great saphenous vein, lymph nodes, gravitational abscess).

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1.3 Diagnosis

1

Fig. 1.22  Gastrointestinal contrast study of a large left-sided scrotal hernia showing obvious contrast filling of small bowel loops in the hernia.

Fig. 1.21  Examination of the inguinal canal by invaginating the scrotal skin at the superficial inguinal ring with the index finger to palpate the canal and deep inguinal ring. The examination should be performed with the patient standing.

1.3.3  Differential Diagnosis ▶ Lymphadenitis. Nonmobile, no change in size on straining.

Gastrointestinal or Colon Imaging with Water-Soluble Contrast Agent •• To demonstrate loops of bowel in the region of the hernia. •• When a sliding hernia of the colon (cecum, sigmoid) is suspected. •• Internal hernias.60

▶ Lipoma. Soft, nonmobile.

Herniography (Peritoneography)

▶ Varicosity of the great saphenous vein. Soft, compressible, typical duplex ultrasonography.

•• Intraperitoneal instillation of contrast to show peritoneal diverticula, to detect rare forms of hernia (e.g., obturator hernia, perineal hernia).26 •• Because of its relatively low sensitivity, specificity, and possible complications, this procedure has been replaced by other imaging methods (ultrasonography, CT, MRI).

▶ Tumors. Indurated, nonmobile, often painless. ▶ Abscess. Fluctuation, possibly a local surrounding reaction.

1.3.4 Investigations Apart from ultrasonography, other investigation methods are reserved for individual cases and rare forms of hernia. The following methods can be used when clinical examination and ultrasonography do not allow diagnosis of a hernia or when knowledge of the precise extent of the hernia, with its topography and anatomy, is required for operation planning.

Plain X-Ray of the Abdomen •• Air-filled bowel loops in the region of the hernia175 (▶Fig. 1.22). •• Signs of obstruction are found with incarceration.

Computed Tomography, Magnetic Resonance Imaging •• CT and MRI are important supplements to ultrasonography but are rarely indicated to confirm the diagnosis of a groin hernia241 (▶Fig. 1.23), though they may be used to detect a sliding hernia of the bladder when this is filled simultaneously with contrast. •• CT and MRI are good methods of imaging the entire abdominal wall and its relation to intra-abdominal organs.2 CT or MRI is also indicated for preoperative planning when there are large abdominal wall defects so that the volume of the hernia contents relative to the abdominal cavity can be

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Fig. 1.24  CT scan of a large ventral hernia. Fig. 1.23  CT of the pelvis without contrast enhancement with an incidental finding of an inguinal hernia with a sliding hernia of the bladder.

Fig. 1.25  Magnetic resonance imaging of abdominal wall relaxation. Atrophy of all affected muscles without a fascial defect on the right.

assessed (▶Fig. 1.24). Diagnosis of abdominal wall muscle relaxation is another indication for CT and MRI (▶Fig. 1.25, ▶Fig. 1.26).

1.3.5 Ultrasonography The advantages of ultrasonography are that it is noninvasive and economical, repeatable at will, can be used anywhere, and does not result in radiation exposure of the patient.

Fig. 1.26  Patient with abdominal wall relaxation on the right. Bulging of the abdominal wall on the affected side.

•• The scan is performed with and without a Valsalva maneuver. •• The scan is performed with the patient lying and standing. •• The rectus sheath, muscles, fascia, and vessels can be clearly distinguished (▶Fig. 1.27).

Ultrasonographic Hernia Criteria

Equipment and Examination Technique

•• Evidence of a gap in the fascia. •• Imaging of hernia contents. •• Increase in the volume of the hernia contents or in the size of the hernial orifice with the Valsalva maneuver (▶Fig. 1.28).

•• Real-time device with a transducer for short focus settings (5–7.5 MHz). •• The transducer is placed over the swelling or pain‑ ful region.

▶ Inguinal hernia. The transducer is placed above the inguinal ligament. With a direct hernia, the orifice is medial to the epigastric vessels but with an indirect hernia it is lateral to these vessels (▶Fig. 1.29). When incarceration with

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1.3 Diagnosis

1

Fig. 1.27  Normal ultrasound anatomy of the lateral abdominal wall above the umbilicus. 1 Subcutaneous fat. 2 External oblique. 3 Internal oblique. 4 Transversus abdominis. 5 Rectus abdominis. 6 Fascia at the linea alba.

Skin Bowel

Fascia

Fascia

Fig. 1.28  Ultrasound appearance of an incisional hernia. Fascial defect with a hernia containing bowel.

Abdominal muscle

Inguinal ligament Inguinal hernia

Fig. 1.29  Ultrasound appearance of a left-sided inguinal hernia on longitudinal section.

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Fig. 1.30  Ultrasound appearance of an incarcerated inguinal hernia containing ischemic small bowel.

bowel ischemia occurs, thickening of the bowel wall in the hernial sac can often be identified (▶Fig. 1.30). ▶ Femoral hernia. The transducer is positioned below the inguinal ligament in the fossa ovalis. The femoral hernia appears between the common femoral vein and symphysis as a hypoechoic structure that bulges inferiorly on straining or coughing57,58 (▶Fig. 1.31). ▶ Epigastric hernia. The transducer is placed over the linea alba. The fascial defect in the midline with corresponding hernial sac is apparent. ▶ Spigelian hernia. The transducer is placed over the semilunar line, using the rectus muscle for orientation. The hernia is shown by a break in the contour (fascial gap) and bulging at the lateral border of the rectus sheath71,219 (▶Fig. 1.32). ▶ Lumbar hernia. The transducer is placed over the superior and inferior (Petit) lumbar triangles. The orientation points are the iliac crest inferiorly and the costal margin superiorly. Superior lumbar hernias are found below latissimus dorsi while inferior lumbar hernias are located lateral to the inferior insertion of latissimus dorsi.

Femoral vein Femoral artery Femoral hernia with incarcerated small bowel Fig. 1.31  Ultrasound appearance of an incarcerated femoral hernia containing small bowel.

Hernial sac Rectus muscle

Lateral muscle

Fig. 1.32  Ultrasound appearance of a spigelian hernia.

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1.3 Diagnosis

Ultrasonographic Differential Diagnosis of Pathological Findings in the Abdominal Wall and Groin ▶ Hematoma. A recent hematoma appears as a sharply demarcated, hypo- to anechoic mass with fine regular internal echoes (▶Fig. 1.33). ▶ Rectus sheath hematoma. This is located between the anterior and posterior leaves of the rectus sheath. A feathered increase in the volume of the affected rectus muscle is often found. A recent rectus sheath hematoma has few internal echoes, while an old rectus sheath hematoma appears to have few or nonhomogeneous echoes (▶Fig. 1.34). ▶ Seroma. Anechoic structure without internal echoes and with posterior acoustic amplification and sharp outer contour. ▶ Abscess. Hypoechoic mass with nonhomogeneous internal structure, stratification due to cell detritus, or characteristic small, roundish, hyperechoic reflections due to gas bubbles (▶Fig. 1.35). ▶ Metastases. Homogeneous, hypoechoic, solid masses with a roundish or irregular outline. When located deeply

in muscle and growing within the abdomen, they can be distinguished from intra-abdominal tumors by their unchanging position during forced inspiration and expiration or on straining (▶Fig. 1.36). ▶ Lymphoma. Homogeneous, hypoechoic or centrally hyperechoic, solid masses with a rounded or irregular outline. Unlike a hernia, lymphomas do not communicate with deeper structures or the abdominal cavity and appear constant on dynamic examination (▶Fig. 1.37). ▶ Abdominal wall relaxation. Postoperative abdominal wall relaxation often arises following surgery involving lateral access to the retroperitoneum. The incidence is 23% after a retroperitoneal approach to the aorta or iliac vessels. The lateral incision causes denervation of the segmental innervation of the abdominal wall muscles with consequent atrophy of the affected muscle. Relaxation is apparent clinically as a visible bulge in the flank without any obvious gap in fascia. All three muscle layers and an intact fascial layer can be seen on ultrasound. However, the volume of the affected muscle layers is reduced by about one-third compared with the healthy side156,229 (▶Fig. 1.38).

1

Fig. 1.33  Ultrasound appearance of a postoperative abdominal wall hematoma.

Anterior rectus sheath

Hematoma

Subcutaneous fat

Skin

Posterior rectus sheath

Fig. 1.34  Ultrasound appearance of a rectus sheath hematoma.

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Introduction

$EGRPLQDOZDOO

$EVFHVV

*DVEXEEOHV

Fig. 1.35  Ultrasound appearance of an abscess in the abdominal wall.

6NLQ

$EGRPLQDO PXVFOHV 0HWDVWDVLV

Fig. 1.36  Ultrasound appearance of an abdominal wall metastasis with intra-abdominal tumor extension.

Subcutaneous fat

Enlarged lymph nodes Fig. 1.37  Ultrasound appearance of a subcutaneous enlarged lymph node.

1.3.6  Doppler Ultrasonography, Duplex Ultrasonography Doppler ultrasonography and color-coded duplex ultrasonography are used primarily to determine testicular

blood flow. They are essential for prompt identification of ischemic orchitis and impaired venous drainage. No other method is as suitable for detecting vascular disorders and possibly influencing their treatment (revision, thrombolysis, testicular encapsulation, etc.). The sensitivity of

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1.4  The History of Hernia Surgery Fig. 1.38  a and b. a Ultrasound appearance of abdominal wall relaxation. The atrophic muscle layers on the right side are clearly thinner compared with the normal left side. b Patient with abdominal wall relaxation on the right side.

1

a

b

Testis

Fig. 1.39  Demonstration of testicular artery flow by color-coded duplex ultrasonography.

Testicular artery

color-coded duplex ultrasonography in diagnosing ischemic orchitis has been reported in the literature as up to 90%69,228 (▶Fig. 1.39). Furthermore, color-coded duplex ultrasound enables preoperative identification of the relation of approximately 80% of direct and indirect inguinal hernias to the readily visible caudal parts of the epigastric vessels. This may be important when selecting the operative procedure. Varicose veins can also be diagnosed precisely by color-coded duplex ultrasonography.

1.4  The History of Hernia Surgery Volker Schumpelick

1.4.1  Definition, Anatomy, and Pathogenesis The first descriptions of groin hernias are found in the Ebers papyrus (1555 BC). Hippocrates (460–375 BC)

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Introduction mentions hernias in the groin and navel region in his second book, “On generally prevalent diseases.” They were considered to be the result of a wound, a direct blow, or excessive use of emetics. Praxagoras of Kos (400 BC) recommended milking the hernia when incarceration occurred. Cecal coprostasis was suspected to be the cause of incarceration. Celsus (25 BC to 40 AD) described reducible inguinal hernias, assuming that rupture of the abdominal wall due to trauma or inflammation was the cause. Trusses were used to treat them. The first anatomical studies of the groin region date back to Galen (131–210 AD). Based on comparative anatomical investigations in monkeys, he concluded that the peritoneal process extending to the testicle remains patent. His thesis was again studied by Franco in 156170 and Falloppio in 1562.66 Heliodorus in the second century was the first to distinguish irreducible from reducible hernias. Numerous suggestions for conservative treatment of hernia were made in subsequent centuries during the Middle Ages, but these were not based on new knowledge regarding

Fig. 1.40  Historical illustration of medieval hernia treatment with a truss and taxis.

the anatomy or pathogenesis of hernia (▶Fig. 1.40). There was no surgery of groin hernias as surgery was generally prohibited by the church (“ecclesia abhorret a sanguine”) and was limited to barbers, executioners, and stonecutters. As the Middle Ages waned, Guy de Chauliac (1363) and Falloppio (1562) precisely described groin hernias. At the same time, Vallesco de Taranta was the first to dispute the hitherto prevailing view of groin hernias as a consequence of trauma. They came to be regarded as a separate congenital disorder of the abdominal wall and an abnormal anatomical gap in the tissues. The first description of a femoral hernia goes back to Guy de Chauliac (1363). In the 16th century, Caspar Stromayr (1559) differentiated direct from indirect inguinal hernias (▶Fig. 1.41). Heister (1724) finally provided an anatomically correct description of a direct inguinal hernia. Many years elapsed, however, before the full significance of the difference between direct and indirect hernias was acknowledged. The concept of a hernia that “has lost its right of residence in the abdomen” on account of its size came from Petit at the end of the 17th century. In 1700, Littré described a Meckel diverticulum in the hernial sac (genuine Littré hernia), even though the actual Meckel diverticulum was only recognized as an entity in 1809.131 Incomplete hernia was first described in 1788 by Richter (▶Fig. 1.42).189

Fig. 1.41  Medieval hernia operation according to Caspar Stromayr in Textbook of Herniology, 1559.

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1.4  The History of Hernia Surgery in 1814 by Scarpa.199 Identification of the inguinal ligament in 1705 by Poupart178 and of the layered structure of the abdominal wall by Bidloo in 1685 were the precursors of these anatomically exact descriptions. Thus, the anatomical description of inguinal and femoral hernia was largely complete in the 19th century, providing an anatomical basis for successful surgical treatment. Nevertheless, surgery of groin hernias remained an exception until the middle of the 19th century despite the introduction of anesthesia. Hernia surgery only developed with wider use of asepsis and antisepsis. McVay and Anson, who studied the relationship of the transversalis fascia to the inguinal ligament in detail, provided a new impetus in the 20th century.147 This continued in 1971 with Condon’s investigations.

1

1.4.2  Conservative Treatment

Fig. 1.42  Original title page of the 1788 treatise on hernia treatment by August Gottlieb Richter in 1788. (Richter AG. Abhandlungen von den Brüchen. Göttingen, Germany: Dietrich; 1778.)

The 18th century saw the investigations by René Renerulin (1721) and Ganz (1744); according to them, the main cause of hernia was not trauma but an increase in intra-abdominal pressure. While the oblique course of the inguinal canal normally prevents the intestine from passing through it, tensing of the abdominal muscles can straighten the canal, with the superficial inguinal ring projected over the deep ring, paving the way for emergence of the intestine. Important anatomical advances were made at the start of the 19th century. These include the first descriptions of the lacunar ligament by Gimbernat in 1793,55 the superior pubic ligament by Cooper in 1804,48 the transversalis fascia by Cooper in 1807,48 the iliopubic tract and deep inguinal ring by Hesselbach in 1814, and above all, Hesselbach‘s description in 1816 of the muscle-free triangle. The sliding hernia (“en glissade”) was described

It would be impossible to describe in detail within the confines of this chapter all the historically recorded methods of conservative treatment of inguinal hernia. They range from Celsus’s initial prescriptions of blood letting, diet, hot compresses, and trusses, to the injection therapy of groin hernia still practiced by some doctors. It is difficult to imagine all the procedures that were tried out to cure hernias by non-surgical methods. For instance, in the fifth century AD, Brunus used resin and sticking plasters and recommended placing patients on their backs for 40 days. Paul of Aegina (seventh century AD) recommended the use of cautery, plasters, and bandages. Falloppio (17th century) reported good experiences with enemas, kneading the hernia, bathing with the legs elevated and the head down (▶Fig. 1.40), and with the patient standing on his head and shaking his feet. Other curious suggestions from that time include administration of tobacco enemas, repeated bloodletting, application of iron filings for magnetic reduction of the hernia, and hot and cold compresses for application of all conceivable essences. The idea behind all these treatments was to close the hernial orifice securely by inducing scar contraction.

1.4.3 Surgery Surgical attempts to treat groin hernia offered little competition to conservative efforts. As early as the seventh century AD, Paul of Aegina recommended an operation to remove the hernial sac, closing the wound with an X suture, but this proposal remained an exception. Heliodorus, too, in the second century AD advised a truss for small hernias in youth but operation for the large hernias that occur in adulthood. The operation should consist of resection of the hernial sac and excess peritoneum so that recurrence could not occur. The Middle Ages were the great era of the hernia cutters, who split the inguinal ring to reduce the intestine.

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Introduction These strolling surgeons moved about the country, but not without leaving behind a trail of infections, castrations, bowel gangrene, and hemorrhages. Sutures of gold, silver, tin, bronze, copper, and iron were used to seal the hernial opening; also, screws, nails, needles, or rods made of wood, iron, ivory, or bone were introduced. A rival treatment was injection of the hernial orifice with gelatin, iodine, tincture of iodine, sea salt solution, or high-strength alcohol. All these “operative methods” sought to produce scarring of the inguinal canal by provoking inflammation. Their catastrophic results were shown in Danzel’s statistics (1854), according to which over 300 of the 571 patients whose operation involved opening of the sac died, whereas “only” 9 out of 66 patients died when the hernial sac left unopened. It is thus understandable that Dupuytren (1828) and Roux (1830) had extreme reservations about radical surgery of groin hernia. Surgical treatment only became attractive when the introduction of anesthesia and, in particular, antisepsis and asepsis made elective procedures possible. Disregarding the early hernia treatments by barbersurgeons and hernia cutters, the real history of inguinal hernia surgery started only at the end of the 19th century. Up to this time, so-called radical operations only meant removal of the hernial sac but not tightening of the hernial ring. The first attempts to tighten the ring were made by Marcy in 1871,141 Steele in 1874,213 and Czerny in 1877.52 Czerny noted self-critically: “If one surveys the numerous attempts to achieve radical cure of hernia that were then abandoned, it requires some courage to reopen discussion about this question.” After comprehensive study of the literature, Czerny became convinced that a radical operation method was clearly the way forward: the sac must first be exposed and, after returning the hernia contents to the abdomen, its neck should then be ligated and closed with catgut and then excised. The hernial ring then had to be tightened directly by a type of “lacing” suture that joined the femoral with the inguinal ring. The skin over the hernia should then be closed with sutures. For Czerny, use of the Lister method of antisepsis was essential for the success of this procedure. But even Czerny, like all his predecessors, operated on inguinal hernia through the superficial ring without opening the inguinal canal so the deep inguinal ring remained intact. It was therefore a significant advance when LucasChampionnière (1881) first split the external oblique aponeurosis. The deep inguinal ring could then also be exposed to allow repair of the defect in the transversalis fascia. The assumption that this step had already been taken by Marcy in 1871141 has been dispelled by more recent research. It may be assumed that Lucas-Championnière was the first to take the plunge in 1881 from the superficial to the deep inguinal ring, providing the basis for high ligature of the sac and repair of the transversalis fascia. Recommendations regarding high sac ligature soon became widespread and were made by Marcy in 1881,142 Bassini in 1887,15 Halsted in 1890, and Ferguson in 1899.68

The inguinal incision, first recommended by Annandale in 1876,5 then by Ruggi in 1892193 and later by Lotheissen in 1897, became the accepted approach for inguinal hernia repair. Bassini in 1894 was the first to use the crural approach for operation on femoral hernia.20 Despite all the surgical advances, groin hernia surgery remained a risky and unreliable procedure until 1890. According to surveys by Billroth in 1881 in Europe27 and by Bull in 1890 in the United States, the mortality was 2.7% and the recurrence rate was 30 to 40% after 1 year and 100% after 4 years. As late as 1883, Kraske still recommended routine castration and McBurney omitted primary skin suture to achieve a better and stabilizing scar by secondary healing.89 Czerny summarized the situation 136 years ago:52 “When we look around at what is advised for irreducible or recurrent groin hernia, the answer sounds so desolate because it is generally admitted that the permanent growth and threat of incarceration are not only a great burden that interferes with the ability to work but also represent an immediate danger for the patients. Often enough, they are sent from one truss-maker to another until, after great sacrifices of time and money, they resign themselves to their fate, grumbling about the lack of skill of the doctors and truss-makers.” In this period of uncertainty, the methods proposed by Bassini and his excellent results (1890,19) were of epochal significance (▶Fig. 1.43). Repair of the posterior wall of the inguinal canal with tightening of the deep inguinal

Fig. 1.43  Eduardo Bassini, ordinary professor of clinical surgery at the Royal University in Padua.

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1.4  The History of Hernia Surgery ring, in particular, proved to be superior to all other methods (▶Fig. 1.44). Closure of the deep ring had already been described by Halsted in 1887. Bassini’s outstanding importance is based on his pioneering definition of a tactical operative principle for hernia treatment, which

he then implemented successfully. His achievement did not consist in the individual steps, some of which had already been described and tested, but his development of a treatment concept. The systematic procedure is exemplary. In Bassini’s famous publication of 1890,19 the operation is presented in three stages by means of timeless illustrations (▶Fig. 1.44):

1

1. The skin is incised and the external oblique aponeurosis and superficial inguinal ring are exposed. 2. The external oblique aponeurosis is divided, the spermatic cord is dissected completely, the hernial sac is isolated and the neck of the sac is exposed “as far as the iliac fossa,” the sac is opened, its contents are reduced if necessary, adhesions are divided, and the sac is twisted, ligated, and excised 0.5 cm below the ligature. 3. The spermatic cord and testis are drawn laterally and the upper lip of the internal oblique aponeurosis is drawn cranially. The original then continues: “I then separate the outer border of the rectus abdominis and the triple layer formed by the internal oblique muscle, the transverse muscle, and the vertical fascia of the transverse ligament and vertical fascia of Cooper ligament from the aponeurosis of the external oblique muscle and from the subserous adipose connective tissue until the aforementioned rejoined triple layer can be approximated to the posterior isolated border of Poupart ligament without difficulty. After this has been done, I suture these two parts together over a distance of 5 to 7 cm outward from the iliac crest toward the spermatic cord, which was displaced about 1 cm toward the anterior iliac spine.” The original description of 1890 does not include splitting of the transversalis fascia.19 Nevertheless, this is suggested by the mention of the Cooper ligament. Medial recurrences are prevented by picking up the rectus sheath and lateral recurrences by high dissection and ligature of the sac and restoration of the obliquity of the inguinal canal. Bassini used non-absorbable silk as suture material. The recommendation that the patient should mobilize as soon as possible and the hospitalization duration of about 15 days—relatively brief for that time—seem quite modern. The great response to Bassini’s radical operation was helped by the fact that no previous method delivered such outstanding results. In a subsequent study of 266 hernias he had operated on, with a follow-up rate of 95% after 6 years, Bassini demonstrated objectively the compelling advantage of his method (▶Table 1.4). The recurrence

Fig. 1.44  Original illustrations of the Bassini inguinal hernia repair in 1890. (Bassini E. Über die Behandlung des Leistenbruches. Arch Klin Chir 1890;40:429.)

Table 1.4  Recurrence and follow-up rates of groin hernia repair (indirect and direct) by Bassini and Brenner Source

Duration of follow-up (y)

Number of operated patients

Number of followed-up patients (%)

Recurrence rate (%)

Maximum possible recurrence rate (%)

Bassini 189019

6

266

98.4

2.9

4.2

Brenner 189831

6

358

47.2

5.9

52.8

624

65.4

4.2

14.5

Total

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Introduction

Fig. 1.45  Original illustration of the Ferguson inguinal hernia repair, 1899. (Ferguson HW. Oblique inguinal hernia, typic operation for its radical cure. JAMA 1899;33:6.)

rate of 2.9% was all the more remarkable since an article by Heidenthaler in the same issue of the Archive of Surgery (1890) identified a rate of recurrence of 68.2% with the operation methods of that period. Various modifications of the Bassini procedure were developed in subsequent years. Ferguson (1899) omitted dissection of the spermatic cord and only fixed the muscle over it (“leave the cord alone”) for fear of testicular atrophy (▶Fig. 1.45).68 Brenner (1898), too, limited the procedure to the attachment of the “triple layer” consisting of the cremaster, internal oblique, and transverse muscles, without including the transversalis fascia (▶Fig. 1.46).31 The posterior wall of the inguinal canal was reconstructed only superficially, and the hernia was removed incompletely. Halsted’s method (1893/1897), with its principle of “lining the Fig. 1.46  a and b Original illustration of the Brenner inguinal hernia repair, 1898. (Brenner A. Zur Radikaloperation der Leistenhernien. Zentralbl Chir 1898;25:1017.)

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1.4  The History of Hernia Surgery wound with muscle,” was similar, but was also characterized by high recurrence rates (▶Fig. 1.47).

Fig. 1.47  Original illustration of the Halsted inguinal hernia repair, 1893. a Before completing the sutures. b After completing the sutures.

Use of the Cooper ligament to repair groin hernias was first reported by Ruggi in 1892.193 Systematic use of this ligament goes back to Lotheissen, who developed this method from an emergency situation (▶Fig. 1.48):133 in a female patient, whose inguinal ligament was destroyed as a result of two operations for recurrence, he could only remedy the situation by attaching the abdominal wall to the Cooper ligament. This method was later further refined by Moschcowitz in 1907155 and McVay in 1942.147 Wölfler in 1892,244 and later Bloodgood in 189929 and Halsted in 1903 were the first to make the relieving incision in the rectus sheath that is often necessary with this procedure (see ▶Fig. 1.47). Transfer of the spermatic cord into the subcutaneous tissue was inaugurated by Halsted in 1889 and later developed further by Hackenbruch (▶Fig. 1.49) and Kirschner. Removal of the cremaster muscle, which allows more complete dissection and more visible tightening of the deep ring, is also attributed to Halsted (1893).

1

Fig. 1.48  Original illustration of the Lotheissen inguinal hernia repair, 1898. (Lotheissen G. Zur Radikaloperation der Schenkelhernien. Zentralbl Chir 1898;25:548.) a Before completing the sutures. b After completing the sutures.

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Introduction

Fig. 1.49  Original illustration of the Hackenbruch inguinal hernia repair, 1908. (Hackenbruch P. Zur Radikaloperation der Leistenhernie, Faszien Knopfnähte. Munch Med Wochenschr 1908;32:1693.)

Repair of the transversalis fascia goes back to Bassini (1890).19 Its importance has only been recognized slowly in the past 100 years and further advances in repair technique are linked with the name of Shouldice, Condon, McVay, and Nyhus. The preperitoneal approach to an inguinal hernia was developed by LaRoque (1919), Cheatle (1921), and Henry (1936).40,91,124 Nyhus, Condon, and Harkins (1960) developed this further.161 Annandale in 1876 was the first to describe a successful operation method to treat femoral hernia.5 He recommended an inguinal approach, as Lotheissen did later in 1898.133 Fabricius developed the crural approach in 189565 (▶Fig. 1.50), Bassini in 189420 (▶Fig. 1.51), and Kocher in 1895. While Langenbeck found in 1888 that “radical healing of a femoral hernia consists only of ligature and removal of the hernia sac and adequate suture closure as in inguinal hernia does not have to be achieved”,238 Bassini, Lotheissen, Kocher, Kummer, Salzer and others attempted different methods for suturing closed the femoral opening. Mikkelsen and Berne (1954) finally recommended the preperitoneal approach for closing the femoral hernial orifice.151 In 1901, Mayo proposed doubling the fascia to treat umbilical hernias that later became the standard procedure for treating incisional hernias. In general, nearly all methods developed for inguinal hernias were also used, with a degree of latency, to treat primary or incisional hernias elsewhere in the abdominal wall. Within a few decades, the chapter on hernia surgery, and inguinal hernia surgery in particular, was then closed for many years as the radical operation became the treatment of choice. Numerous technical modifications,

Fig. 1.50  Original illustration of the Fabricius femoral hernia repair, 1895. (Fabricius J. Wien Klin Wochenschr 1895;8:553.)

for instance, doubling of the external oblique aponeurosis, were described, e.g., by Kirschner in 1920110 and by Hackenbruch in 1908,83 without generally altering Bassini’s method. It was only in the middle of the 20th century that Bassini’s concept was developed further. It was increasingly found that the best results could be expected when reconstruction of the posterior wall of the inguinal canal starts at the level of the transversalis fascia. Studies by Shouldice (1945) and McVay and Anson (1946) showed that the transversalis fascia acts as “first line of defense” and is the most important layer in inguinal hernia repair. Especially in the Shouldice method, an anatomical and atraumatic reconstruction procedure was developed, which has led to excellent subjective and objective methods even outside “hernia centers.”

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1.4  The History of Hernia Surgery

Fig. 1.51  Title page of Bassini’s original publication on femoral hernia repair. (Bassini E. Neue Operationsmethode zur Radikalbehandlung der Schenkelhernie. Arch Klin Chir 1894;47:1.)

The standardized Shouldice technique with continuous doubling of the transversalis fascia replaced the usually superficial “modified” Bassini repair in the 1970s and 1980s but did not significantly reduce the relatively constant recurrence rate of 15%. However, when recurrent hernias were treated, it was apparent that simple suture of the posterior wall of the inguinal canal was associated with a high recurrence rate such that additional reinforcement of the inguinal region appeared desirable. The idea of reinforcing a hernial repair with artificial material is over 180 years old. Belams experimented in 183224 with gold-beater’s skin for groin hernias. After implanting the foreign body in the hernial opening, he hoped to heal the hernia by provoking “adhesive inflammation.” He tested this method successfully in 30 female dogs and finally in 3 humans, too—always successfully. Billroth was convinced that only an artificial material with the strength of fascia would reveal the secret of radical hernia treatment.23,89 MacEwen (1886) reinforced the closure of the deep ring by gathering the entire hernial sac with a continuous suture and pushing this plug of tissue to the inside of the deep ring in front of

the peritoneum.140 His patients were confined to bed for 6 weeks; however, the use of fascial repair to close large hernial openings and recurrent hernias is based on the method developed by Halsted (1903), Kirschner (1908), and Koontz (1926). Trendelenburg198 used a flap of periosteum from the symphysis, 4 cm long and 3 mm thick, to reinforce the inguinal canal. Rehn used a strip of fascia lata,155,177 Loewe and Rehn used a skin flap in 1913 and 1914, which Schütter combined with a mesh in 1995.204 Not only autologous but also artificial material was used. In 1889 Witzel220 described the use of silver wire mesh for ventral hernias and Busse even used gold in 1901.223 Fieschi used rubber sponges in 1931. In 1940, Ogilvie published the successful implantation of fabric meshes in contaminated war injuries, and Preston used wire meshes.168 Polymers for medical use were only developed after the Second World War. In Europe, Acquaviva and Bourret were the first to use synthetic material (nylon) for herniorrhaphy in 1948. In 1952, Cumberland reported the use of meshes for hernias.61 Stock (1954) was the first to use nylon in the groin. Martinez suspected in 1958 that the suture materials used in hernia surgery worked only by stimulation of fibroblasts and induction of a strong scar.64 It took until 1959, however, until Usher230,231,232,233 first used an alloplastic mesh systematically in the abdominal wall and confirmed its suitability in animal studies. While these meshes, usually made of polypropylene or polyester, were initially only kept in reserve for large abdominal wall defects, French surgeons in particular (Rives, Stoppa, Chevrel, Flament) developed different repair methods in the 1970s for treating ventral hernias using these alloplastic materials. The synthetic meshes were usually placed preperitoneally, through a transinguinal (Rives) or midline approach (Stoppa), and sealed the hernial orifice from within. These mesh techniques were increasingly accepted for treating incisional hernias in particular, in view of the lack of alternatives. Lichtenstein recognized in 1986 that tension-free repair was possible for the first time if the groin region was reinforced with mesh and favored insertion of mesh under the external oblique aponeurosis under local anesthesia, which is relatively simple technically.128 Isolated hernial openings are closed from anterior with twisted plugs of mesh and larger meshes are introduced into the preperitoneal space through an extraperitoneal approach. The explosive growth in laparoscopy at the end of the 1980s suggested that the mesh principle could be combined with minimally invasive laparoscopic techniques. Laparoscopic management of inguinal hernias, initially without mesh, started with Ger in 1982 and Bogojavalensky in 1989,140 though with an unsatisfactory recurrence rate. It was only the additional: •• Transabdominal extraperitoneal (TAPP technique, developed by Schultz 1990). •• Transabdominal intraperitoneal (IPOM, Popp 1990). •• Totally extraperitoneal (TEP, Ferzli 1992).

1

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Introduction Table 1.5  Historical development of hernia repair with mesh Method

First described by

Mersilene

Year 1954

Marlex

Usher

1959

Grande procedure de reinforcement du visceral sac (GPRVS)

Stoppa

1973

Transinguinal preperitoneal

Rives Schumpelick

1973 1996

Subfascial Lichtenstein graft

Lichtenstein Amid

1986

Preperitoneal graft through extraperitoneal access

Nyhus Wantz

1988 1989

Mesh plug

Rutkow Gilbert

1989

Plug, laparoscopic

Schultz

1990

Intraperitoneal onlay mesh graft

Popp

1990

Transabdominal preperitoneal graft

Schultz Corbitt

1990 1991

Totally extraperitoneal graft

Ferzli McKernan

1992 1993

Laparoscopic incisional hernia repair

LeBlanc

1993

implantation of plastic mesh that led to outstanding recurrence rates and, in many studies, less wound pain compared with open surgery. The first successful laparoscopic mesh repairs of incisional hernias have been performed (first by LeBlanc in 1993)126 (▶Table 1.5).51,150 The developments of the last 20 years have included refinement and standardization of open and laparoscopic techniques, production of guidelines (EHS 2009), improvement of the meshes with a switch to use of light-weight, large-pore grafts (used by the Aachen group since 1998), systematic monitoring of results by single-center or multicenter prospective randomized studies, and, in recent years, the to date largely unsuccessful use of biologically degradable meshes instead of nonabsorbable plastic meshes. The history of hernia surgery can be summarized by stating that it will always be an open-ended process without stable endpoints, without taboos and without permanently secure knowledge. And that is what makes it so fascinating.

•• Repair principles must also take into account that patients and types of hernia may have a different risk profile.

1.5  Repair Principles and Materials

•• For chronic pain: ○○ Preoperative pain. ○○ Low BMI. ○○ Young patient. ○○ Re-operation.

Uwe Klinge and Matthias Pross

1.5.1  Choice of Procedure •• Every repair must be guided by how the defect can be permanently closed with low risk. Important priorities include avoidance of recurrence, low pain levels, and a low infection rate. •• Adequate personal experience is naturally a basic requirement for choosing a procedure but this is difficult to express in numbers.

The Patient The following are the risk factors: •• For recurrence: ○○ Familial predisposition. ○○ Multiloculated hernia. ○○ Recurrent hernia. ○○ Connective tissue disorders. •• For infection: ○○ Contaminated wound. ○○ Hypotrophic or infected skin condition. ○○ High BMI. ○○ Shock. ○○ Incarceration.

Hernia Type Depending on the anatomical location and hernia size, a method should be chosen that can best achieve adequate reinforcement (with mesh), with a low rate of complications such as pain or infection. Different procedures for “simpler” forms of hernia can be regarded as largely equivalent.

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1.5  Repair Principles and Materials

Hernia Classification by the European Hernia Society •• Inguinal: large direct M3 hernias are associated with a higher risk of recurrence (▶Fig. 1.52). •• Abdominal wall hernias closely related to the bony skeleton are associated with more recurrences (▶Fig. 1.53). •• Special conditions apply for reoperation depending on the previous access and whether a mesh was implanted and, if so, whether mesh removal was indicated. A change of approach is often advisable for management of a recurrent hernia as the defect can then be closed EHS inguinal hernia classification

Size

Recurrent

0 1 2 Incipient < 1.5 cm 1.5–3 cm

L

lateral

M

medial

F

femoral

3 ≥ 3 cm

Fig. 1.52  European Hernia Society classification of inguinal hernias. EHS, European Hernia Society.

Subxiphoid

M1

Epigastric

M2

Umbilical

M3

3cm 3cm

Infraumbilical Suprapubic

M4 M5

3cm

in a different anatomical layer. If the mesh is to be removed, however, the same approach as in the previous operation, is often the best. All reoperations demand an individualized choice of procedure.

1



Caution

Light-weight large-pored meshes can often not be removed in full.

Operation Techniques There are fewer recurrences with mesh but reoperation may be more difficult, which is more relevant in younger than in older patients; there is less pain with laparoscopic/endoscopic methods but these are more expensive and also depend on the surgeon’s experience (▶Fig. 1.54).

x

1.5.2  Principles for Choice of Procedure A hernial orifice can be closed by a suture, preferably continuous to avoid uneven tension. This requires intact wound healing and an adequately strong suture placement site so that the sutures do not tear out immediately.

3cm

Hernia defect

Lumbar

L4

L1

Subcostal

L2

Flank

3cm 3cm

L3 Iliac

Multiple hernia defects

Length

Length

Width

Width

Fig. 1.53  European Hernia Society classification of abdominal wall hernias.

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Introduction Decision triad

Onlay

Inlay

Surgeon – experience with a procedure

Patient

Material

Recurrence-pain-infection Fig. 1.54  Patient, material, and surgeon determine the risk for recurrence, pain, and infection.

Tissue approximation is usually only achieved with tension; therefore, suture methods are initially perceived as more painful. By contrast, mesh repair is based on tension-free reinforcement, which can even compensate wound healing defects if the tissue is overlapped sufficiently by nonabsorbable materials. Locating the mesh beneath the defect in the direction of maximum pressure (the abdominal cavity) is ideal as otherwise the mesh can lift off the tissue beneath it when under pressure. These theoretical biomechanical considerations do not match clinical experience; however, as quite acceptable incisional hernia recurrence rates can be achieved with onlay methods, even though recent studies have confirmed that sublay positions are superior. In the case of inguinal hernia, similarly good results can be obtained with the premuscular Lichtenstein mesh compared with the TAPP or TEP preperitoneal retromuscular mesh (▶Fig. 1.55). The choice of procedure is based on the patient’s risk profile, surgeon’s skill, and operating team’s experience. While there is little difference in the results and risks with uncomplicated simple hernias, complex hernias often require individualized therapy, which may necessitate referral to a specialist center.

1.5.3  Basic Hernia Repair Procedures Inguinal Hernias See ▶Table 1.6, ▶Table 1.7. Over 85% of primary inguinal hernias in patients without risk factors can be treated successfully by suture methods. The convalescence period is shorter and less painful with all mesh procedures. For decades, however, the need for reoperation has remained largely constant

Retromuscular Preperitoneal Intraperitoneal Fig. 1.55  Mesh position in relation to hernial orifice and intraabdominal pressure.

at 10 to 15%. There are more options for revision following a sutured repair compared with a mesh procedure, when the graft region is usually difficult to dissect. This must be considered in the case of younger patients in whom the lifetime risk of recurrence is not low. On the other hand, chronic groin pain occurs particularly often in young patients; so, from this aspect, preperitoneal mesh grafts (TAPP, TEP) are more advisable for them. The Lichtenstein procedure, which is technically simple and can be performed under local anesthesia, has become the standard, not only in the EHS guidelines. It is by far the most widely used mesh method worldwide. For uncomplicated inguinal hernias, all methods can currently be regarded as largely equivalent. Each has its specific advantages and disadvantages which must be weighed jointly by the patient and surgeon. The specific advantages and disadvantages of a procedure may be much more relevant in the case of a complicated hernia so discrimination in the choice of method is needed. In any case, there is currently no obligation to use a certain procedure.

Abdominal Wall Primary abdominal wall (ventral) hernias can be repaired by suture, but with recurrence rates of 5 to 30%. When there is clear evidence of an increased risk (e.g., BMI, hernia size, etc.), reinforcement with mesh should be considered, even though this makes the operation more complex.

Caution



Coexisting rectus diastasis indicates a connective tissue problem (and high risk of recurrence following suture repair).

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1.5  Repair Principles and Materials Table 1.6   Current inguinal hernia repair methods with their main advantages and disadvantages

1

For

Against

Comment

Suture

Easier re-operation possible

Somewhat higher recurrence rates compared with mesh procedures

10–15% re-operation in the long term with suture procedures

e.g., Shouldice

Layered repair Everything under vision, can be done under LA

Not a one-person operation

Regarded by Cochrane and guidelines as best procedure

e.g., Bassini

> 100 years experience Can be done under LA

Many modifications Sutures placed subjectively

Quite good result in selected young patients in the original description but high risk of recurrence overall

Lichtenstein

Simple LA Intraoperative modification possible

Weak anterior covering at the external ring Weak site acts as a slit for lateral recurrence Mesh anterior to muscle, suture fixation on the inguinal ligament with risk of nerve injury Femoral hernia often overlooked

Fixation is controversial

TIPP

Mesh posterior to muscle

Placement not clearly visible and difficult to ensure adequate overlap

Placement possibly easier with ring reinforcement Combination of TIPP and Lichtenstein as PHS, UHS etc.

Plug

Simple Under LA

Tissue reinforced only at some points Dissection of the inguinal canal is usually incomplete High use of materials Plug migration possible

Because of recurrence at the margins, the plug and patch combination is usual, with additional anterior mesh graft

Triple prostheses

Plug closure of the defect with additional preperitoneal and anterior mesh No suture fixation to the inguinal ligament with danger to nerves

Re-intervention difficult especially if the prosthesis has to be removed because of pain High use of materials Extensive scarring

Results similar to with Lichtenstein mesh alone

Inguinal hernia

Anterior mesh procedures

(Continued)

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Introduction (Continued) Current inguinal repair methods with their mainand advantages and disadvantages Table 1.6   Current inguinal hernia repairhernia methods with their main advantages disadvantages For

Against

Comment

TAPP

GA or regional anesthesia Few problems for surgeons with laparoscopic experience Good visibility Excellent results in teaching hospitals also With incarcerated hernias allows assessment of vitality of the incarcerated bowel

Transabdominal procedure Injury of abdominal organs Adhesions

The largest mesh (10 × 15 cm) compared with inguinal repair procedures

TEP

Preferable for bilateral hernias Technically more demanding as experience of laparoscopy alone does not suffice

Management of complications is difficult Less suitable for complex hernias

Laparoscopic/endo-mesh

Abbreviations: GA, general anesthesia; LA, local anesthesia; PHS, Prolene hernia system; TAPP, transabdominal preperitoneal mesh repair; TEP, totally extraperitoneal mesh repair; TIPP, Transinguinal preperitoneal patch; UHS, UltraPro hernia system.

On the other hand, patients with an incisional or recurrent hernia already have an obvious disorder of wound healing. Accordingly, simply repeating the sutured repair (such as laparotomy closure) leads to recurrence rates of more than 50%. Liberal use of non-absorbable mesh to reinforce incisional hernia repair should therefore be regarded as the standard procedure. If overlapping of the entire existing scar is omitted, later development of further hernias in the remainder of the incision can be expected when a wound healing disorder is suspected (especially in the case of multilocular hernias). An overlap of approximately 5 cm is considered necessary, though this may have to be modified depending on the technical possibilities and local muscle tension. In regions where more recurrent hernias are seen, the degree of overlap should therefore be greater. On the other hand, the degree of overlap may be restricted by the anatomy (e.g., close to the costal margin or when the semilunar line is crossed) (▶Fig. 1.56). As in the inguinal region, the mesh placement can be retromuscular (sublay) or prefascial (onlay), or can bridge the gap in the muscle (inlay). •• While the edge-to-edge fit of an inlay demonstrates high recurrence rates, as with sutured repair, this leads to quite acceptable results in patients with traumatic defects when a 5-cm overlap is observed at all margins. •• Epifascial onlay is considerably easier to carry out but increases the risk for wound complications and is technically limited close to bone. •• Hernia repair with a retromuscular mesh (sublay) is a very effective method, especially for incisional hernias

following midline laparotomy, if an adequate overlap can be ensured cranially (in the fatty triangle behind the xiphoid) and caudally (in the retropubic space of Retzius). However, this method is more demanding technically in the case of incisional hernias that cross the semilunar line, as extensive dissection of the fasciae that merge here is necessary to ensure adequate overlap, with the associated risk of vessel and nerve transection. Close to the costal margin or iliac spine, because of the insertion of the abdominal muscles, preperitoneal placement is preferable if IPOM is not an alternative. With intraperitoneal onlay mesh (IPOM), the mesh is fixed over the hernial opening from the inside after extensive division of adhesions. This can be done by open surgery but is performed laparoscopically in most cases. Close to the pubic bone, placement of the mesh in the extraperitoneal/prevesical space (similar to TAPP) is required with IPOM. To avoid the risk of intestinal fistula, polytetrafluoroethylene (PTFE) film, polyvinylidene difluoride (PVDF) mesh, or PP and PET mesh coated with a protective film (composites meshes) should be used exclusively. Systematic follow-up with MRI, ultrasound, or relaparoscopy has now shown that adhesions can be expected in more than 80% of patients but that the aforementioned materials with their protective mechanisms lead very rarely to fistula. The need for these materials to have intrinsic elasticity and the best method of fixation are controversial. There is currently no consensus regarding the use of mesh reinforcement of diaphragmatic hernia at

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1.5  Repair Principles and Materials Table 1.7  Current repair methods for abdominal wall hernias with the main advantages and disadvantages

1

For

Against

Comment

Sublay open

Technically standardized, few recurrences if cranial or caudal overlap is observed Reconstruction of abdominal wall anatomy

Wound infections especially with high BMI Technically difficult on leaving the rectus sheath

Fixation apparently not crucial On the other hand, fascial closure (continuous, non-absorbable) is necessary

IPOM laparoscopic

No need for a large skin incision especially for primary hernias Fewer wound infections than with open procedure (significant result of meta-analysis) Outstanding visibility for the entire team Usually no closure of the hernial orifice

Intra-abdominal adhesiolysis with risk of undiscovered iatrogenic bowel injury Unanswered question of optimal fixation (suture or tacks? How many? Absorbable?)

Studies of whether closure of the hernial opening or endoscopic extraperitoneal mesh placement is beneficial are currently ongoing

Medial abdominal wall hernia

Lateral hernia e.g., transverse, transrectal, paramedian incision Open

Reconstruction of abdominal wall anatomy

Technically demanding High recurrence rate with insufficient overlap

Laparoscopic

Sufficient overlap readily possible with the exception of very large or very lateral hernias

Additional dissection inferiorly in the extraperitoneal space often required

Laparoscopy not possible after complex previous surgery including with open access

Circumscribed primary hernia (umbilical, epigastric) Mesh open

Large overlap, no intraperitoneal injuries

Large incision with considerable tissue trauma for a small hernia

Mesh laparoscopic

Small skin incision, usually few adhesions

Complex procedure for a small hernia, costly

Plug/patch

Smaller skin incision than with open sublay mesh

Mesh is intraperitoneal, flush position with peritoneum is often not guaranteed Placement difficult and not always certain

Abbreviation: BMI, body mass index.

the hiatus. Mesh migration into the esophagus, which is rare but difficult to treat, precludes its routine use in all patients. Optimization of the implants and identification of the patients who are most likely to benefit from an additional mesh are therefore priorities.

Parastomal hernias are usually associated with a failure of fixation of the stoma to the muscle, fascia, and subcutaneous tissue; so, herniation beside the stoma occurs regularly when intestinal motility is high. Randomized controlled trials have clearly shown the benefit of prophylactic mesh. The best results are currently reported

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Introduction

Fig. 1.56  Anatomical dissection of a cross-section showing retromuscular mesh running laterally between the external and internal oblique (right) and preperitoneal mesh (left).

with the laparoscopic sandwich technique, though only limited conclusions are possible regarding long-term results. If re-intervention is necessary, the implanted mesh must be divided sharply and then replaced by a nonabsorbable mesh. If the mesh structure has high anisotropy and low resistance to tearing, an additional mesh to reinforce the new incision may have to be introduced.

1.5.4 Materials Uwe Klinge and Bernd Klosterhalfen The function of the material is to reinforce the tissue and/or secure the closure of the hernial opening. Integration of the implant in the developing scar tissue assumes porosity, while sheet-like structures become enveloped by a connective tissue capsule. Only temporary fixation is generally required for the former, while the latter require permanent fixation. Following physiological wound contraction, which is quite variable individually, all implants show a certain degree of shrinkage of the implant surface, which is proportional to the intensity of the inflammatory and scarring reaction but which is negatively associated with the rigidity of the material. Shrinkage of the implant surface of 10 to 20% can be expected with large-pored structures, while this can be > 80% in the case of small-pored structures. This effect cannot be prevented by fixation (▶Fig. 1.57, ▶Fig. 1.58). The requirement for implant stability is currently controversial; a minimum tensile strength of 16 N/cm for the groin region or for closing abdominal wall fascia is generally accepted as sufficient. If the fascia is not closed, implants in the abdominal wall should ensure minimum stability of 32 N/cm. Monofilament meshes have less exposed foreign body surface area for potential bacterial adherence than meshes made of multifilament materials.

Meshes for intra-abdominal use must be made of PTFE or PVDF or they require additional barriers such as cellulose or collagen. Most meshes consist of carbon polymers, either polypropylene (PP), polyethylene terephthalate (polyester, PET), expanded polytetrafluorethylene (ePTFE), or poly­ vinylidene fluoride (PVDF). Filament manufacture sometimes requires additives that are responsible for transparency, fire resistance, or flexibility. More precise details of the additives, which are only present in small amounts, are usually not available but these may vary from one manufacturer to another. Depending on their chemical stability, the polymers exhibit different resistance to degradation, though the relevance for clinical use is controversial. In the case of polyester, this happens within only a few years on account of the ester bond. PVDF is currently regarded as the most stable polymer in the long term (▶Fig. 1.59). Most porous structures have a certain degree of anisotropy based on their manufacture, that is, they have different properties in vertical or horizontal direction, as the threads essentially run in parallel and are linked to the neighboring threads by more or less complex loops. The weft threads typical of woven materials are lacking but this allows intraoperative trimming of the implant without the structure disintegrating. The resulting anisotropy leads to sometimes substantial differences in strength and elasticity depending on the direction. Whether this anisotropy needs to be considered when placing an implant, e.g., with its main stretch in the line of the muscle, is still unclear (▶Fig. 1.60, ▶Table 1.8). All materials induce a foreign body reaction characterized by foreign body giant cells and an inflammatory monocytic infiltrate with a surrounding capsule of fibrosis. This granuloma can still be found years later, though with diminished inflammatory activity over time. Systematic analysis of human mesh explants showed clearly that removal to treat chronic pain has

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1.5  Repair Principles and Materials

1

Fig. 1.57  Sublay mesh with integration into scar tissue.

Fig. 1.58  Expanded polytetrafluorethylene implant with marked reduction of the implant area due to shrinkage of the scar capsule.

become rare following widespread use of large-pored structures. Currently, over 100 different products are available, some of which differ considerably but some only very slightly. No significant advantage has been shown in clinical studies for most of these modifications, not least because they are intended to further reduce the occurrence of rare complications, and these complications may only occur with a latency of years. Both of these factors make it almost impossible to demonstrate the superiority of a medical device in general and of a mesh in particular in clinical studies. To date, an advantage has been shown in clinical trials only for high porosity, while other differences usually led to improvements that were without statistical significance. Accordingly, there is no evidence that multifilament materials are worse than monofilament materials, or that a super-hydrophilic titanium coating, a special polymer, the addition of absorbable filaments, or

Fig. 1.59  Mesh filament degradation. a Polypropylene. b Polyvinylidene fluoride. c Polyethylene terephthalate.

a special anisotropy or shape can contribute to significant improvements in the results. Since a certain grouping of mesh materials is essential for scientific comparisons, however, so that “similar”

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Introduction

Fig. 1.60  Thread pattern in knitted mesh.

Table 1.8  Assessment of implants according to textile properties Textile property

Assessment

Anisotropy

Porosity

The larger the pores, the smaller the resulting scar tissue

No

Shrinkage

Physiological wound contraction, correlates with the intensity of inflammation and scar formation

Yes

Elasticity

Based on deformation of the pores, usually with constriction and reduction of porosity on longitudinal expansion

Yes

Stability

Minimum strength 16 N/cm and 32 N/cm

Yes

Degradation

PET > PP > PVDF

–

Abbreviations: PET, polyethylene terephthalate; PP, polypropylene; PVDF, polyvinylidene fluoride.

implants can be evaluated against each other, grouping largely based on porosity has been developed: •• I: Large-pored meshes (textile porosity > 50%, effective porosity > 0%): ○○ 1a: Monofilament. ○○ 1b: Multifilament. ○○ 1c: Mixed structure or polymer. •• II: Small-pored meshes (textile porosity > 50%, effective porosity > 0%): ○○ 2a: Monofilament. ○○ 2b: Multifilament. ○○ 2c: Mixed structure or polymer. •• III: Porous meshes with special properties, e.g., against adhesions. •• IV: Films without porosity or pores < 1 µm or secondarily punched pores. •• V: Preshaped, preformed, 3D. •• VI: Biologicals: ○○ Cross-linked. ○○ Non-cross-linked. It can be assumed that no significant differences are found in clinical studies on comparison of materials within a group. Otherwise, it would be necessary to set up a new group. Whether individual materials or groups of materials have significant advantages for special procedures or forms of hernia or whether the available materials are all

similarly excellent, without leading to differences in the postoperative outcome, must be tested.

1.6  Hernia Biomechanics Christian Hollinsky

1.6.1 Introduction Operations to treat abdominal wall hernias are the most frequently performed procedures in an abdominal surgery department. Hernia development depends on many factors, including mechanical influences such as forces and pressures. Even since the introduction of meshes to hernia surgery, the recurrence rates have fallen significantly but are still far too frequent, e.g., over 15% in ventral hernia surgery.137 This section explains why this is so and shows the importance of biomechanics in the occurrence or prevention of abdominal wall hernias. The mechanics will also be unraveled so that the surgeon, faced with a difficult hernia operation, can select a mesh and the method of fixing it after considering the individual needs of that hernia.

Muscle Forces in the Abdominal Wall Abdominal wall function and integrity are essential for many activities of daily life such as coughing,

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1.6  Hernia Biomechanics laughing, and defecation. Intra-abdominal pressure (IAP) is increased by contraction of the oblique abdominal muscles and, to a lesser degree, the rectus muscles, thereby enabling these activities. These muscles meet in the midline, passing mainly horizontally from both sides to the linea alba. Coughing, in particular, generates sudden strong tensile stresses on the midline so that patients do not infrequently report bulging of the abdomen after “an attack of coughing.” These tensile stresses acting in the midline depend on the forces exerted by the muscles; the maximum force of the musculature averages about 40 N/cm2 25 of physiological cross-section. The greater the cross-section of a muscle, the more force it can exert. In this connection, the Ramirez relieving incisions for large ventral hernias are interesting, as they not only move the rectus muscles more medially again but also reduce the tensile stress of the oblique muscles on the midline to a minimum. In his study, Haider showed that the external oblique makes the greatest contribution to the lateral muscle force, at 42% on average.85 A Ramirez relieving incision182 thus leads to an obvious reduction in the lateral tensile stress of over 40%.

Linea Alba The tensile strength of muscle is consistently reported in the literature as about 100 N/cm2 while that of tendon is 10,000 N/cm2.25 The linea alba is a highly specialized tendinous strip and the forces acting on it correspond to the orientation of the collagen fibers. Axer13 showed that the majority of these collagen fibers are arranged horizontally and many also run crosswise. By contrast, no fibers run in cranial to caudal direction. This indicates that the main stress on the midline is in horizontal and oblique direction. From cadaver tensile tests, several authors have recognized independently that the linea alba can be stressed with 10 N/mm2 in horizontal direction but only 4.5 N/mm2 in vertical direction.99,118,183,206 An orderly arrangement of the collagen fibers is not found in the scar tissue following midline laparotomy. Peak horizontal stresses can therefore lead to tearing of the scar tissue and even incisional hernias.

strength of 40 N and the average tensile strength of 13 MPa are well above the stresses reported in the abdominal wall.56 Nevertheless, there are high recurrence rates of over 15%, especially in ventral hernia surgery, but tearing of the mesh or sutures tearing out of the mesh is very rarely the cause of recurrence. Nearly always, the join between mesh and tissue is insufficient so the mesh slides into the hernial opening or the scar tissue is insufficiently reinforced with the mesh.

Hernia Mesh Surfaces and Shear Areas Synthetic materials have two surfaces that come in contact with the tissue. Depending on their properties (surface, pore size, material, etc.) and their position in the abdominal wall, greater or lesser shear forces are present that prevent the prosthesis from slipping. Some of the first synthetic materials used in hernia surgery had a uniform surface without pores. Subsequently, prostheses made of these materials often slipped due to the absence of tissue integration. Nowadays, large-pored meshes are generally preferred and plastic sheets are hardly used. Many manufacturers endeavor to produce plastics with a smooth surface so as to cause as few foreign body reactions as possible. From the mechanical aspect, however, a rough surface is much better as this increases the adhesion properties in the tissue. ProGrip mesh, which has small micro hooks on one side to obtain good tissue fixation, is a good example. The area with which these micro hooks come in contact is critical for whether these hooks can be anchored well in the tissue. Muscle is ideal for hook integration as the strength of fixation even exceeds that of a hernia stapler.101 Fat or loose connective tissue is equally suitable. The micro hooks exhibit poor or absent integration in tendinous tissue such as the linea alba.102 ProGrip mesh is used in inguinal hernia surgery in both the Lichtenstein and TAPP technique. It is also used very successfully for the sublay technique in ventral hernia surgery.

Prosthesis Overlapping

Among the synthetic materials used in recent years, PP and polyester have proved to be very good for hernia surgery; there are no major differences in their mechanical properties.

Prosthesis overlapping increases the shear area and therefore adhesion in the tissue. Too much synthetic material is not useful as the prosthesis is a foreign body that can cause an immune reaction (e.g., development of scar tissue, chronic pain, etc.). Optimal overlapping of the prosthesis for the respective hernia is desirable but this depends on so many factors that a simple recommendation, e.g., a 5-cm mesh overlap over the hernial opening, is not feasible for all prostheses and hernias. Nonetheless, several parameters will be described here so that the reader can determine the required overlap for themselves.

Tensile and Tear Strength

Shear Stress/Shear Area

The meshes used currently in hernia surgery have adequate tear resistance. Both the average suture retention

Avoidance of recurrence depends primarily on the shear stress between the prosthesis and the surrounding tissue,

1.6.2  Mechanics of Hernia Surgery with Mesh Reinforcement Material Properties of Hernia Meshes

1

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Introduction especially in the case of ventral hernias. The shear stress τ is related to the shear force K and the area A as follows: τ=

K in (N/mm2) (1.1) A

Therefore: τ × A = K

T×A≥K K a

Shear surface A

T T×A1

~ ¾

1:1

1(–2)

2

>1

~1

1:2

0.5

1

2

>1

~1

1:4

300

0.5

1(–2)

2

>1

~1

1:4

600

400

–

~2

> 1–2

~1

1:4

Marcaine (bupivacaine)

150

150

–

0.25–0.375

3–5

≥ 30

~3

1:16

Duranest (etidocaine)

300

300

–

0.25–0.5

3–5

≥ 18

~2

1:10

200

0.75

0.75

1–5

Naropin (ropivacaine)

2–6

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1.8 Anesthesia Fig. 1.70  Local anesthesia II. Successive intradermal wheals along the skin incision.

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Fig. 1.71  Local anesthesia III. Injection sites after division of the subcutaneous tissue over the external oblique aponeurosis.

(▶Fig. 1.71). This floods the still closed inguinal canal and anesthetizes the three main nerves in the region. At the same time, the external oblique aponeurosis is separated from the ilioinguinal nerve beneath it. •• The base of the spermatic cord is injected (approximately 5–10 mL) in a circle around the deep ring and spermatic cord; this can usually be omitted around the round ligament in women (▶Fig. 1.72).

•• The periosteum of the pubic tubercle (Bassini, Shouldice) and iliopectineal eminence (McVay, Lotheissen) is injected depending on the planned form of repair (2 mL). • • The sac is injected at the ring (▶Fig. 1.73), guiding the tip of the needle with the index finger (5 mL).

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Introduction Fig. 1.72  Local anesthesia IV. Injection sites at the base of the spermatic cord over the deep inguinal ring.

Fig. 1.73  Local anesthesia V. Injection of the peritoneal sac at the base of the hernia.

The duration of action of the local anesthetic can be prolonged by spraying 10 mL on the opened inguinal

canal before closing the external oblique aponeurosis and on the subcutaneous tissue before closing the skin.

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1.9  Pediatric Hernia

1.9  Pediatric Hernia Gerhard Steinau

1.9.1 Indication Emergency operation for incarceration is an absolute indication and surgery is otherwise elective. The diagnosis of an inguinal hernia means surgery is indicated. This is usually an open procedure but pediatric hernias can also be managed laparoscopically.1,132 Diagnosis: History and findings on palpation: credible evidence of a hernia justifies operation. Surgery can be postponed in premature babies who should remain in hospital until their weight is above 2,000 g.214,215 There are no alternative procedures.

1.9.2  Preparation for Operation Preoperative diagnosis include History, findings on palpation, possibly ultrasonography.

1.9.3  Special Risks and Informed Consent •• Recurrence: 0.5 to 2%. •• Testicular atrophy: 0.5%. •• Wound infection: 2%.190,216

•• Exposure of the testicular vessels is helpful in identifying the hernial sac and distinguishing it from a bladder diverticulum. •• The best way to prevent recurrence is to excise the sac and close it at the deep inguinal ring. •• When cryptorchidism coexists with an inguinal hernia, orchidopexy must be performed simultaneously.

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1.9.8  Management of Special Complications •• Vas deferens injury: microsurgical suture. •• Recurrence: repeat high hernial sac excision.

1.9.9  Postoperative Care •• Wound inspection. •• Physical rest for 1 to 2 days.

1.9.10  Operation Techniques Inguinal Hernia Operation in Boys The operation steps are illustrated in ▶Fig. 1.74, ▶Fig. 1.75, ▶Fig. 1.76, ▶Fig. 1.77, ▶Fig. 1.78, ▶Fig. 1.79, ▶Fig. 1.80, ▶Fig. 1.81, ▶Fig. 1.82, ▶Fig. 1.83, ▶Fig. 1.84, ▶Fig. 1.85, ▶Fig. 1.86, ▶Fig. 1.87, and ▶Fig. 1.88.

1.9.4 Anesthesia General anesthesia up to the age of 14 to 16 years. Local anesthesia, spinal, or general anesthesia for cooperative patients over 16 years. Spinal or caudal anesthesia for premature infants and babies below 5,000 g.122

1.9.5 Position Supine with a roll under the buttocks to elevate the pelvis.

1.9.6 Access Transverse incision in the lower abdominal crease.

1.9.7  Relevant Anatomy, Dangers, and Tricks •• Injury and crushing of the vas deferens must be avoided. Fig. 1.74  The incision is made in the lower abdominal crease.

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Introduction Fig. 1.75  Splitting the external oblique aponeurosis. The superficial inguinal ring must not be split.

Fig. 1.76  The internal oblique muscle is pushed off the inguinal ligament.

Fig. 1.77  The cremaster fibers are split longitudinally.

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1.9  Pediatric Hernia Fig. 1.78  The shining whitish sac is grasped.

1

Fig. 1.79  The sac is opened between two clamps.

Fig. 1.80  The edges of the sac are grasped with clamps and the posterior wall of the sac is under-run with Wittgenstein scissors.

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Introduction Fig. 1.81  The posterior wall is under-run with Wittgenstein scissors, forming a ridge by applying two clamps.

Fig. 1.82  Opening the scissors facilitates detachment of the posterior wall of the sac from the spermatic cord structures. After completely under-running the sac, it is divided. The spermatic cord structures are pushed off the posterior wall of the sac.

Fig. 1.83  The proximal part of the sac is stretched with the clamps and the spermatic cord structures are pushed away with a fine swab.

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1.9  Pediatric Hernia Fig. 1.84  The sac is twisted, transfixed, and ligated. The spermatic cord structures are pushed away with a fine swab in retroperitoneal direction to avoid injury to the vas deferens.

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Fig. 1.85  Attachment of the internal oblique muscle to the inguinal ligament with 1–2 sutures.

Fig. 1.86  The external oblique aponeurosis is closed with continuous or interrupted sutures.

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Introduction Fig. 1.87  The subcutaneous tissue is closed with absorbable interrupted sutures.

Fig. 1.88  The skin is closed with continuous or interrupted absorbable sutures.

Hydrocele

Inguinal Hernia Surgery in Girls

Hydroceles often regress spontaneously in the first two years of life. Surgery is indicated after the age of 2 years, when the hydrocele is large or when an inguinal hernia is suspected (▶Fig. 1.89 and ▶Fig. 1.90).

Unlike the operation in boys, the hernial sac with the adherent round ligament is fixed below the internal oblique muscle with a transfixion ligature to secure the round ligament in position (▶Fig. 1.91, ▶Fig. 1.92, ▶Fig. 1.93, and ▶Fig. 1.94).

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1.9  Pediatric Hernia Fig. 1.89  Dissection of the processus vaginalis from the spermatic cord structures.

1

Fig. 1.90  After dividing the processus vaginalis, the spermatic cord structures are dissected bluntly and the processus vaginalis is transfixed and ligated at the deep inguinal ring. If necessary, the anterior wall of the hydrocele is opened to drain the fluid.

Fig. 1.91  Exposure of the hernial sac and ligature prior to division (the round ligament can bleed).

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Introduction Fig. 1.92  Dissection of the sac as far as the deep inguinal ring. It is opened, inspected, and closed with a transfixation ligature.

Fig. 1.93  The sac is removed and the round ligament is transfixed behind the internal oblique muscle in the Bastianelli procedure (caution: ilioinguinal nerve).

Fig. 1.94  The internal oblique muscle is attached to the inguinal ligament with 1–2 sutures.

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Introduction

Inguinal Testis When an inguinal testis is present with an inguinal hernia, orchidopexy should be performed at the same time. Hormone treatment is contraindicated in these

1.9  Pediatric Hernia

cases. ▶Fig. 1.95, ▶Fig. 1.96, ▶Fig. 1.97, ▶Fig. 1.98, ▶Fig. 1.99, ▶Fig. 1.100, ▶Fig. 1.101, ▶Fig. 1.102, ▶Fig. 1.103, ▶Fig. 1.104, ▶Fig. 1.105 and ▶Fig. 1.106 illustrate the operation steps.

1

Fig. 1.95  The external oblique aponeurosis including the superficial inguinal ring is split and the testis is mobilized after dividing the gubernaculum testis.

Fig. 1.96  The hernial sac is opened approximately 1 cm distal to the deep inguinal ring.

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Introduction

1.9  Pediatric Hernia Fig. 1.97  The sac is divided after forming a ridge on its posterior wall.

Fig. 1.98  The vas deferens can be dissected off the back of the sac by opening the tip of the scissors, and the posterior wall can be divided without injuring the vas deferens.

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Introduction

1.9  Pediatric Hernia Fig. 1.99  The sac is detached from the spermatic cord and closed with a transfixion ligature at the level of the deep inguinal ring.

1

Fig. 1.101  Horizontal incision of the ipsilateral scrotum.

Fig. 1.100  High retroperitoneal mobilization of the vessels and vas deferens with a fine swab.

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Introduction

Fig. 1.102  A subcutaneous pouch is formed between the skin and dartos fascia.

1.9  Pediatric Hernia

Fig. 1.103  Incision of the dartos fascia.

Fig. 1.104  A clamp is introduced from below and guided by the fingers to grasp the inferior pole of the testis.

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1.9  Pediatric Hernia

1

Fig. 1.105  The testis is pulled through and placed in the prepared pouch (beware of torsion).

Fig. 1.106  Suture fixation of the testis to the dartos fascia. The skin is closed with interrupted sutures.

Fig. 1.107  A 0.5-cm optical trocar at the umbilicus and 0.3-cm working trocars in the right and left middle and lower abdomen.

1.9.11 Laparoscopy The indications for laparoscopy are exactly the same as those for open procedures. The laparoscopic method is

increasingly regarded as an equivalent to open surgery. However, it involves higher equipment costs, which are not always covered by insurance. The operation steps are illustrated in ▶Fig. 1.107, ▶Fig. 1.108, and ▶Fig. 1.109. 63,76,152

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Introduction Fig. 1.108  Laparoscopic view of an indirect inguinal hernia.

Fig. 1.109  Closure of the hernia with a nonabsorbable suture.

Further Reading [1] Aasbø V, Thuen A, Raeder J. Improved long-lasting postoperative analgesia, recovery function and patient satisfaction after inguinal hernia repair with inguinal field block compared with general anesthesia. Acta Anaesthesiol Scand. 2002; 46(6):674–678 [2] Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall hernias: imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics. 2005; 25(6):1501–1520 [3] Albert E. Beiträge zur Geschichte der Chirurgie. Bd. III. Die Herniologie der Alten. Vienna: Urban & Schwarzenberg; 1877 [4] Amid PK, Shulman AG, Lichtenstein IL. Local anesthesia for inguinal hernia repair step-by-step procedure. Ann Surg. 1994; 220(6):735–737 [5] Annandale T. Case in which a reducible oblique and direct inguinal and femoral hernia existed on the same side and were successfully treated by operation. Edinburgh Med J. 1876; 21:1087

[6] Ansaloni L, Catena F, Coccolini F, Gazzotti F, D’Alessandro L, Pinna AD. Inguinal hernia repair with porcine small intestine submucosa: 3-year follow-up results of a randomized controlled trial of Lichtenstein’s repair with polypropylene mesh versus Surgisis Inguinal Hernia Matrix. Am J Surg. 2009; 198(3):303–312 [7] Ansaloni L, Catena F, Coccolini F, Negro P, Campanelli G, Miserez M. New “biological” meshes: the need for a register. The EHS Registry for Biological Prostheses: call for participating European surgeons. Hernia. 2009; 13(1):103–108 [8] Anson BJ, McVay CB. The anatomy of the inguinal and hypogastric regions of the abdominal wall. Anat Rec. 1938; 70:211–225 [9] Anson BJ, McVay CB. Inguinal hernia: I. The anatomy of the region. Surg Gynecol Obstet. 1938; 66:186–191 [10] Anson BJ, Morgan EH, McVAY CB. The anatomy of the hernial regions; inguinal hernia. Surg Gynecol Obstet. 1949; 89(4): 417–423 [11] Anson BJ, Reimann AF, Swigart LL. The anatomy of hernial regions. II. Femoral hernia. Surg Gynecol Obstet. 1949; 89:753–763

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1.9  Pediatric Hernia [12] Anson BJ, Morgan EH, McVAY CB. Surgical anatomy of the inguinal region based upon a study of 500 body-halves. Surg Gynecol Obstet. 1960; 111:707–725 [13] Axer H, Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths. I. General scheme and morphological aspects. J Surg Res. 2001; 96(1):127–134 [14] Axer H, von Keyserlingk DG, Prescher A. Collagen fibers in linea alba and rectus sheaths. J Surg Res. 2001; 96(2):239–245 [15] Bassini E. Nuovo metodo per la cura radicale dell’ernia inguinale. Atti Congr Assoc Med Ital. 1887; 2:179 [16] Bassini E. Sulla cura radicale dell’ernia inguinale. Arch Soc Ital Chir. 1887; 4:380–388 [17] Bassini E. Sopra 100 casi di cura radicale dell’ernia inguinale operata col metodo dell’autore. Arch Atti Soc Ital Chir. 1888; 5:315–319 [18] Bassini E. Nuovo metodo per la cura radicale dell’ernia inguinale. Padua: Prosperini; 1889 [19] Bassini E. Über die Behandlung des Leistenbruches. Arch Klin Chir. 1890; 40:429–435 [20] Bassini E. Neue Operationsmethode zur Radikalbehandlung der Schenkelhernie. Arch Klin Chir. 1894; 47:1–26 [21] Bay-Nielsen M, Kehlet H, Strand L, et al. Quality assesment of 26,304 herniorrhaphies in Denmark; a nationwide questionnaire study. Lancet. 2001; 358:1124–1128 [22] Bay-Nielsen M, Kehlet H. Anaesthesia and post-operative morbidity after elective groin hernia repair: a nation-wide study. Acta Anaesthesiol Scand. 2008; 52(2):169–174 [23] Beets GL, Oosterhuis KJ, Go PM, Baeten CG, Kootstra G. Longterm followup (12–15 years) of a randomized controlled trial comparing Bassini-Stetten, Shouldice, and high ligation with narrowing of the internal ring for primary inguinal hernia repair. J Am Coll Surg. 1997; 185(4):352–357 [24] Belams. Magazin für ausländische Literatur der gesamten Heilkunde und Arbeiten des ärztlichen Vereins in Hamburg. Hamburg: Perthes & Besser; 1832 [25] Bennighoff A, Drenckhahn D. Anatomie. 16th ed. Munich: Urban & Fischer; 2003 [26] Berg RA. Labial hernia: demonstration by herniography. AJR Am J Roentgenol. 1979; 133(1):138–139 [27] Billroth T. Clinical surgery: Reports of surgical practice between the years 1869–1876. London: New Sydenham. Soc.; 1881 [28] Bittner R, Arregui ME, Bisgaard T, et al; International Endohernia Society (IEHS). Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc. 2011; 25(9): 2773–2843 [29] Bloodgood JC. Operations on 459 cases of hernia in the Johns Hopkins Hospital from June 1889–January 1899. Johns Hopkins Hosp Rep. 1899; VII:223 [30] Braus H. Anatomie des Menschen. Fortgef. v. C. Elze. 3rd ed. Berlin: Springer; 1954 [31] Brenner A. Zur Radikaloperation der Leistenhernien. Zentralbl Chir. 1898; 25:1017–1023 [32] Brunus. Bruno von Langoburgo, cited from Gurlt, E., Geschichte der Chirurgie, Vol. III. Hildesheim: Olms; 1964: 729 [33] Bull WT. Cited by Halsted. In: The radical cure of inguinal hernia in the male. Johns Hopkins Hosp 1893;4:17 [34] Burton CC. The inguinal canal, a trihedral space; the adaptation of its anatomic boundaries to modern hernia repair. Surgery. 1954; 36(1):106–116 [35] Callesen T, Bech K, Kehlet H. One-thousand consecutive inguinal hernia repairs under unmonitored local anesthesia. Anesth Analg. 2001; 93(6):1373–1376 [36] Callesen T, Bech K, Kehlet H, Hvidovre Hospital Hernia Group. The feasibility, safety and cost of infiltration anaesthesia for hernia repair. Anaesthesia. 1998; 53(1):31–35 [37] Catterina A. Die Bruchoperation nach Bassini. Berlin: Urban & Schwarzenberg; 1933 [38] Celsus. De medicina. Vol. II. 19, vol. III, translated by Spencer. Cambridge: Harvard Univ. Press; 1938

[39] Championnière L. Cure radical des hernies avec une étude statistique de deux cents soixante-quinze opérations et cinquante figures intercalées dans le texte. Paris: Rueff; 1892 [40] Cheatle GL. An operation for inguinal hernia. BMJ. 1921; 2(3181):1025–1026 [41] Chelala E, Gaede F, Douillez V, Dessily M, Alle JL. The suturing concept for laparoscopic mesh fixation in ventral and incisional hernias: preliminary results. Hernia. 2003; 7(4):191–196 [42] Cloquet J. Recherches anatomiques sur les hernies de l’abdomen. Librairie Méquignon-Marvis; Paris 1817. Vol. 133:67–68 [43] Condon RE. Anatomy of the inguinal region and its relationship to groin hernias. In: Nyhus LM, Harkins HN, eds. Hernia. Philadelphia: Lippincott; 1964:28 [44] Condon RE. Surgical anatomy of the transversus abdominis and transversalis fascia. Ann Surg. 1971; 173(1):1–5 [45] Condon RE. The anatomy of the inguinal region and its relation to groin hernia. In: Nyhus LM, Condon RE. Hernia. London: Lippincott; 1989 [46] Conze J, Prescher A, Kisielinski K, Klinge U, Schumpelick V. Technical consideration for subxiphoidal incisional hernia repair. Hernia. 2005; 9(1):84–87 [47] Conze J, Prescher A, Klinge U, Saklak M, Schumpelick V. Pitfalls in retromuscular mesh repair for incisional hernia: the importance of the “fatty triangle”. Hernia. 2004; 8(3):255–259 [48] Cooper A. The Anatomy and Surgical Treatment of Abdominal Hernia. London: Longman; 1804:1807 [49] Cooper AP. Von den Brüchen. In: Lee A, ed. Vorlesungen über Chirurgie. Leipzig: Th. Fischer; 1838:1 [50] Corning HK. Lehrbuch der topographischen Anatomie für Studie­ rende und Ärzte. 24th ed. Munich: Bergmann; 1949 [51] Costanza MJ, Heniford BT, Arca MJ, Mayes JT, Gagner M. Laparoscopic repair of recurrent ventral hernias. Am Surg. 1998; 64(12):1121–1125, discussion 1126–1127 [52] Czerny V. Studien zur Radikalbehandlung der Hernien. Wien Med Wochenschr. 1877; 27:497 [53] de Castro Brás LE, Shurey S, Sibbons PD. Evaluation of crosslinked and non-crosslinked biologic prostheses for abdominal hernia repair. Hernia. 2012; 16(1):77–89 [54] De Chauliac G. La Grande Chirurgie composée en 1363 Revue avec des notes, une introduction sur le moyenage. Sur la vie et les oevres de Guy de Chouliac pan E. Nicaise. Paris: F. Alcan; 1890: 522 [55] De Gimbernat A. Nuevo metodo de repar en la hernia crunal. Madrid: Ibarra; 1793 [56] Deeken CR, Abdo MS, Frisella MM, Matthews BD. Physicomechanical evaluation of polypropylene, polyester, and polytetrafluoroethylene meshes for inguinal hernia repair. J Am Coll Surg. 2011; 212(1):68–79 [57] Deitch EA, Soncrant MC. The value of ultrasound in the diagnosis of nonpalpable femoral hernias. Arch Surg. 1981; 116(2): 185–187 [58] Depasquale R, Landes C, Doyle G. Audit of ultrasound and decision to operate in groin pain of unknown aetiology with ultrasound technique explained. Clin Radiol. 2009; 64(6):608–614 [59] Douglas KM. The anatomy of the transversalis muscle and its relation to inguinal hernia. J Anat Physiol. 1890; 24(Pt 2):220–226 [60] 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(4):448–451 [61] Egger B, Fawcett J, Dowling BL. Use of skin staples for securing the mesh in the Lichtenstein repair of inguinal hernia. Ann R Coll Surg Engl. 1996; 78(1):63–64 [62] Eisler P. Die Muskeln des Stammes. In: von Bardeleben K, ed. Handbuch der Anatomie des Menschen. Vol. 2, section 2, part 1.1. Jena: Fischer; 1912 [63] Esposito C, St Peter SD, Escolino M, Juang D, Settimi A, Holcomb GW, III. Laparoscopic versus open inguinal hernia repair in pediatric patients: a systematic review. J Laparoendosc Adv Surg Tech A. 2014; 24(11):811–818

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Chapter 2 Adult Inguinal Hernia

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Indications and Choice of Procedure

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2  Adult Inguinal Hernia 2.1  Indications and Choice of Procedure Volker Schumpelick As in the past, discussion continues to focus on the choice of inguinal hernia repair procedure, but the indications themselves are now the topic about which opinions vary widely.

2.1.1 Indications Only a few years ago, the finding of an inguinal hernia was an undisputed indication for surgery. The main argument was the risk of incarceration, which was estimated at 10% in the natural course of the condition. This was not confirmed by any studies, however, and has not been borne out by more recent studies, which reported the incidence of incarceration as less than 1% with a watch-and-wait approach. In addition, it was apparent that, apart from incarceration, the potential risk of an inguinal hernia in terms of morbidity and mortality is extremely low. The admonishments of surgeons in the past to operate early are thus no longer justified. When an inguinal hernia is diagnosed, the surgeon can suggest the patient to undergo surgery at a time that suits him if and when the hernia bothers him. This decision should be guided by his personal situation and without any compulsion. The timing should be sooner for patients with greater risk, general physical weakness, and troublesome comorbidities than for physically fit and athletic patients. This applies especially to patients with risk features such as iatrogenic or spontaneous blood clotting disorders, immune suppression, or other hazardous comorbidities. Patients with cardiovascular risk factors, diabetes, renal impairment, or previous abdominal surgery should undergo surgery when optimal preparation is possible; that is, they should have early elective surgery. It does not make sense to operate on these patients only when complications occur. This rule has not changed in the more recent era of watch-and-wait studies, where an early elective procedure continues to be the best approach. The same applies for giant hernias, recurrences, and inguinal hernias with detectable skin damage. Emergency surgery in these situations may be life-threatening and should therefore be avoided wherever possible by a well-timed elective procedure. Furthermore, operation is indicated when the patient desires it because the hernia is physically annoying or interferes with sporting activities, and also when the patient is concerned about it aesthetically. Even if the risk of incarceration is low, the body-conscious patient can be extremely bothered by the hernia swelling with the need for manual reduction after physical effort and his wish provides sufficient indication.

▶Absolute indications •• Incarcerated, nonreducible hernia. •• Incarcerated hernia with peritonitis or suspected bowel necrosis. •• Recurrent incarceration. ▶Relative indication •• Impaired general operability in elderly or severely ill patients. ▶Contraindications •• Incurable intra-abdominal conditions (e.g., peritoneal carcinomatosis). •• General and local inoperability (maximum 1% of all inguinal hernias). ▶Preparation •• Bowel cleansing by enema or laxatives the night before surgery. •• Shaving or chemical depilation of the operation area on the day of surgery. •• Topical disinfection of the operation area with conventional skin disinfectants. •• Transurethral catheter if necessary (e.g., in the case of prostatic hyperplasia). •• Medications can be given safely during inguinal hernia surgery, with the exception of anticoagulant drugs. Patients on warfarin should be switched to heparin. Patients on aspirin can be operated on safely at a dose of 100 mg per day but at higher doses this should be discontinued at least a week before the operation and these patients may need to be switched to heparin. ▶Position •• Supine position with the hips extended, and the head lowered if necessary. ▶ Anesthesia •• Local anesthesia: optional depending on hospital practice, advantageous especially for anterior sutured and patch and plug procedures and in elderly patients with cardiopulmonary disorders having outpatient surgery. •• Regional anesthesia: optional depending on hospital practice, advantageous especially for posterior mesh procedures without opening of the abdominal cavity. •• General anesthesia: optional depending on hospital practice, obligatory especially for laparoscopic techniques and complicated recurrent hernias.

Choice of Procedure This is currently the most controversial issue, with surgeons divided into different groups. Inguinal hernia repair procedures can be classified systematically into anterior and posterior approaches and into sutured and mesh procedures. The anterior sutured repairs include the

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2.2  Open Suture Techniques Bassini, Zimmerman, Lotheissen/McVay, and Shouldice methods, and the anterior mesh techniques include the mesh and plug techniques of Lichtenstein, Kugel, Rutkow, and others, such as the transinguinal preperitoneal technique (TIPP). The posterior approaches include the Nyhus technique with and without mesh, the Wantz, Stoppa, and Ugahary methods, and the laparoscopic totally extraperitoneal mesh repair (TEP), transabdominal preperitoneal mesh repair (TAPP), and intraperitoneal onlay mesh (IPOM). The decision is often made by the book and is more a matter of belief than factually grounded. This explains the regional, national, and international differences.

2.2  Open Suture Techniques 2.2.1  Approach and Dissection Volker Schumpelick

Indication

Relevant Anatomy, Dangers, and Tricks •• The transversalis fascia is the crucial plane for successful surgery so exposure and reconstruction must be anatomically exact. •• In routine cases, repair with reconstruction of the anatomy continues to be preferable to repair with introduction of alloplastic material.

Management of Special Complications •• Vascular injury: suture under vision (5/0 to 7/0 polypropylene). •• Vas deferens injury: direct suture (7/0 PDS).

Postoperative Management ▶Medical care. If a drain is placed then it is removed on day 2. Male patients should wear close fitting underpants in the first few days. The patient should be provided with an information leaflet on gradual resumption of physical effort and sports activities.

▶Relative. Proven inguinal hernia. Timing: soon after diagnosis and as an emergency if incarceration is present.

▶ Diet. Immediately.

▶Contraindications. None apart from absolute general inoperability or absence of consent.

▶ Mobilization. Immediately.

▶ Alternative procedures. Many, see below.

Operation Preparation ▶ Preoperative diagnostics. •• Ultrasonography. •• Doppler ultrasound of testis before surgery of recurrence.

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▶ Bowels. Enema if necessary.

▶ Physical therapy. None required. ▶ Incapacity for work. One to two weeks.

Operation Techniques Access

See ▶Fig. 2.1

Special Risks, Informed Consent •• Spermatic cord injury (1%). •• Wound infection (2%). •• Chronic groin pain (< 5%). •• Recurrence (1–10%). •• Mortality (< 0.2%).

Anesthesia Local anesthesia is preferable in cooperative patients; otherwise, spinal/epidural anesthesia or general anesthesia is used.

Position Supine.

Access Transverse or slightly oblique incision above the inguinal crease.

Fig. 2.1  Access is through a transverse skin incision in the lower groin crease; an oblique inguinal incision is an alternative. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.) 1 Iliohypogastric nerve. 2 Ilioinguinal nerve.

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Splitting the External Oblique Aponeurosis I See ▶Fig. 2.2. Fig. 2.2  After opening the subcutaneous tissue, the external oblique aponeurosis with the superficial inguinal ring is exposed. It is split superiorly, starting at the superficial ring. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

Splitting the External Oblique Aponeurosis II

Protecting the Nerves

See ▶Fig. 2.3.

See ▶Fig. 2.4.

Fig. 2.3  If the superficial ring is difficult to identify, the external oblique aponeurosis can be divided with a scalpel in cranial to caudal direction toward the superficial ring. The fascial edges are grasped with sharp clamps to draw them apart. The external oblique aponeurosis must be opened fully, including the superficial inguinal ring. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

Fig. 2.4  After opening the inguinal canal, the internal oblique and cremaster muscles are exposed. The ilioinguinal nerve, which usually runs on the internal oblique, is identified, dissected bluntly, and moved under the cranial retractor. The genital branch of the genitofemoral nerve is rarely visible immediately, as shown here; it is usually more posterior and only becomes visible after the cremaster is divided. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

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2.2  Open Suture Techniques

Splitting the Cremaster See ▶Fig. 2.5.

Fig. 2.5  The cremaster muscle is split with scissors, using 3 Roux hooks to expose the operation field. It is split down to the shiny internal cremasteric fascia, which can be separated easily from the spermatic cord beneath it. Injury to the spermatic cord structures is avoided by blunt dissection. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

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Dissection of the Cremaster Muscle See ▶Fig. 2.6.

Fig. 2.6  The spermatic cord is dissected from the cremaster by a combination of blunt and sharp dissection. The genital branch of the genitofemoral nerve in the posterior part must be protected carefully and preserved. It often runs jointly with the external cremasteric vessels in the deep inguinal ring. The spermatic cord is snared with a loop and the two parts of the cremaster are pushed away bluntly in cranial and caudal direction. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

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Resection of the Cremaster Muscle See ▶Fig. 2.7. Fig. 2.7  The cremaster muscle can be divided between clamps and resected, and the stumps can be ligated. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

Dissection of the Hernial Sac See ▶Fig. 2.8.

Fig. 2.8  By pulling gently on the rubber snare around the spermatic cord and, if necessary, grasping the sac with Duval forceps, the sac can be detached gradually from the spermatic cord and transversalis fascia by blunt and sharp dissection. If it is highly adherent and its course is unclear, it can sometimes be helpful to open the sac at this stage of the dissection to expose the structures more clearly. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

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2.2  Open Suture Techniques

Dissection of the Neck of the Sac See ▶Fig. 2.9.

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Fig. 2.9  Dissection of the sac must extend to the gap in the transversalis fascia. If this is at the deep inguinal ring, in the case of an indirect hernia, the deep ring must be exposed completely. The spermatic cord must be dissected at the deep ring to expose the bifurcation of the vas deferens and spermatic vessels clearly. The hernial sac must be dissected on all sides at the deep ring and detached from all adhesions to the transversalis fascia. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

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Management of the Hernial Sac See ▶Fig. 2.10. Fig. 2.10  If the sac contents cannot be reduced or intra-abdominal involvement (incarceration, metastases, etc.) is suspected, the sac must be opened. It is grasped between forceps, opened longitudinally, and stretched between four clamps (a and b). Adherent bowel can be dissected with scissors if it is not fixed too extensively (c). Otherwise, the bowel should not be detached widely but the sac should be closed and buried with a purse string suture. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

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b

c

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2.2  Open Suture Techniques

Division of the External Cremasteric Vessels

Direct Hernial Sac Dissection

See ▶Fig. 2.11.

See ▶Fig. 2.12.

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Fig. 2.11  The external cremasteric vessels, which arise from the inferior epigastric vessels, should be divided and ligated with a transfixion suture. The genital branch of the genitofemoral nerve regularly runs in this area and should be preserved where possible. It is not essential to divide the external cremasteric vessels but this provides clearer exposure at the deep ring. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

Fig. 2.12  With direct inguinal hernias, an incision is made in the transversalis fascia around the sac leaving superior and inferior fascial margins that can be sutured. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

Management of the Hernial Sac II See ▶Fig. 2.14.

Management of the Hernial Sac I See ▶Fig. 2.13.

Fig. 2.13  The sac is managed in different ways. At the deep ring, it can be twisted, transfixed, and ligated. The protruding end is excised. This is the simplest and at the same time the most common method. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

Fig. 2.14  Direct inguinal hernial sacs, sacs containing adherent bowel that cannot be mobilized, and sliding hernias are buried with a purse string suture. The purse string suture must be placed without injuring any internal structures. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

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Management of the Hernial Sac III See ▶Fig. 2.15. Fig. 2.15  Opening the sac of a direct hernia can usually be omitted. A purse string suture is placed and tightened after reducing the sac contents, and the sac is buried behind the fascia. When this method is used, it is important to split the transversalis fascia fully beforehand and hold it apart with clamps (a). This is the only way to ensure that the sac is buried without involving the transversalis fascia, which is later so important for the repair (b). (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

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2.2  Open Suture Techniques

Removal of a Preperitoneal Lipoma See ▶Fig. 2.16. Fig. 2.16  After (and sometimes before) dealing with the hernial sac, the preperitoneal lipoma must be dissected sharply from the spermatic cord. It is then transfixed at its base, ligated, and excised. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.97)

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Inspection of the Transversalis Fascia See ▶Fig. 2.17. Fig. 2.17  After exposure of the posterior wall of the inguinal canal, the strength of the transversalis fascia is tested by inserting the index finger into the deep ring. If the fascia can be moved easily and is not highly resistant, complete posterior repair must be performed. The hernia type is then classified, distinguishing between lateral (L) = indirect and medial  (M) = direct hernias, size I (< 1.5 cm), II (< 3 cm) and III (> 3 cm). LI and MI hernias can be sutured directly, LII and MII hernias can be repaired by complete fascial doubling, and larger hernias may be repaired with a polypropylene mesh. The most important methods, which are used for 85% of all inguinal hernias, will be shown. Small indirect hernias can be repaired by the Zimmerman method of isolated reconstruction of the deep ring. However, complete division of the transversalis fascia and repair by doubling it (the Shouldice method) is usually the procedure of choice. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

2.2.2  Hernia Repair Bassini Repair Volker Schumpelick

Indication The Bassini repair is rarely indicated routinely nowadays. We have not performed this operation for many years as it has been replaced by the Shouldice repair. It should nevertheless be in every surgeon’s potential repertoire. After excising the hernial sac, the posterior wall of the inguinal canal is exposed and the spermatic cord is snared and retracted laterally. The wall is palpated with a finger to detect any instability or defect.

Operation Techniques Repair Principle See ▶Fig. 2.18.

Fig. 2.18  The Bassini inguinal hernia repair consists of attachment of the three-layer abdominal wall to the inguinal ligament by a single row of interrupted sutures through the three layers. The spermatic cord is positioned in front of the muscle and behind the external oblique aponeurosis. (From Hollinshead WH. The abdominal wall and inguinal region. In: Anatomy for Surgeons: The Thorax, Abdomen and Pelvis. Vol. 2. New York, NY: Hoeber; 1956.)

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2.2  Open Suture Techniques Incision of the Transversalis Fascia Although omission of this step is often advocated, splitting the transversalis fascia is an essential part of the Bassini repair. This is the only way to obtain the three layers for suturing. The fascia is split from the deep inguinal ring to the pubic tubercle (▶Fig. 2.19). This includes the orifice of a medial hernia. As in the fascial splitting that forms part of the Shouldice repair, the epigastric vessels should be carefully preserved.

Splitting the transversalis fascia opens the hernial orifice. This exposes the tissue layers that will later be sutured: the transversalis fascia, the transversus abdominis and internal oblique muscles, and the inguinal ligament (▶Fig. 2.19).

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First Three-Layer Medial Bassini Suture Closure of the hernial opening starts at the medial angle of the groin. Nonabsorbable (2/0 polypropylene) or slowly absorbable (2/0 PDS) suture material is used. The first suture passes through the junction of the internal oblique with the edge of the transversus abdominis (conjoint tendon or inguinal falx). This is followed by the two margins of the transversalis fascia and finally the reflected ligament and pubic periosteum. This is the actual Bassini suture (▶Fig. 2.20). It is important that the stitch through the periosteum does not injure the bone (causing subsequent pain).

Complete Row of Bassini Sutures Prior to Tying Interrupted sutures are now placed at intervals of 0.6 cm as far as the deep inguinal ring, which catch the inferior border of the inguinal ligament tangentially instead of the periosteum. These can also be placed as U-sutures but must have wide bridges so as not to

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Fig. 2.20  Placement of the first suture, the actual Bassini suture, at the medial end of the wound, picking up the pubic periosteum.

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Adult Inguinal Hernia interfere with tissue perfusion. These are held with clamps (▶Fig. 2.21). If the cremaster was not resected, it can be included to reinforce the posterior wall.18

Tying the Bassini Sutures The Bassini sutures are tied individually to approximate the tissue, starting at the medial end. The newly constituted deep ring must admit the tip of the little finger or forceps to ensure that the spermatic cord has enough room. If the deep ring remains too large due to a high position of the internal oblique, a suture anterior to the spermatic cord can fix the internal oblique to the inguinal ligament (▶Fig. 2.22). If the sutures are tense, a relieving incision in the rectus sheath may be indicated.

Girard Variation This suture can also be placed so that the aponeurosis forms a double layer, in the Girard or Halsted/Ferguson method (▶Fig. 2.24).

Kirschner Variation The Kirschner method is a modification of the Bassini procedure.49 In this, the split external oblique aponeurosis is sutured beneath the spermatic cord, making it subcutaneous in position (▶Fig. 2.25). This should theoretically produce additional reinforcement of the posterior wall of the inguinal canal. In fact, however, moving the spermatic cord to a subcutaneous position abolishes the offset closure of the inguinal canal, which degenerates into a direct “hernial hole” due to superimposition of the deep and superficial rings, with an extremely high risk of recurrence.

Closure of the External Oblique Aponeurosis

The Hackenbruch Variation

The anterior wall of the inguinal canal is reconstructed by closing the external oblique aponeurosis with interrupted sutures of the same material (2/0 polypropylene or PDS; ▶Fig. 2.23). This allows a new superficial ring to be constructed, which should be reduced in size and located as far medially as possible.

Some surgeons prefer to combine Bassini hernia repair with the Hackenbruch doubling of the external oblique aponeurosis42 in the hope that this will further secure the hernial opening (▶Fig. 2.26). The operation concludes with a subcutaneous vacuum drain and skin suture.

Fig. 2.21  Complete placement of 4–6 Bassini sutures, held with clamps.

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2.2  Open Suture Techniques Fig. 2.22  Tying the Bassini sutures from medial to lateral. The deep ring is tightened so that it just admits the tip of a forceps or the tip of the little finger beside the spermatic cord.

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Fig. 2.23  Closure of the external oblique with interrupted or continuous sutures.

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Adult Inguinal Hernia Fig. 2.24  Girard modification, doubling the external oblique aponeurosis in front of the spermatic cord.

Fig. 2.25  The Kirschner modification of the external oblique aponeurosis closure by doubling it behind the spermatic cord.

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2.2  Open Suture Techniques Fig. 2.26  The Hackenbruch modification of external oblique aponeurosis closure by doubling it and creating a new inguinal canal lined by fascia.

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The Zimmerman Repair Karsten Junge

Indication The Zimmerman anterior sutured repair is suitable especially for small lateral hernias in young patients. It is indicated when the hernial opening at the deep inguinal ring (L1) is less than 1.5 cm in size following exposure of stable transversalis fascia with complete dissection of the spermatic cord from the deep ring. The deep ring is usually only moderately extended and irregular, and barely admits more than one fingertip (▶Fig. 2.27).

Operation Preparation •• Preoperative diagnosis by clinical examination. •• Ultrasonography of the groin.

Special Risks None apart from the usual complications of inguinal hernia repair: •• Spermatic cord injury (1%). •• Wound infection (2%).

•• Chronic groin pain (< 5%). •• Recurrence (1–10%).

Anesthesia Local anesthesia in cooperative patients, otherwise spinal or epidural anesthesia or general anesthesia.

Position Supine.

Access Transverse or slightly oblique incision above the inguinal crease.

Relevant Anatomy, Dangers, and Tricks The crucial requirements for a successful outcome are medially stable transversalis fascia and accurate tightening of the deep ring without a risk of recurrence or strangulation.

Management of Special Complications Ligature of epigastric vessels and suture of vas deferens if injured.

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Adult Inguinal Hernia Fig. 2.27  Wide deep inguinal ring with the transversalis fascia otherwise strong as far as the pubic bone (L1): tightening of the deep ring by the Zimmerman method is indicated.

Postoperative Management ▶Medical care. •• Male patients should wear close fitting underpants in the first few days. •• The patient should be provided with an information leaflet on gradual resumption of physical effort and sports activities. ▶ Diet. Immediately. ▶ Bowels. Enema if necessary. ▶ Mobilization. Immediately. ▶ Physical therapy. Not required.

Operation Techniques Dissection of the preperitoneal fat is a precondition for safely tightening the deep inguinal ring. The spermatic cord is first snared and held under tension and the fat attached to the deep ring and transversalis fascia is pushed bluntly off the fascial margin. The edges of the deep ring are then grasped with Kocher clamps and drawn medially (▶Fig. 2.28). The superior part of the abdominal muscles is retracted to allow suture of the entire circumference of the deep ring. Suturing is done medial to the spermatic cord, and the cranial parts of the transversalis fascia and possibly the transversus abdominis aponeurosis and the inferior

fibers of the iliopubic tract, and, if necessary, the inguinal ligament can be included in the suture. In Zimmerman’s original method, the caudal part of the iliopubic tract and the inguinal ligament are included (▶Fig. 2.29). Stable medial transversalis fascia is essential for this repair method. If this is weak and tenuous, it should be doubled completely, as in the Shouldice procedure. When the fascia is stable and especially when there is merely a persistent processus vaginalis, repair of the deep inguinal ring alone is just as safe. The deep ring should be tightened to fingertip width as there is a risk of recurrence if the deep ring is too wide but excessive tightening risks strangulation of the spermatic cord with a consequent danger of ischemic orchitis. An 11.5 Hegar dilator can be used for standardization. A continuous single-layer or two-layer suture is an alternative to a single row of interrupted sutures (▶Fig. 2.30, ▶Fig. 2.31). After tightening the deep inguinal ring, the internal oblique and transversus abdominis muscles can be fixed to the inguinal ligament in a single row of interrupted sutures or a two-row continuous suture, starting medially behind the spermatic cord. This corresponds to the Bassini and Shouldice reconstruction of the muscle plane. In Zimmerman’s original method, any fixation of muscle to the inguinal ligament is omitted to preserve its mobility. The operation ends with suture of the external oblique aponeurosis (▶Fig. 2.32) after repositioning the spermatic cord, approximating subcutaneous interrupted sutures, and wound closure.

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2.2  Open Suture Techniques

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Fig. 2.28  Grasping the mobilized fascial edges of the deep inguinal ring with Kocher clamps.

Fig. 2.29  Placing the sutures through the superior (transversus abdominis aponeurosis) and inferior (iliopubic tract) suture lines.

Fig. 2.30  Alternative reconstruction of the deep inguinal ring by a singlerow continuous suture from medial to lateral (a). It is tightened until it just admits a closed clamp or forceps beside the spermatic cord (b).

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Fig. 2.31  a and b Alternative reconstruction of the deep inguinal ring by direct closure (a) and doubling of the superior layer of the transversalis fascia over the inferior layer (b). The suture starts laterally, turns around at the medial end, and continues back laterally.

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Adult Inguinal Hernia Fig. 2.32  The external oblique aponeurosis is closed by a continuous suture.

Minimal Repair Technique Ulrike Muschaweck and Christoph Peter Schuhmacher

Indication The minimal repair technique is an innovative operation technique that can be used for inguinal hernia repair and to treat sports hernia. Minimal repair is performed without insertion of mesh. The technique was developed by our working group in 2002 and we have now treated more than 3,500 patients with the minimal repair method. The minimal repair technique is suitable for all patients in whom the consistency and structure of the transversalis fascia allows direct suture. Therefore, the final decision on this type of repair is often made only at operation after an assessment of the anatomy. We use the minimal repair technique mostly for groin pain due to sportsman’s groin (see section ▶3.2), where there is protrusion of the posterior wall of the inguinal canal with compression of the genital branch of the genitofemoral nerve (▶Fig. 2.33). However, patients with a direct (M 1–2) or indirect (L 1–2) inguinal hernia are benefiting increasingly from the technique. In patients with sportsman’s groin, operative intervention is indicated, especially when targeted rest combined with anti-inflammatory medication is in‑­ effective within 6 to 8 weeks. This recommendation

Fig. 2.33  Pathomechanism of “sportsman’s groin.” Weakness of the posterior wall of the inguinal canal can cause sudden or chronic recurrent irritation of the genital branch of the genitofemoral nerve.

is based on the highest available level of medical evidence. In a randomized study,27 professional footballers with the described symptom complex were divided into four groups: a control group without treatment,

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2.2  Open Suture Techniques two treatment arms with different physical exercise programs, and a group treated surgically. Patients who had reinforcement of the inguinal canal (posterior wall) and neurolysis and neurectomy of the genital branch of the genitofemoral nerve had a significantly better outcome 6 months after the respective treatment. The preoperative diagnostic tests are described in section ▶3.2.

Special Risks and Informed Consent When selecting treatment, conservative management should always be considered first, if this has not been attempted already. When the history and clinical symptoms are consistent, however, one should be aware that further delay of surgery may lead to chronification rather than improvement of the symptoms. Conservative therapy should therefore not continue longer than 6 to 8 weeks. Patients must be given complete preoperative information about risks such as secondary bleeding, seroma, wound infection, spermatic cord injury, testicular atrophy, chronic groin pain, and persistent numbness, and about the possibility of recurrence.

Anesthesia The operation is performed under local conduction anesthesia, which is injected at the anterior superior iliac spine and in the area of the planned skin incision. The ilioinguinal and iliohypogastric nerves and the genital branch of the genitofemoral nerve are exposed at operation and local anesthetic is injected directly into the perineurium. The patient is fully monitored by an anesthesiologist. Concomitant analgosedation can be given if the patient wishes.

Position As in inguinal hernia surgery, the operation is performed with the patient in the supine position. To relieve the groin region, gel pads are place beneath the buttocks and knees. To minimize wound infections, appropriate sterile preparation of the operation field including the genital region, must be ensured. An adhesive incision drape is applied to the skin.

Access The incision is similar to the classic inguinal hernia incision in the groin but is only 4 cm long. The distal medial part of the incision should be slightly oblique to allow adequate dissection on the pubic bone.

Relevant Anatomy, Dangers, and Tricks Sportsman’s groin is often due to irritation of the genital branch of the genitofemoral nerve (▶Fig. 2.33). The

circumscribed weakness of the transversalis fascia forces apart the matrix of muscle fasciae and tendons passing to the pubic bone, and symptoms are worsened by pinpoint stress on the bone insertion sites on the pubic bone. This was described by Morales-Conde73 as “syndrome of muscle imbalance of the groin.” The epigastric vessels posterior to the transversalis fascia, with their cremasteric branches, are at risk during dissection of the inferior fascial leaf that is needed for the first row of sutures. In most cases, it should be possible to push back the epigastric vessels by blunt dissection, resecting the small branches of the cremasteric vessels, and this will create a fascial border 0.5 cm wide for this row of sutures.

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Complication Rate The management of special complications is generally identical with that of regular hernia surgery. A prospective study of recurrence after minimal repair of inguinal hernia is currently in progress. The initial results show that the outcome is similar to or better than the compared methods (Shouldice, Lichtenstein). As mesh implantation is omitted, the rate of postoperative seroma and hematoma is much lower compared with the Lichtenstein repair. The abdominal wall muscles still slide smoothly, which is essential, especially for athletes.

Postoperative Management When the patient is discharged on the day of operation, postoperative care includes ultrasonography including Doppler ultrasound of the testis on the operated side. Adequate nonsteroidal anti-inflammatory analgesia is prescribed. For patients with sportsman’s groin, we draw up an individual training program with the following guidelines: light running is permitted from the second postoperative day. Training units are increased from the third day, and full stress is permitted from the fifth day. Full stress without any restriction, including high-performance sport, should always be possible after 10 to 14 days.

Results of Minimal Repair of Sportsman’s Groin According to an Australian study in footballers,112 the risk of symptom persistence after a year is 59% with conservative treatment only. In our study of 132 consecutive patients who underwent minimal repair surgery, 78.9% were completely asymptomatic a median 14 days after the operation (range 7–28 days). 83.3% of the professional athletes in this group (87 of 129; 67%) reached their peak preoperative performance after a median 14 days (range 10–28 days).74

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Adult Inguinal Hernia

Operation Techniques Following dissection of the subcutaneous tissue, the external oblique aponeurosis is exposed and is split from lateral to medial above the midline. It is important that the ilioinguinal nerve and more superior iliohypogastric nerve beneath the aponeurosis are not injured. The nerves should not be mobilized from their fascia. The cremaster muscle should always be preserved in full. The pampiniform plexus is snared together with the ilioinguinal nerve. The posterior wall of the inguinal canal can then be palpated directly and the weak area of tissue can be exposed (▶Fig. 2.33). The defect is now opened (▶Fig. 2.34).

Caution



To ensure that the defect is not extended, it is important to grasp the edges of the defect precisely with small sharp forceps and dissect it accurately. The genital branch of the genitofemoral nerve must always be exposed and its surface assessed. If this is smooth and shining, resection can be omitted. If the nerve surface is dull and yellowish, and macroscopically fibrosed, resection is advisable. Resection is also recommended if the anatomical position of the nerve prevents adequate closure of the posterior wall defect at the deep inguinal ring.

Fig. 2.34  After dissecting the subcutaneous tissue and splitting the external oblique aponeurosis, the posterior wall of the inguinal canal is exposed and the weak area of tissue is opened, without enlarging the defect. The genital branch of the genitofemoral nerve is assessed macroscopically and resected if necessary.

When dissecting the leaf of fascia needed for the first row of sutures, it is important that these can be placed without tension. The inferior leaf is dissected from the iliopubic tract from superomedial to inferolateral, avoiding inclusion of the inguinal ligament in the first row of sutures. It is also important not to go beyond the fascial border of the defect (▶Fig. 2.35). The first row of sutures starts at the medial edge of the defect, placing them from inferior to superior. As in the Shouldice repair, the white line is the superior boundary. The superior leaf of fascia created by the first suture is now grasped and fixed by a continuous suture to the lowest point of the inguinal ligament (▶Fig. 2.36), using a 2/0 monofilament nonabsorbable suture (e.g., Prolene). The suture turns back at the deep inguinal ring, which it tightens; it should still admit an 11.5 mm Hegar dilator easily. The suture is now continued medially to the pubic bone to lateralize the rectus abdominis thereby reducing the vertical pull on the pubic bone (▶Fig. 2.37). Finally (▶Fig. 2.38), the pampiniform plexus with the preserved ilioinguinal nerve is protected from mechanical irritation by forming a small lateral lip of the internal oblique muscle. The external oblique aponeurosis is then doubled by a two-row continuous suture using monofilament absorbable material (e.g., Monocryl, 3/0) with the spermatic cord replaced in subfascial position. After careful hemostasis, the wound can now be closed in layers with a continuous subcutaneous suture. A vacuum drain is not placed. The skin is closed with a continuous absorbable intracutaneous suture, e.g., Monocryl 4/0.

Fig. 2.35  After splitting the transversalis fascia and creating the inferior leaf of fascia from the iliopubic tract, the inferior leaf is fixed to the posterior wall of the superior leaf with a continuous suture, starting medially. The superior boundary is the white line. The suture is tied medially and positioned below the second row of sutures.

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2.2  Open Suture Techniques

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Fig. 2.36  The resulting layer of fascia is doubled from superior to distal with a continuous suture. The suture picks up the inguinal ligament deeply, thus reinforcing the anterior abdominal wall.

Fig. 2.37  With this suture, the rectus abdominis is lateralized, thereby reducing the vertical pull on the pubic bone.

After exposing the deep inguinal ring, the index finger (of the left hand on the right side and right hand on the left side) is inserted in the deep ring to test the resistance of the transversalis fascia to pressure from behind. This test is unnecessary with medial hernias as fascial defects requiring repair are present in any case, and fascial doubling is indicated. With lateral hernias, extensive weakness is found in nearly 90% of the cases, indicating additional fascial doubling. Occasionally, for instance with small hernias, only the lateral part of the fascia is thinned. In this situation, partial splitting and repair will suffice. The transition with the Zimmerman procedure of only tightening the deep inguinal ring is fluid.

Operation Techniques Repair Principle See ▶Fig. 2.39. Fig. 2.38  Creation of a lateral sleeve of muscle with the lower border of the internal oblique around the spermatic cord to reinforce the deep inguinal ring and protect the pampiniform plexus against mechanical irritation.

Digital Examination of Fascial Stability See ▶Fig. 2.40.

Splitting of the Transversalis Fascia

Shouldice Repair Volker Schumpelick and Andreas Tittel

Indication This is the standard open anterior hernia repair nowadays.

The first step is to split the transversalis fascia obliquely from the deep inguinal ring toward the pubic tubercle (▶Fig. 2.41). The length of the incision is guided by the extent of the fascial weakness or hernial orifice but usually extends fully to the pubic bone. Partial splitting followed by doubling occasionally suffices with small indirect hernias and stable transversalis fascia. With large

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Adult Inguinal Hernia direct hernias, it is often difficult to identify the fascial edges. These should be dissected gradually off the hernial sac and marked with the Kocher clamps. After managing the sac, fascial doubling can take place. When incising the transversalis fascia, the epigastric vessels beneath it must be carefully preserved. They are located in the loose preperitoneal fat and usually comprise two veins and one artery. Collateral vessels to the spermatic cord (the external cremasteric vessels) are regularly found and must be ligated between clamps and divided. Without this precaution, persistent and troublesome bleeding can occur. If the epigastric vessels are injured, they must be double ligated and divided. Fig. 2.39  The principle of the Shouldice inguinal hernia repair consists of doubling of the defective transversalis fascia by two continuous rows of fascial suture and attachment of the transverse and internal oblique muscles to the inguinal ligament by a continuous suture. The spermatic cord is positioned in front of the muscle and behind the external oblique aponeurosis.

Dissection of the Superior Fascial Layer After splitting the transversalis fascia, the superior part is grasped with sharp forceps and dissected bluntly from the preperitoneal fat (▶Fig. 2.42). The femoral canal can be demonstrated inferiorly. Any femoral hernia is first closed.

Fig. 2.40  Digital examination of the strength of the transversalis fascia by palpation through the deep inguinal ring. If the wall is weak, the transversalis fascia may bulge forward. Fascial doubling using the Shouldice method is indicated for small fascial defects or weak areas; Lichtenstein mesh repair is indicated for bigger defects (see section ▶2.3.1).

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2.2  Open Suture Techniques Fig. 2.41  Extent and direction of transversalis fascia splitting.

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Fig. 2.42  Dissection of the superior fascial layer from the underlying preperitoneal fat until the lateral border of the rectus sheath and arch of the transversus abdominis aponeurosis (the white line) are exposed. This is followed by sparing dissection of the inferior leaf.

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Adult Inguinal Hernia Excision of Defective Fascia and Creation of Stable Borders The inferior leaf of the transversalis fascia should be mobilized only until the femoral hernial orifice is visualized. It too is grasped with sharp forceps. If the central

part is thin and fragile, it is resected to provide strong edges that can be sutured (▶Fig. 2.43). The superomedial leaf of the transversalis fascia is usually narrower than the inferolateral one, which should be approximately 1.5 to 2.0 cm wide, if possible. Fig. 2.43  When there is a fascial defect with a large medial hernia, the weak part of the fascia is resected. It is incised (a) and dissected off (b) to leave the edges that can be sutured.

D

E

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2.2  Open Suture Techniques First Suture “Lower Below Upper” from Medial to Lateral Repair of the transversalis fascia starts with suture of the inferior leaf behind the superior leaf. The first suture is placed in the medial corner of the fascia at the pubic tubercle and fixes the caudal border of the divided transversalis fascia to the underside of the cranial part (▶Fig. 2.44). In the medial part, the sutures are placed in the posterior surface of the rectus sheath, which gleams through the transversalis fascia (the “white line”). In the lateral segment, the sutures are placed in the tendinous part of the transversus abdominis aponeurosis. The suture is continuous, placed at intervals of 0.6 cm, and each stitch is inserted 0.6 to 1.0 cm from the edge of the tissue. The suture (monofilament, polypropylene 0 to 2/0 or PDS 0 to 2/0) should be under even tension and not too tight so that a continuous approximation is obtained.

After inserting the first stitch at the pubic tubercle, the suture is tied, leaving a long end. The suture is continued as far as the deep inguinal ring, where the superior part of the cremaster muscle can be included. Additional securing (“plugging”) of the deep hernial orifice can be achieved in this way. The deep ring should be tightened so that it admits the index finger tip or a 11.5 Hegar dilator alongside the spermatic cord, which has been dissected free of the cremaster.

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Second Suture “Upper Over Lower” from Lateral to Medial Starting from the deep inguinal ring, the suture direction is reversed and continues by suturing the cranial to the caudal leaf from above. The sutures are placed in the iliopubic tract (▶Fig. 2.45) and the insertion of the inguinal ligament. Fig. 2.44  Start of fascial doubling medially on the pubic periosteum with a continuous suture. The caudal leaf of the transversalis fascia is sutured below the cranial leaf, pushing the preperitoneal fat back with a swab.

Fig. 2.45  Second fascial suture from lateral to medial attaching the cranial leaf to the caudal one. The sutures are placed in the iliopubic tract at the base of the inguinal ligament. The suture is continuous.

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Adult Inguinal Hernia Medial Oversewing of the First Knot and Tying

Third Suture as First Muscle Suture

After the pubic tubercle is reached, the continuous suture is continued two more stitches medially (▶Fig. 2.46a) to prevent suprapubic recurrence. After turning around and locking it at the pubic tubercle, the suture is tied with the long end left at the start (▶Fig. 2.46b).

When the double row of fascial sutures is complete, the transversus abdominis muscle is fixed to the inguinal ligament with a continuous suture, starting from the deep inguinal ring. This suture is fixed at the base of the inguinal ligament to avoid any dead space (▶Fig. 2.47).

D

E

Fig. 2.46  At the medial end, the suture is continued over the reflected ligament (a) and then returns to the starting point (b). Here it is tied with the initial long end.

Fig. 2.47  Attachment of the muscle to the inguinal ligament by a two-row continuous suture, starting laterally. The first row picks up the transversus muscle and the lower edge of the internal oblique.

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2.2  Open Suture Techniques Fourth Suture as Second Muscle Suture After the deep muscle suture has reached the pubic bone, it turns back to fix the internal oblique to the inguinal ligament in a fourth row (▶Fig. 2.48). When the deep inguinal ring is reached, the continuous suture is tied with the long end of the first muscle suture. According to Berliner,9 the double attachment of the muscle can achieve a similarly good result with a single row of sutures that combine both muscle

components. We prefer two rows of suture because of the better attachment of the muscles.

Closure of the External Oblique Aponeurosis The external oblique aponeurosis is closed over the spermatic cord with a single-row continuous suture using 2/0 PDS (Maxon; ▶Fig. 2.49). The operation concludes with an optional subcutaneous vacuum drain (not used routinely) and skin suture.

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Fig. 2.48  Second row of the muscle suture, attaching the anterior parts of the internal oblique to the inguinal ligament using a continuous suture from medial to lateral.

Fig. 2.49  Closure of the external oblique aponeurosis by a continuous suture.

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Adult Inguinal Hernia

Lotheissen/McVay Repair

▶   Diet. Immediately.

Karsten Junge

▶   Bowels. Enema if necessary. ▶   Mobilization. Immediately.

Indication The Lotheissen/McVay anterior sutured repair is rarely used nowadays; it is technically complex, painful, and often unsafe, as the elastic muscles may tear out of the Cooper ligament, which is attached to bone, in the long term. TEP is a better alternative today.

Operation Preparation The preoperative diagnosis is made by clinical examination, ultrasonography of the groin, and Doppler ultrasound of the testicular vessels in the case of surgery for recurrence.

Special Risks None apart from the usual complications of inguinal hernia repair: •• Spermatic cord injury (1%). •• Wound infection (2%). •• Chronic groin pain (< 5%). •• Recurrence (1–10%).

Anesthesia Local anesthesia in cooperative patients, otherwise spinal or epidural anesthesia or general anesthesia.

Position Supine.

Access Transverse or slightly oblique incision above the inguinal crease.

Relevant Anatomy, Dangers, and Tricks Adequate exposure of the often deep structures, especially in obese patients, is crucial for success.

Management of Special Complications Ligature of the corona mortis and suture of the femoral vein if injured.

Postoperative Management ▶   Medical care. Male patients should wear close fitting underpants in the first few days and the patient should be provided with an information leaflet on gradual resumption of physical effort and sports activities.

▶   Physical therapy. None required.

Operation Techniques The transversalis fascia is split along its entire length where it is still present (▶Fig. 2.50). After splitting the transversalis fascia, the preperitoneal space is opened and the peritoneal sac can be dissected bluntly off the pectineal (Cooper) ligament with a swab. The horizontal ramus of the pubic bone and the pectineal ligament overlying it are exposed laterally from the lacunar (Gimbernat) ligament in the medial corner of the wound (▶Fig. 2.51). The anastomosis between the inferior epigastric artery and the obturator artery, the corona mortis, varies in caliber and must be protected. The pectineal ligament is located considerably deeply, especially in obese patients, and can be exposed only by generous use of retractors. In the lateral part of the wound, the vascular sheath is seen with the femoral vein medially, and this is retracted laterally. The hernia is repaired by attaching the triple layer consisting of transversalis fascia, transversus abdominis, and internal oblique to the pectineal ligament. It is technically simpler to place five to six nonabsorbable sutures (2/0) in the inferior column first. The most medial suture picks up the lacunar (Gimbernat) ligament as well as the periosteum of the pubic tubercle. The average distance to be bridged is 4 cm (▶Fig. 2.52). Elevation of the internal oblique muscle exposes the cranial suture line consisting of transversalis fascia, the aponeurosis of the transversus abdominis, and the internal oblique muscle. The sutures pass through the three layers from posterior to cranial. Once all the sutures have been placed, they are tied from medial to lateral so that the knots lie increasingly deep. The sutures are placed as laterally as possible, sparing the femoral vein (▶Fig. 2.53). McVay recommends concluding the sutures laterally with a “transition stitch,” which includes the pectineal ligament and femoral vascular sheath as well as the triple-layered abdominal muscle. This is intended to prevent a perivascular hernia. The transversalis fascia can be reconstructed by the Zimmerman method if it is still gaping at the deep inguinal ring to prevent later indirect recurrence (▶Fig. 2.54). A relieving incision of the rectus sheath is obligatory; this greatly reduces suture tension (▶Fig. 2.55). Closure of the external oblique aponeurosis after replacement of the spermatic cord and wound closure as usual conclude the operation.

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2.3  Open Mesh Techniques Fig. 2.50  Direction and extent of the splitting of the transversalis fascia on the posterior wall of the inguinal canal, shown here with a repaired direct hernial sac.

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Fig. 2.51  After splitting the transversalis fascia, the preperitoneal fat is pushed bluntly in posterosuperior direction and the pectineal (Cooper) ligament is exposed.

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Adult Inguinal Hernia Fig. 2.52  Placement of the sutures at the medial end of the wound and in the pectineal (Cooper) ligament.

Fig. 2.53  The cranial ends of the sutures are passed through the three cranial layers of the suture line. The femoral vascular sheath is included in the suture laterally, sparing the femoral vein (transition stitch).

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2.3  Open Mesh Techniques Fig. 2.54  Closure of the posterior wall of the inguinal canal after tying the medial sutures and tightening the deep inguinal ring laterally with interrupted sutures as in the Zimmerman procedure.

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Fig. 2.55  Full reconstruction of the posterior wall of the inguinal canal and relieving incisions in the rectus sheath.

2.3  Open Mesh Techniques 2.3.1  Lichtenstein Repair Georg Arlt

Repair Principle The principle of the Lichtenstein repair is to ­reinforce the posterior wall of the inguinal canal by a mesh

measuring approximately 6 × 14 cm, which, in the transinguinal method, is placed behind the spermatic cord from the base of the inguinal ligament as far as the internal oblique muscle (▶Fig. 2.56). The procedure was developed in the 1970s by I.L. Lichtenstein (Los Angeles, CA, United States of America) and has spread worldwide in the past 20 years as, it is a relatively simple procedure technically that can be performed under local anesthesia.

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Adult Inguinal Hernia The Lichtenstein repair technique as currently employed by most surgeons is described below. For indirect hernias, after opening the inguinal canal, the cremaster muscle is split over the deep inguinal ring, the preperitoneal lipoma is resected, and the sac is reduced. In the case of direct hernias, the spermatic cord together with the cremaster sleeve is snared initially and the sac is reduced.

Tip

To secure sac reduction, a continuous suture is recommended between the superior and inferior margins of the transversalis fascia from medial to latera l, e.g., with 2/0 polypropylene or PDS.

Fig. 2.56  Cross-section of mesh position.

Indication The Lichtenstein repair is suitable for all direct and indirect hernias that require mesh repair and for repair of femoral hernias through an inguinal approach.

Operation Techniques The operation can be performed under local anesthesia, epidural or spinal anesthesia, or general anesthesia (laryngeal mask or intubation). It starts with the usual technique of transinguinal dissection until the inguinal canal is exposed.

Background



8

In the original description3 resection of the cremaster muscle was omitted, the spermatic cord was snared together with the ilioinguinal nerve and the external cremasteric vessels including the genital branch of the genitofemoral nerve, the hernial sac was reduced without opening it after appropriate dissection, and the hernial orifice was merely covered with the mesh without further treatment. The sac should be buried over an absorbable suture only in the case of large direct hernias. All the nerves located in the operation field (genital branch, ilioinguinal and iliohypogastric nerves) should be left intact. The mesh size was reported to be 8 × 16 cm. Since then, a series of studies have shown that the treatment of the nerves must be revised. Consistently leaving sensory nerves in the operation field in direct contact with the mesh is associated with a high rate of postoperative chronic pain and foreign body sensation. 87 When in doubt, the current recommendation is for optional neurectomy at the primary operation. In the past 15 years, several modifications of the Lichtenstein technique have been described. These have addressed mesh size and material and the form of fixation. In the great majority, the aim of these modifications was to reduce the risk of postoperative pain.41

In our experience, the external cremasteric vessels should not be snared with the genital branch that runs in the floor of the inguinal canal but should be ligated and divided together with the nerve laterally where they join the deep epigastric vessels. This allows optimal medial mesh coverage at the deep inguinal ring and prevents painful irritation of the nerve by the mesh. The ilioinguinal nerve can be left in place on the cremaster muscle unless it has to be dissected and moved from its enclosing fascia to avoid direct mesh-nerve contact. Otherwise, infiltration with local anesthetic followed by neurectomy lateral to the deep inguinal ring is recommended.47 A large-pore, lightweight mesh is recommended for the repair. It should measure 6 × 14 cm and be cut as per the size (▶Fig. 2.57). Mesh fixation starts over the pubic bone with a U-shaped suture (e.g., Prolene 2/0), without picking up the periosteum. The mesh should overlap by 1 cm medially. The suture is continuous, attaching the inferior border of the mesh to the base of the inguinal ligament as far as immediately lateral to the deep inguinal ring (▶Fig. 2.58). From the lateral side, the mesh is incised 2 cm above the lower edge of mesh as far as the medial boundary of the deep inguinal ring. The cranial tongue is wrapped around the spermatic cord, and the medial part of the mesh is placed on the internal oblique muscle beneath the spermatic cord.

Caution



The iliohypogastric nerve, which emerges from the internal oblique and penetrates the external oblique aponeurosis, must be noted. Direct mesh-nerve con­ tact must be avoided.

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2.3  Open Mesh Techniques It is then fixed to the internal oblique fascia with 2–3 interrupted sutures (e.g., 2/0 Prolene), which should preferably not be tight so as not to irritate the iliohypogastric nerve running within the muscle (▶Fig. 2.59). The inferior edge of the cranial tongue of mesh, lateral to the deep inguinal ring is sutured to the base of the inguinal ring together with the caudal tongue beneath it and the projecting parts of the mesh are pushed laterally under the external oblique aponeurosis (▶Fig. 2.60). To treat a femoral hernia, caudal mesh fixation, medial to the femoral vessels is not to the inguinal

ligament but more deeply to the Cooper ligament. When repairing inguinal hernias, mesh fixation with fibrin glue is a possible alternative that has been well investigated.78 To date, there have been no studies in this regard for the rarer femoral hernia and mesh fixation with a continuous suture is recommended. The operation concludes with closure of the external oblique aponeurosis in front of the spermatic cord and suture of the Scarpa fascia and skin. A vacuum drain is usually not required.

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Fig. 2.57  Top: Mesh cutting pattern. Bottom: after trimming the mesh, it is fixed to the inguinal ligament with a continuous suture.

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Adult Inguinal Hernia Fig. 2.58  Complete continuous fixation suture to the inguinal ligament (e.g., polypropylene 2/0).

Fig. 2.59  Cranial fixation to the internal oblique aponeurosis/muscle with 2–3 loose sutures (e.g., 2/0 polypropylene).

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2.3  Open Mesh Techniques Fig. 2.60  “Swallowtail” overlapping of the lateral ends of the mesh and fixation with an interrupted suture to the inguinal ligament (e.g., 2/0 polypropylene).

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2.3.2  Transinguinal Preperitoneal Patch Volker Schumpelick, Ralph Lorenz, and Andreas Koch

Repair Principle The transinguinal preperitoneal patch (TIPP) is an operative method that uses an anterior approach to close the hernial orifice with a plastic mesh. This mesh is placed and fixed in the preperitoneal space behind the abdominal wall muscles (▶Fig. 2.61). This corresponds to the position of the mesh in the TAPP and TEP endoscopic techniques. It combines the advantages of retromuscular mesh position with a simple and open operative access.

Indication Large medial hernias, with an unstable inguinal canal posterior wall, are an ideal indication for TIPP repair. Recurrent hernias after anterior mesh procedures (e.g., Lichtenstein repair) are also suitable and are a potential alternative to endoscopic methods.4

Operation Techniques The preperitoneal approach can be difficult or even impossible after previous surgery and radiation in the lower abdominal and inguinal region. The operation is usually performed under general anesthesia but epidural/spinal or local anesthesia is also possible. A 3- to 7-cm transverse or oblique skin incision is made above the inguinal ligament. After splitting the

Fig. 2.61  Cross-section of mesh position.

external oblique aponeurosis, all three nerves of the inguinal region are exposed and preserved: •• Hypogastric nerve. •• Ilioinguinal nerve. •• Genital branch of the genitofemoral nerve.

Tip



If the nerve sheaths are injured or there is a risk of nerve-mesh contact, neurectomy of the nerves in question may be necessary to avoid chronic groin pain.

The hernial sac is then exposed. If this is adherent or incarcerated, it is opened to allow an inspection of its contents and treatment, where necessary. The hernia contents are then replaced in the abdomen, the sac is excised, and the peritoneum is sutured closed. If there is no adhesion or

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Adult Inguinal Hernia incarceration, the sac is usually simply returned through the hernial orifice without opening it. The preperitoneal space (retromuscular space) is then opened to create space for a plastic mesh. The crucial step is identification and dissection of the epigastric vessels. These are picked up and elevated by a Langenbeck retractor.

Tip



If there is extensive scarring, the epigastric vessels should be divided to avoid secondary postoperative bleeding. The preperitoneal space can be largely opened up by blunt dissection with an unfolded gauze swab or a dissecting swab (▶Fig. 2.62). This space is also palpated in medial, cranial, and lateral direction with a finger. It should be noted that the finger is in direct contact with the back of the transversalis fascia and pushes the preperitoneal fat posteriorly. The gauze or swab retains the hernia and aids dissection but it also acts as an indicator of bleeding in the preperitoneal space.

Caution



Particular caution is required when a corona mortis is present, that is, an anastomosis between the inferior epigastric artery and the obturator artery. There may be venous as well as arterial anastomoses. The incidence of an arterial and/or venous corona mortis is reported as up to 40%.59,85

Rives Preperitoneal Repair This transinguinal technique was first described in 1973 by Rives.85,86 A polypropylene (Dacron) mesh is introduced into the preperitoneal space and fixed there with sutures. The transversalis fascia is split to give access to the preperitoneal space. The preperitoneal fat is pushed off the transversalis fascia with a dissecting swab. The fascial layer is undermined to provide an underlay for the mesh at least 5 cm wide. Anteriorly, the external oblique aponeurosis is dissected from the subcutaneous tissue and 5 to 8 cm of it are exposed on all sides. The 12 × 15 cm polypropylene mesh is inserted horizontally in the retrofascial space. A slit is made laterally for passage of the spermatic cord, the mesh is wrapped around this, and the slit is then closed with several interrupted sutures (▶Fig. 2.63). The mesh is pushed into the preperitoneal space on the spermatic cord and placed without creases. It covers the myopectineal orifice and therefore all potential hernial orifices completely. It is then fixed to the Cooper ligament in inferomedial direction with several sutures. In addition, the mesh is fixed cranially by several transaponeurotic/transmuscle sutures (▶Fig. 2.64, ▶Fig. 2.65). The fascia is closed over the mesh, followed by wound closure as usual (▶Fig. 2.66).

Fig. 2.62  Dissection of the scarred borders of the transversalis fascia and preperitoneal space from the inguinal aspect. The fascial edges are grasped with clamps and the retrofascial preperitoneal space is exposed by blunt dissection. If there is extensive scarring, the inferior epigastric vessels are divided and ligated. The mesh is cut to a slightly rhomboid shape measuring 12 × 15 cm.

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2.3  Open Mesh Techniques Fig. 2.63  Slitting the mesh and suturing it around the spermatic cord. The mesh is pushed down on the spermatic cord and positioned in the preperitoneal space.

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Fig. 2.64  Fixation with 3–5 U sutures to the Cooper ligament (3–4 sutures medial to the vessels) and laterally to the inguinal ligament. This is followed by cranial fixation by 2–3 transaponeurotic and transmuscle U sutures, 0 polypropylene).

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Adult Inguinal Hernia Fig. 2.65  Mesh placement without creases to cover all hernial orifices.

Fig. 2.66  Internal view of mesh placement. The Shouldice or Bassini fascial repair over the mesh.

Kugel Preperitoneal Repair

Pélissier Preperitoneal Repair

This transinguinal technique was developed in 1999 and first described by R.D. Kugel (Washington, United States).54,55 It uses a specially developed oval two-layer polypropylene mesh (▶Fig. 2.67), known as a Kugel patch, with a memory recoil polyester ring and a pocket to aid placement. The operative access is through a small incision over the deep inguinal ring (▶Fig. 2.68).

This transinguinal technique was developed in 2001 by Edouard Pélissier (Besançon, France).79 It uses a specially developed oval polypropylene mesh with a memory recoil polyester ring. The C.R. Bard Polysoft patches are available in medium (7.5 × 14 cm) and large (9.5 × 16 cm) sizes (▶Fig. 2.69).80,81,82

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2.3  Open Mesh Techniques This mesh is introduced into the preperitoneal space through the hernial orifice: •• For lateral and combined hernias, the mesh should be inserted from the lateral side (lateral to the epigastric vessels through the deep inguinal ring). •• For large medial hernias, the mesh should be inserted from the medial side (through the direct transversalis fascia access; ▶Fig. 2.70).

Fig. 2.67  Kugel patch in different sizes.

Fig. 2.68  Preperitoneal view of the inguinal region. Position of the Kugel patch. 1 Inferior epigastric vessels. 2 Site of the transverse incision. 3 Deep inguinal ring. 4 Testicular vessels. 5 Inguinal ligament. 6 Symphysis. 7 Vas deferens. 8 External iliac vessels.

3

6

2

Fig. 2.69  C.R. Bard Polysoft hernia patch in two sizes.

1

2

The polypropylene mesh is first pushed medially, then cranially and laterally, where it is spread out flat behind the muscle. The inferior part of the mesh is then fixed to the inguinal ligament with nonabsorbable monofilament sutures (2/0, 3/0). Reattachment of the previously divided cremaster to the internal oblique is optional.10,11,51,61 The fascia is closed over the mesh, followed by wound closure in the usual way.

5 4

7 8

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Ugahary Preperitoneal Repair This technique, developed in 1995 by Frans Ugahary (Tiel, the Netherlands) combines the advantage of preperitoneal mesh placement with the convenience of access through a small gridiron incision. The preperitoneal space is dissected and held open through two long specula. A 10 × 15 cm polypropylene mesh, rolled up inside out, is then inserted under vision into the preperitoneal space where it is spread out with the long specula. The mesh is fixed with a craniolateral suture as necessary.98,109,111 This operation method was used mainly in the Nether­ lands and is now used only rarely, possibly because of

the long learning curve and the availability of numerous alternatives.25

Transrectus Sheath Preperitoneal Patch Repair Technique This innovative technique52 was first presented in 2011 by G.G. Koning and W.L. Akkersdijk’s working group from the Netherlands. The preperitoneal space is reached through a small transverse lower abdominal incision through the rectus sheath (transrectus sheath preperitoneal patch repair [TREPP]; ▶Fig. 2.71). The mesh is placed in the preperitoneal space under vision. The Polysoft mesh with memory ring described above is used (▶Fig. 2.69). Fig. 2.70  Position of the Polysoft patch (anterior view).

Fig. 2.71  Skin incision for the TREPP technique.

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2.3  Open Mesh Techniques

2.3.3  Nyhus Repair with Mesh Georg Arlt

Repair Principle

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The principle of traditional preperitoneal repair consists of exposure of the inguinofemoral region, demonstrating the three potential hernial orifices from behind through a transverse lower abdominal incision.

Background

8

The first descriptions date back to the end of the 19th century. Bates8 and Cheatle20 developed the method, which was later revived by Nyhus and Condon in the early 1960s.76 The operation method, which was linked from then on with the name Nyhus, was not used widely in Europe. As an open sutured procedure for primary hernias, it had to compete here with the much more popular Bassini and Shouldice procedures. In 1995, Nyhus described a technique defined by the hernia classification, which included the use of alloplastic mesh materials.77

Indications The Nyhus repair with alloplastic mesh augmentation is suitable for all primary indirect and direct hernias that require mesh repair and for repair of femoral hernias through an open preperitoneal access. Recurrent hernias following open transinguinal repair are also a good indication for this method as it circumvents the potentially complicated dissection due to the altered anatomy and scar tissue in the inguinal canal.

Operation Techniques The operation can be performed under epidural/spinal or general anesthesia with laryngeal mask or intubation. The skin incision is horizontal, about 4 cm above the inguinal ligament. It starts close to the midline and extends 5 to 6 cm laterally (▶Fig. 2.72). After reaching the fascial plane, the superficial inguinal ring can be exposed inferiorly in the medial part of the incision. This is followed by splitting of the anterior layer of the rectus sheath medially and the external oblique aponeurosis laterally. This incision must be above the deep inguinal ring. The rectus muscle is retracted medially and the posterior layer of the rectus sheath formed by the transversalis fascia is incised medially; the internal oblique and transversus muscles are incised laterally until the preperitoneal fat is exposed (▶Fig. 2.73). The preperitoneal space is then dissected bluntly and the hernial orifices are exposed by pushing the preperitoneal fat off the back of the transversalis fascia (▶Fig. 2.74,

Fig. 2.72  Horizontal skin incision above the inguinal canal (a). Horizontal splitting of the external oblique aponeurosis laterally and rectus sheath medially (b).

▶Fig. 2.75, ▶Fig. 2.76). Small penetrating vessels are coagulated and the deep epigastric vessels may have to be ligated and divided. Direct hernias can usually be reduced without difficulty. With incarcerated femoral hernias, it may be necessary to extend the orifice medially by dividing the fibers of the lacunar ligament. Opening of the sac and inspection of the contents are necessary only with incarcerated hernias. Long sacs of lateral hernias should not be excised completely to reduce the extent of dissection along the spermatic cord vessels.

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Adult Inguinal Hernia Fig. 2.73  Medial retraction of the rectus muscle and lateral splitting of the internal oblique and transversus muscles. This and the following illustrations show the surgeon’s view from cranial (bottom) to caudal (top).

Fig. 2.74  After splitting the transversalis fascia, the preperitoneal fat is pushed away bluntly.

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2.3  Open Mesh Techniques Fig. 2.75  Exposure of the preperitoneal space behind the transversalis fascia. In this case, there is a femoral hernia.

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Fig. 2.76  Dislocation of the hernia from the femoral canal.

Tip



As in the transinguinal repair, a circular incision around the sac is recommended with reduction of the sac contents and proximal closure. The distal sac remains patent in situ. An increased incidence of hydrocele is not observed after this maneuver.

Femoral Hernia Repair of the femoral hernial orifice starts medially with nonabsorbable suture (2/0) of the base of the inguinal ligament to the Cooper ligament (▶Fig. 2.77). In the inguinal ligament, the stitches must pass at an acute angle to ensure that they do not accidentally include the spermatic cord on the other side. The femoral vessels are protected with

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Adult Inguinal Hernia Fig. 2.77  Exposed femoral hernial orifice, grasping the cranial margin with a clamp. The corona mortis is seen above the Cooper ligament.

Fig. 2.78  Femoral hernia repair with a continuous suture between the base of the inguinal ligament and the Cooper ligament.

a Langenbeck retractor and drawn slightly laterally. The suture continues as far as the femoral vein without narrowing it (▶Fig. 2.78).

Direct Hernia The orifice of a direct hernia is closed by suturing the transversalis fascia to the inguinal ligament from medial to lateral. A 2/0 monofilament nonabsorbable suture is recommended (▶Fig. 2.79).

Indirect Hernia The sac of a primary indirect hernia is usually found superolateral to the spermatic cord. After reducing the hernia, the expanded deep inguinal ring can be tight­ened relatively easily by a continuous monofilament suture (2/0) from lateral to medial (▶Fig. 2.80). Combined suture has also been described. With this, the spermatic cord is initially drawn laterally into its natural position above and slightly lateral to the femoral artery, and the

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2.3  Open Mesh Techniques Fig. 2.79  Repair of a direct hernia with a continuous suture between the cranial parts of the transversalis fascia and the base of the inguinal ligament. Caution: avoid transfascial stitching of the spermatic cord structures and genital branch of the genitofemoral nerve.

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Fig. 2.80  Repair of a small indirect hernia with lateral sutures.

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Adult Inguinal Hernia Fig. 2.81  Placement of an 8 × 14 cm polypropylene mesh horizontally, covering all hernial orifices. It is fixed with interrupted sutures to the Cooper ligament and transversus muscle.

transversalis fascia is sutured to the inguinal ligament from the medial side. The deep inguinal ring is then tightened further by a suture from the lateral side close to the spermatic cord.77 This restores the original anatomy in the case of large defects with dislocation of the spermatic cord. The medial suture harbors a risk, however, of accidentally catching the vas deferens or blood vessels. Sutured repair suffices only for smaller indirect hernias. Direct hernias, femoral hernias, and large indirect hernias require additional augmentation with alloplastic mesh. Since the hernial defects have already been sutured closed, comparatively small polypropylene meshes are used, measuring 6 × 14 cm when aligned vertically77 or 8 × 12 cm when horizontally aligned.95 To avoid early dislocation, the mesh is fixed inferiorly to the Cooper ligament and superiorly to the transversus muscle with interrupted sutures (e.g., 2/0 polypropylene) (▶Fig. 2.81). The risk of injuring the ilioinguinal nerve or iliohypogastric nerve is much lower

in the Nyhus repair compared with transinguinal mesh implantation by the Lichtenstein method. On the other hand, the genital branch of the genitofemoral nerve is at risk where it enters the deep inguinal ring due to direct dissection and in its course on the floor of the inguinal canal when it may be caught blindly when the hernial orifice is sutured.

2.3.4  The Stoppa/Wantz Procedure Volker Schumpelick The Stoppa repair concept consists of reinforcement of the transversalis fascia in the preperitoneal space by a large prosthesis that extends in all directions far beyond the boundaries of the hernial orifices. The prosthesis, which is intended to replace the endopelvic fascia, is fixed against the inside of the abdominal wall by peritoneal pressure, that is, it does not require further fixation. The mesh later becomes integrated by ingrowth of

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2.3  Open Mesh Techniques connective tissue. Hernias can no longer occur since all orifices are covered. Separate closure of the hernial orifice is unnecessary. In the TEP and TAPP era, the Stoppa and Wantz procedures have been largely superseded by laparoscopy. Nevertheless, they are mentioned here to provide a comprehensive overview of various repair processes.

Background

8

The French surgeon, René Stoppa was the first to introduce reinforcement of the abdominal wall with a larger nonabsorbable mesh in 1969. The operation was described as “grand prosthetic reinforcement of the visceral sac (GPRVS)” and is generally called the Stoppa procedure. Stoppa refers deliberately to abdominal wall reinforcement and not to hernial orifice closure. When the mesh is of the right size and tailored and placed correctly, recurrences are hardly ever possible.

Indications •• Bilateral recurrent hernias in patients over 50 years. •• Hernias in patients with connective tissue disorders (Ehlers–Danlos syndrome, Marfan syndrome). •• Hernias in patients with chronically elevated intra-abdominal pressure (patients with ascites, weightlifters, etc.). Another indication can be fear of damaging the testicular blood supply during surgery of recurrence as dissection of the spermatic vessels in the scar tissue can be omitted.

Contraindications •• Intolerance of alloplastic materials. •• Infected hernia region. •• Incarceration. •• Young patients (< 50 years). •• Unilateral hernia.

Material Mersilene (polyester) has been the preferred mesh material as it is flexible, nonrigid, and adapts well to the abdominal cavity. Other materials such as Marlex, Teflon, and Prolene are less suitable. They do not adapt well to the configuration of the abdominal sac. We have had initial positive experiences with Vypro mesh.

The size of the mesh should allow all potential hernial orifices to be closed (▶Fig. 2.82). The ideal configuration is the width between the midline and the anterior iliac spine minus 1 cm with a length of about 12 cm (see ▶Fig. 2.89).

2

Preparation See section ▶2.3.2.

Anesthesia General or epidural/spinal anesthesia.

Position Supine with the hips extended and the buttocks slightly elevated.

Postoperative Care The drain is removed after 48 hours. Full loading is possible soon after the abdominal wound has healed. The patient is hospitalized for a few days.

Operation Techniques Repair Principle The principle of the bilateral Stoppa procedure is to line the lower abdominal cavity with a large bilateral roofshaped prosthesis (▶Fig. 2.82).

Access through a Midline Lower Abdominal Incision The operation starts with a lower abdominal midline incision that divides the linea alba (▶Fig. 2.83). It is important to ensure that the peritoneum is not opened.

Detaching the Peritoneal Sac After exposing the peritoneum, the peritoneal sac is dissected bluntly off the abdominal wall with a dissecting swab. Blunt retractors are then placed under the muscles (▶Fig. 2.84).

Dissection of the Hernial Sac If strong adhesions are present, e.g., after herniorrhaphy or appendectomy, the peritoneum is detached from the scars by a sharp dissection. The space of Retzius is then exposed

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Fig. 2.82  The GPRVS should line the lower abdomen. It is placed between the peritoneum and transversalis fascia to reinforce the abdominal wall.

Fig. 2.83  Midline lower abdominal incision between the symphysis and umbilicus.

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2.3  Open Mesh Techniques Fig. 2.84  Mobilization of the lateral abdominal wall margins without opening the peritoneum, using blunt retractors. View from the left: umbilicus on right, symphysis on left.

2

Fig. 2.85  Wide lateral and caudal mobilization, laterally as far as the iliopsoas muscle, inferiorly as far as the space of Retzius. The right-sided hernial sac is dissected bluntly from the hernial orifice.

and the bladder is dissected down to the prostate. The rectal musculature is dissected laterally and the inferior epigastric vessels are exposed. Dissection proceeds posteriorly as far as the iliopsoas muscle. Deep in the wound, the obturator foramen, the iliac vessels, and the ureter are exposed. The spermatic cord is then sought along the inferior epigastric vessels and the medial and lateral hernial orifices are exposed. The hernial sac is dissected bluntly and retracted (▶Fig. 2.85).

Snaring the Hernial Sac if Irreducible If mobilization of the sac is not possible, the distal part can be resected. For this, the sac is snared (▶Fig. 2.86).

If the Hernia Is Irreducible, It Is Opened and Reduced The neck of the sac is divided under vision (▶Fig. 2.87).

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Adult Inguinal Hernia Fig. 2.86  If the hernia is irreducible, the neck of the sac is snared with rubber tubing.

Fig. 2.87  Resection of the irreducible sac leaving the distal part.

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2.3  Open Mesh Techniques Fig. 2.88  In the case of resection or opening of the hernial sac, this must be sutured carefully to avoid later contact between the mesh and the intestine.

2

Fig. 2.89  The prosthesis is cut into an inverted V, with the width corresponding to the distance between the superior iliac spines and the height in the midline matching the distance between the umbilicus and symphysis. The upper horizontal lines slope downward by 4 cm laterally, and 6 cm is added laterally to the bottom lines, giving the V-shape. When it is fitted, the V is upside down with its apex at the umbilicus. The fixation points are numbered clockwise, starting at the symphysis.

Suturing of the Peritoneum during Hernia Reduction

Cutting the Mesh and Placing It in Ideal Position

The peritoneal sac is then closed securely with an absorbable suture (3/0 PGA) and the spermatic cord is snared with rubber tubing (▶Fig. 2.88). The peritoneal sac can then be dissected further cranially. The Y-shaped course of the vas deferens and the spermatic vessels is followed, The peritoneal sac must be detached as far as possible.

The mesh is prepared when blunt dissection of the peritoneal sac has been completed. The width should ideally be the distance between the two superior iliac spines with the height matching the distance between the symphysis and the umbilicus. It is cut into a chevron shape with the apex at the umbilicus 4 cm above the line connecting the iliac spines and the inferior indentation at the level of the symphysis, i.e., 6 cm above the line connecting the inferior points (▶Fig. 2.89).

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Adult Inguinal Hernia Fig. 2.90  Fitting the mesh starts with marking the corner points (2, 3, 4, 6, 7, and 8) and the two vertical midpoints  (1 and 5) with clamps. The right half is first inserted by introducing clamps 1 and 5 into the center and clamps 2, 3, and 4 far posterolaterally. This part of the mesh bypasses the entire lateral abdominal sac on the right.

Fig. 2.91  The mesh is fixed deeply to the iliopsoas muscle posterior to the right peritoneal sac using clamps 2 to 4. Clamps 1 and 5 hold the midline.

Placement of the Mesh After cutting the prosthesis to shape, it is grasped with clamps at eight points and gradually introduced into the preperitoneal space (▶Fig. 2.90). The midline clamp 1 is inserted deeply into the space of Retzius and the mesh is held there by an assistant, using the clamp.

Anchoring the Mesh behind the Peritoneal Sac Clamp 5 is held by the assistant at the level of the umbilicus. Clamps 2, 3, and 4 are introduced as far posteriorly as possible on the right, stretching the prosthesis so that the right half unfolds completely (▶Fig. 2.91). The midline clamps 1 and 5 are left in fixed position and clamps 2 to 4 are removed.

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2.3  Open Mesh Techniques

Removal of the Posterior Clamps The next step is insertion of clamps 6 to 8 on the left side, symmetrical with the right side (▶Fig. 2.92). After complete placement of the left half of the mesh, clamps 6 to 8 are first removed. The Stoppa procedure of hemispherical covering of the peritoneum is complete.

Crease-Free Placement The surgeon must ensure that there are no creases. The midline clamps 1 and 5 are then removed (▶Fig. 2.93).

▶Fig. 2.94). The midline abdominal incision is closed to conclude the operation. The Stoppa hemispherical reinforcement of the abdominal wall is complete (see ▶Fig. 2.82).

2

Wantz Unilateral Mesh Repair Procedure ▶ Transverse lower abdominal incision. After splitting the muscle, the peritoneal sac is dissected bluntly. The hernial sac is mobilized and reduced, leaving the hernial orifice free. The defect can now be closed by a large unilateral mesh (▶Fig. 2.95).

Drainage The preperitoneal space is drained and the mesh is fixed to the linea alba at point 5 with a suture (0 polypropylene; Fig. 2.92  After mesh insertion on the right side, clamps 2, 3, and 4 are removed and clamps 1 and 5 are left in the midline. The process is repeated on the left side with clamps 6, 7, and 8.

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Adult Inguinal Hernia Fig. 2.93  The mesh is wrapped posteriorly around the left peritoneal sac with clamps 6, 7, and 8. Clamps 1 and 5 in the midline are left in place and are removed when the mesh is in place posteriorly without creases.

Fig. 2.94  Fixation of the apex of the mesh to the infraumbilical linea alba (with 0 suture). Further fixation can usually be omitted (two sutures to the Cooper ligament if necessary). Suction drain and closure of the abdominal wall.

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2.3  Open Mesh Techniques Fig. 2.95  Unilateral reinforcement of the abdominal wall by a preperitoneal mesh that covers all hernial orifices.

2

Mesh Position in the Wantz Repair The mesh size selected should close all potential hernial orifices. The ideal mesh configuration is the width between the midline and the anterior iliac spine minus 1 cm, with a height of about 12cm (▶Fig. 2.96).

Retromuscular Mesh Fixation in the Wantz Procedure The mesh is fixed cranially by three U sutures, the medial one through the rectus muscle, the intermediate one through the semilunar line, and the lateral one through the oblique muscles. The sutures, which should be nonabsorbable 0 polypropylene, can be placed with Reverdin or large needles (▶Fig. 2.97).

Tying the Muscle Sutures in the Wantz Procedure The medial suture should be placed as far medially as possible and the lateral one as far laterally as possible under tension. The medial and intermediate sutures are tied subcutaneously and the lateral one transcutaneously. The transcutaneous knot is buried in a skin pocket (▶Fig. 2.98).

Anchoring the Mesh behind the Peritoneal Sac in the Wantz Procedure Once all three sutures are fixed, the inferior part of the mesh is placed between the peritoneal sac with three clamps, as in the Stoppa procedure (▶Fig. 2.99). The operation concludes with a subcutaneous drain, fascia and muscle closure, and skin suture.

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Tip



The surgeon should ensure that the clamps are pushed as far posteriorly as possible to stretch out the mesh without creases. Posterior fixation is not necessary and is rather hazardous.

Fig. 2.96  Measuring and placing the unilateral mesh to reinforce the abdominal wall.

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2.3  Open Mesh Techniques

2

Fig. 2.97  Transmuscular fixation to the rectus muscle, oblique abdominal muscles, and external oblique aponeurosis with monofilament nonabsorbable sutures. The suture through the rectus can be placed with a Reverdin or large needle.

Fig. 2.98  Tying the median and intermediate muscle fixation sutures subcutaneously and the lateral one through the skin, burying the knot in a skin pocket.

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Adult Inguinal Hernia Fig. 2.99  After cranial suture fixation to the abdominal wall, the mesh is buried posteriorly and laterally behind the peritoneal sac with three clamps, as in the Stoppa procedure.

2.3.5  Three-dimensional Mesh Procedures Tim Tollens and Ralph Lorenz

Introduction and History: The Gilbert Technique with the Prolene Hernia System/Ultrapro Hernia System The three-dimensional (3D) mesh procedure is a tensionfree operation method with transinguinal access. It uses a double-layer polypropylene mesh, consisting of a top layer, onlay part, a connecting cylinder, and a bottom layer, the sublay part. The mesh is placed and fixed both in front of and behind the abdominal muscles (in the preperitoneal space). The aim of the 3D mesh method is to combine the advantages of all currently available operation techniques in one system, at the same time eliminat­ ing all undesirable features. As in the TAPP and TEP endoscopic techniques and the open TIPP techniques, the major stabilization of the abdominal wall is retromuscular. The operation technique was first described in 1999 by Arthur I. Gilbert (Miami, United States).36,38

Initially, the Prolene Hernia System (PHS) was used (▶Fig. 2.100). In 2007, the mesh material was replaced by a large-pored, partially absorbable, and lightweight polypropylene mesh and adapted to the more modern mesh concept as the Ultrapro Hernia System (UHS).50 (▶Fig. 2.101, ▶Fig. 2.102) This mesh currently comes in three sizes: •• M with a posterior mesh layer 7.5 cm in diameter. •• L with a posterior mesh layer 10 cm in diameter. •• OVAL with a posterior mesh layer of 10 × 12 cm.

Operation Techniques The operative access is through a 4 to 5 cm transverse lower abdominal incision, starting 1 cm superior and 1 cm lateral to the pubic tubercle. The subcutaneous fat and Scarpa fascia are divided as far as the fascia of the external oblique using electrocautery. The external oblique aponeurosis is then opened from the lateral side as far cranially as possible, including the superficial inguinal ring. A small incision is made with a scalpel through which the external oblique aponeurosis is split bluntly using dissecting scissors. This access to the internal oblique avoids bleeding and protects the ilioinguinal nerve underneath from injury. It also leaves an adequately large

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2.3  Open Mesh Techniques

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Fig. 2.101  Ultrapro Hernia System size L and OVAL.

Fig. 2.100  Prolene Hernia System.

layer of the external oblique aponeurosis caudally to allow problem-free closure after hernia repair is complete. In the next part of the operation, the fasciae of the external oblique and internal oblique are pushed apart as the onlay part of the UHS is placed in this space.

Caution



Particular care is required in the cranial region to avoid damaging the nerve endings of the iliohypogastric nerve. The spermatic cord is then isolated and adhesions in the inguinal canal are divided. The spermatic cord is pushed bluntly from lateral to medial on the inguinal ligament with the index finger. In this way, the spermatic cord is completely undermined as far as the pubic tubercle and can be snared. The cremaster muscle is then split to identify an indirect hernia. In most cases, medial resection of the cremaster at the deep inguinal ring is necessary for better visibility of the operation field and for greater flexibility.

Tollens/Bonheiden Technique With a nonincarcerated indirect hernia, the sac can be exposed easily and reduced into the abdomen through the deep inguinal ring without opening it. In the case of incarceration, the sac is opened, and the contents are inspected and treated as necessary. They are then returned to the abdomen, and the sac is removed and sutured closed. Dissection of the epigastric vessels is a crucial step in the operation. These vessels provide anatomical orientation that facilitates dissection of the preperitoneal space. The preperitoneal space is always accessed from the lateral side, regardless of whether the hernia is direct or indirect, inguinal or femoral. Blunt dissection of the preperitoneal space can largely be achieved with an unfolded gauze swab. This space is also palpated with a finger, first medially, then cranially and laterally.

Fig. 2.102  Ultrapro Hernia System: lateral view.

Tip



Ensure that the finger dissects in direct contact with the back of the transversalis fascia, pushing the preperitoneal fat posteriorly.

The gauze swab retains the hernia and also aids dissection and acts as an indicator of bleeding. A large direct hernia may have to be lateralized from within under direct vision. The preperitoneal dissection should start below the Cooper ligament and extend over the pubic symphysis. Femoral hernias can be reduced automatically in this way. Following medial dissection, attention turns to lateral preperitoneal dissection. The peritoneal fold is dissected carefully to expose the “triangle of doom” and “triangle of pain” clearly. It should then be easy to introduce and unfold a UHSOVAL with a sublay component measuring 12 × 10 cm (▶Fig. 2.103). If this is not possible, dissection of the preperi­ toneal dissection has been insufficient. The mesh should not be inserted like a plug. Instead, it is inserted transversely like a roll, folded upward. To protect the epigastric vessels, they are elevated from the operation field with a retractor. After the UHS mesh has been pushed as far medially as possible into the preperitoneal space, the lateral part is introduced. The sublay component is now located in the preperitoneal space but it is folded and must be unfolded, starting medially and inferiorly. This caudal sublay component overlaps the

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Adult Inguinal Hernia

Fig. 2.103  Implantation of the Ultrapro Hernia System.

Cooper ligament and pubic bone. This support is necessary to prevent medial recurrence. Having the patient cough facilitates unfolding of the mesh. It is particularly important that the sublay part of the mesh covers the two critical regions, the triangle of doom and the triangle of pain, and also extends over the pubic symphysis (▶Fig. 2.104). At this time, a local anesthetic, e.g., bupivacaine solution in a proportion of 1:2, can be instilled deep into the preperitoneal space below the epigastric vessels for postoperative analgesia. The onlay part of the 3D mesh is then spread out and attached to fixed structures such as the inguinal ligament using minimalist technique through the posterior wall of the inguinal canal. The connecting cylinder is attached to the Henle ligament with a 3/0 suture. The medial part of the onlay is fixed evenly beyond the apex of the pubic tubercle with a monofilament nonabsorbable suture (2/0 or 3/0). An overlap of at least 2 cm is obligatory. A slit is now made in the onlay part of the 3D mesh to allow passage of the spermatic cord. Unlike in the Lichtenstein technique, where the mesh is incised from the lateral side, this incision is made from below. In this way, the spermatic cord is enclosed by the two cut edges of the mesh and drawn to the inguinal ligament. In addition, it is fixed to the inferomedial part of the inguinal ligament with two to three monofilament nonabsorbable sutures (2/0 or 3/0). The aponeurosis of the external oblique muscle is closed with a 2/0 absorbable suture to cover the mesh. Finally, the subcutaneous layers are closed, with skin closure by a continuous intracutaneous suture.40,106

Technique of Gilbert, Lorenz, Koch et al. In addition to the Tollens method of implantation described above, another strategy is based on the original method described in 1999 by Arthur Gilbert.28 This method is promoted in Germany by Lorenz and Koch et al. of the Qualitätssicherung Ambulante

Fig. 2.104  Laparoscopic view of the Ultrapro Hernia System OVAL.

Leistenhernienchirurgie [Ambulant inguinal hernia surgery quality assurance] working group. For a lateral or combined hernia, the mesh is introduced from the lateral side (lateral to the epigastric vessels) through the deep inguinal ring after extensive dissection of the triangle of doom and triangle of pain, as in the Tollens method. With large medial hernias, however, the mesh is inserted from the medial side (through direct access via the transversalis fascia; ▶Fig. 2.105, ▶Fig. 2.106). This somewhat easier and wider access for mesh implantation allows greater retromuscular overlap medially, thus additionally minimizing the risk of medial recurrence. This method of implantation assumes, however, that there is good dissection of the deep inguinal ring beforehand and that an indirect inguinal hernia has been excluded with certainty.

Summary The 3D mesh operation technique can be used for nearly all hernias with a large orifice and also for recurrences or when the posterior wall of the inguinal canal is unstable. The required preperitoneal access can be difficult or even impossible after previous surgery and radiation in the inguinal region. The operation is usually performed under general anesthesia (with laryngeal mask), but can also be carried out with a spinal/epidural or local anesthetic. Our experiences have shown that this 3D mesh procedure yields excellent clinical results with extremely low recurrence rates. The operation technique is simple, reproducible, and economical. The implant system combines secure posterior support through a simple transinguinal access with additional anterior reinforcement. Compared with the Lichtenstein procedure, the myopectineal orifice is completely covered and protected. On the other hand, more extensive dissection in two planes is required, so there

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2

Fig. 2.106  Three-dimensional mesh implantation method according to Gilbert, Lorenz, Koch: medial access, fixation of the anterior part of the mesh.

Fig. 2.105  The three-dimensional mesh implantation method according to Gilbert, Lorenz, Koch: medial access, spreading out the posterior part of the mesh.

may be an increased incidence of seromas and hematomas. Effective acute pain management is required, especially during the first 3 postoperative days. Although long-term results with follow-up for more than 5 years are not yet available, the results to date have been entirely promising.24,28,39,40,43,106

2.3.6  Plug and Patch

of polypropylene mesh through the deep hernial ring and reinforcement of the posterior wall of the inguinal canal with a second polypropylene mesh. In 1993, Robbins and Rutkow89 presented “mesh-plug hernioplasty,” a tension-free form of repair with lower recurrence rates, less extensive dissection, faster rehabilitation, and lower complication rates. The plug-and-patch technique was first published in German-speaking countries in 199791 and has become a regular component of German hernia surgery since then. In 2003, Millikan presented a technical variation, fixing the petals to the fascia instead of to the outer circumference of the plug.66,67

Friedrich-Eckart Isemer

Indications

After presenting an anatomical and functional classification of inguinal hernia,33 Gilbert34,35 reported sutureless repair of inguinal hernia with implantation

According to the Schumpelick classification96, plug-andpatch hernioplasty is indicated for all types of hernia. Mesh-free hernia repair may be preferable in younger

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Adult Inguinal Hernia patients and for small indirect hernias. Conversely, wider and more complex mesh stabilization may be indicated for combined inguinal hernia and for a weak and insufficient abdominal wall. Plug-and-patch hernia repair can be performed under local anesthesia.

Equipment The equipment required to perform the operation is considerably modest. Apart from basic instruments, use of a spreader is recommended, e.g., the Aesculap BabyCollin (Catalog no. BV 327 R) with blades BV 328 R; ropivacaine hydrochloride is a suitable local anesthetic. The author’s experience has been mainly with the PerFix Plug,45 Plug-and-patch sets from other manufacturers can be used similarly. One absorbable suture and one polypropylene suture (3/0) usually suffice for inguinal surgery repair.

Operative Principle The aim of every inguinal hernia repair is to restore the original anatomy. This means that the individual layers of the abdominal wall must be clearly defined and dissected. However, this dissection is not as extensive as when a larger mesh is implanted. With an indirect hernia, high dissection of the sac to deep inside the retroperitoneum, reduction of the sac, and creation of adequate preperitoneal and retrofascial space to accept the plug are essential for positioning the polypropylene plug. Immediate proximity to blood vessels, especially the external iliac vein, must be avoided. With a direct hernia, the dilated transversalis fascia is exposed and opened at the junction with the inguinal ligament. The preperitoneal space and posterior wall of the transversalis fascia are dissected as far as the white line. The transversalis fascia and the inguinal ligament are exposed. The polypropylene plug (PerFix Plug) consists of an outer umbrella-like mesh with two inner layers of mesh,

Fig. 2.107  PerFix Plug components: outer polypropylene umbrella with eight inner petals.

each of which has four little wings known as petals, leading to a total of eight petals (▶Fig. 2.107). The author always uses the “large” size, regardless of hernia size, as it can be tailored to the individual situation, cutting out individual petals so the defect is filled loosely by the plug. The previously trimmed onlay patch is laid on the internal oblique muscle or transversalis muscle and fascia to stabilize the remaining fascia, which is often weakened though not yet herniated, thus preventing recurrence at another site.

Operation techniques A 4 to 5 cm, parainguinal, and roughly transverse skin incision suffices for access. After exposure of the external oblique aponeurosis, the nerves supplying the inguinal region and the spermatic cord region are first infiltrated with local anesthetic using 7.5% ropivacaine hydrochloride.90 The external oblique aponeurosis is then opened in the line of its fibers over the spermatic cord and hernia. Dissection is similar to other hernia operations: the spermatic cord is snared and the cremaster muscle is resected. If the ilioinguinal nerve has an atypical course or is severely scarred, it is dissected laterally to within the muscle and ligated and resected following infiltration of local anesthetic. In a few cases, the iliohypogastric nerve must be removed also. When the hernia is indirect, the sac is dissected off the spermatic cord and far enough into the preperitoneal space to allow it to be reduced effortlessly without a tendency to prolapse outward (▶Fig. 2.108). Any lipomas are ligated and excised. When there is a direct hernia with a dilated transversalis aponeurosis, the preperitoneal space is opened close

Fig. 2.108  Indirect hernia: placement of the PerFix Plug in the lateral hernial orifice behind the transversalis aponeurosis with “physiological” support of the plug behind the fascia.

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2.3  Open Mesh Techniques to the inguinal ligament. The sliding hernia and preperitoneal lipoma are dissected off the abdominal wall so the back of the transversalis aponeurosis is exposed up to the white line and prepared for introduction of the plug (▶Fig. 2.109, ▶Fig. 2.110). When a combined inguinal hernia is present, both hernias are exposed as described above and the plug is placed in the larger one and bent into the smaller part. Division of the inferior epigastric artery and vein is rarely necessary. Depending on the size of the hernia, individual petals are cut out of the plug so the hernia is filled loosely after plug insertion (▶Fig. 2.111). Press-fitting of the plug should be avoided. Dissection in the preperitoneal space should not extend to the neighboring structures; this applies especially to the vascular bundle but also to the bladder. The patient should have emptied his bladder before the operation. When dissection is complete, it should be easy to insert the plug into its retrofascial location in the preperitoneal space, where it rests against the posterior surface of the abdominal wall in semi-stable position. Any tendency to protrusion indicates that dissection was insufficient. The outer border of the plug is fixed with interrupted absorbable sutures (3/0), first to the inguinal ligament and then to the posterior transversalis fascia, as far as the white line in the case of a direct hernia. This prevents dislocation of the plug. Millikan fixes the petals.66,67 Fixing to the white line results in an inferior flap of transversalis aponeurosis, which is fixed with a continuous suture to the lower layer of the transversalis fascia or the inguinal ligament. Monofilament polypropylene (2/0 or 3/0) can be used to fix the caudal border of the plug to the inguinal ligament with a few stitches of the continuous suture, thus preventing later dislocation.

Fig. 2.109  Development of a direct hernial sac. The inguinal ligament is recognized at the lower edge of the picture with the snared spermatic cord laterally, which is held caudally by the spreader.

Covering the plug with the aponeurosis of the transversalis muscle creates a biological underlay for the onlay patch, at the same time moving the plug to a retroperitoneal position so that significant seroma production can be prevented. If infection occurs, the plug is usually not affected.

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2

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In this dissection, it must be ensured that the passage for the spermatic cord through the newly created deep inguinal ring is wide enough to admit a 11.5 Hegar dilator.

The inferior edge of the onlay patch included in the hernia set is trimmed to the anatomy, i.e., it is usually narrowed slightly. The lateral wings are wrapped around the spermatic cord and overlapped and closed laterally with a 3/0 absorbable suture (▶Fig. 2.112). The onlay patch is laid flat on the internal oblique muscle or transversalis aponeurosis and fixed medially with one or two absorbable sutures to avoid early postoperative dislocation (▶Fig. 2.113). Finally, the external oblique aponeurosis is closed from lateral to medial with 3/0 absorbable suture. The spermatic cord is moved to subfascial position. The three inguinal nerves and the subcutaneous tissue are infiltrated with local anesthetic using 7.5% ropivacaine hydrochloride (▶Fig. 2.114). The wound is closed with a subcutaneous suture and absorbable intracutaneous suture. When the operation is performed correctly, a plug can be recognized during laparoscopy as a slight bulge covered with soft tissue and peritoneum (▶Fig. 2.115). The plug-and-patch procedure has become established especially in ambulant hernia surgery as it is rapidly

Fig. 2.110  Direct hernia: after placing the PerFix Plug behind the fascia in the preperitoneal space, it is in a semi-stable position resting on the back of the transversalis aponeurosis.

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Fig. 2.111  Opening the PerFix Plug and reducing the petals to fit the size of the hernia. Fig. 2.112  After wrapping the onlay patch around the spermatic cord, the open lateral ends are overlapped and sutured.

Fig. 2.113  Subfascial position of the onlay patch before closure of the fascia.

Fig. 2.114  After fascial closure, all three sensory inguinal nerves are again infiltrated with local anesthetic with additional subcutaneous infiltration using 7.5% ropivacaine hydrochloride.

learned and is quick to perform. The recurrence and complication rates are low.45,66,67

2.4  Laparoscopic Techniques 2.4.1  Transabdominal Preperitoneal Mesh Reinhard Bittner and Jochen Schwarz

Historical Development Fig. 2.115  Laparoscopic view of the inguinal region after plugand-patch repair with prominent recognizable plug.

The first attempts to treat an inguinal hernia laparoscopically were characterized by poor understanding of both

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2.4  Laparoscopic Techniques the anatomy of the inguinal region from the laparoscopic aspect and of the pathophysiological mechanism of hernia development. In 1982, R. Ger was the first to laparoscopically close the base of the hernial sac with clips.32 Popp84 closed the hernial ring with catgut sutures and backed these up with a 4 × 5 cm dura patch using the onlay technique (IPOM). Schultz94 was the first to open the peritoneum and place a preperitoneal polypropylene plug in the defect without reducing the hernial sac. Corbitt23 went a step further by resecting the sac, placing a preperitoneal plug, and covering the deep inguinal ring with a 5 × 5 cm patch. Toy and Smoot107 recognized that the patch must be bigger than the hernia defect  (5 × 7 cm PTFE patch) and fixed the patch with a hernia stapler, as described by Fitzgibbons31 as the “intraperitoneal onlay mesh technique” (IPOM). Arregui5 criticized this technique, “One must question the reliability of sewing mesh to peritoneum which has the tendency to stretch and has little strength. Moreover, placement of mesh in the peritoneal cavity invites adhesion formation.” A mesh fixed to the peritoneum is comparable to a small boat on rough sea. A high recurrence rate can be expected in the long term, and this has been shown by later studies.100 According to Arregui5, the aforementioned techniques are innovative, but they ignore the classic principles of inguinal hernia repair. Apart from the unstable fixing of the mesh to the peritoneum, Arregui lists the following disadvantages of the techniques published up to then: •• Foreign body sensation following plug implantation. •• Migration of meshes that are too small. •• Overlooked hernia defects due to inadequate dissection of the inguinal region. Arregui5 combined the experiences of the French school102,103 with preperitoneal mesh implantation and the new minimally invasive technique and demands use of a larger mesh (6.4 × 11.4 cm) as well as complete dissection of the inguinal region. He was thus the first to describe the basic principles of transabdominal preperitoneal (TAPP) mesh repair, which are still valid today, although, as described below, some important developments have taken place since then.

Indications In principle, nearly every hernia can be treated with TAPP,14 with the exception of large chronic irreducible hernias even after laparoscopic splitting of the hernial ring and in patients in whom laparoscopy is contraindicated on anesthesiological grounds. Moreover, open operation is recommended for recurrence after previous preperitoneal mesh implantation,99 though the evidence level (level 4) and the recommendation level (D) are low.

The same indications for hernia repair apply for TAPP as for any other operation. Pain in the inguinal region without clinical or ultrasound evidence of hernia (ultrasound increases accuracy by approximately 5%53) is not an indication for surgery, as the risk of developing chronic groin pain postoperatively is increased in these patients. Patients with a hernia but with unusually severe pain or pain with atypical radiation (e.g., to the back) should be informed that the pain may persist after the operation; so, another cause would then have to be sought.

2

Informed Consent, Preoperative Preparation, Perioperative Management Informed consent for TAPP follows the same rules as for any hernia operation under general anesthesia but the potentially increased risk of bowel injury compared with open techniques should be pointed out specifically. As with the open techniques, a small but significant risk for developing chronic pain postoperatively must be mentioned.57

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A special aspect of the informed consent concerns the possibility of discovering a hernia on the opposite side, which is the case in 10 to 25% of patients.53,57 Since up to 30% of these patients become symptomatic within a year,105 they should be informed of the possibility of bilateral operation and should consent if appropriate to bilateral operation. In general, the patient is shaved from the costal margin to the symphysis although there are no specific studies in this regard in hernia surgery and studies of shaving in abdominal surgery have not demonstrated any benefits.57

A bladder catheter is not usually necessary. Before the patient is transferred to the operating room, he must be told to empty his bladder. Should the bladder nevertheless be filled intraoperatively and obstructing the operation, a suprapubic catheter can be placed. Postoperative urine retention is more frequent after surgery under general anesthesia than after spinal or local anesthesia.46 When TAPP is performed adequately, the incidence is very low at < 1%.14 Apart from preoperative active bladder voiding, factors that contribute to this low incidence include minimally traumatic surgical technique, short operation times, and restricted fluid administration by the anesthetist.

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Adult Inguinal Hernia Antibiotic and thromboembolism prophylaxes are not generally recommended as the evidence to date is not compelling;72 patients with risk factors are exceptions: •• Advanced age. •• Taking corticosteroids or other immunosuppressants. •• Obesity. •• Diabetes. •• Malignant disease. •• Long operation times. •• Necessity for drains or urinary catheter. The hernia side should be marked preoperatively to avoid error.

Anesthesia The method of choice is general anesthesia with endotracheal intubation and controlled ventilation.

Patient and Operator Position The patient initially lies flat on his back with both arms by his side. The operator stands on the side opposite the hernia. The camera operator sits opposite and can support his elbow on the patient’s ribcage, which allows smoother camera control. The screen should be positioned so that it is in the same axis as the hernia and operator and is at the surgeon’s eye level. Optimal ergonomy is important to avoid later spinal problems in the operator. After creation of the pneumoperitoneum and diagnostic survey, the patient is brought into a 30 to 40% Trendelenburg position and rotated 10 to 20% toward the operator.

Trocar Choice and Position Trocars with a “blunt” perforator should be used, that is, with a rounded tip that pushes rather than cuts; compared with trocars with a triangular point, the rate of postoperative bleeding from the trocar insertion site and late postoperative trocar hernias can be significantly reduced.57 In our experience, the umbilicus, in particular, is at the risk of later herniation. Weakness of the base of the umbilicus, suggesting an incipient hernia or an actual umbilical hernia should therefore be looked for. In this case, it is advisable to pass the camera trocar through the fascial gap and close the defect like an umbilical hernia at the end of the procedure. The 5-mm optics (30°), which hardly differ in performance from the 10-mm optics, represent a major advance.

Tip

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It is advisable to insert a 5-mm trocar at the umbilicus, which is the weakest point, as this can reduce both the intensity of pain and the incidence of hernias. Simple hernioplasty can in principle be performed today with three 5-mm trocars. A plastic disposable trocar is recommended as right-sided working trocar, since both a lightweight mesh and a standard suture for peritoneal closure can be passed through this. When the hernia is a difficult one, where introduction of gauze for hemostasis can be anticipated, it is advisable to use a 10-mm trocar as right-sided working trocar and place it through the rectus muscle. Later herniation is not expected with this procedure even when the fascial port is not closed separately.

The first sagittal skin incision for the pneumoperitoneum and insertion of the 5-mm optical trocar starts at the upper border of the umbilicus and continues toward its base. With bilateral hernias, the working trocars are inserted through horizontal skin incisions (5 mm, 10 mm) at the level of the umbilicus in line with the nipples, if possible through the rectus muscle. With a unilateral hernia, it is advisable to introduce the contralateral working trocar below the level of the umbilicus to avoid any collisions with the optical trocar.

Pneumoperitoneum Creation The pneumoperitoneum can be created through a special Veress needle (closed) or after introduction of the Hasson trocar (open). The disadvantage of the open technique is the bigger incision with all the known disadvantages and also an increased potential for gas loss during the operation. We use a Veress needle as standard, though this is reputed to have an increased potential risk of intestinal and vascular injury. The evidence presented in studies, however, does not show that one method is superior to another.57 In any case, maximum caution is required, regardless of technique. We perform the Semm safety tests routinely and con­ sistently, although their efficacy has not been proved but they constantly remind the surgeon of the dangers associated with this operation step. It is particularly important to observe the insufflation device: the intra-abdominal pressure must be low (< 2–5 mm Hg) initially and the gas flow high (> 3–5 L/min). If there are any abnormalities, the needle position should be

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2.4  Laparoscopic Techniques checked or the procedure should be converted to the Hasson technique. We also prefer the Hasson technique in patients with scars after previous periumbilical surgery. The pneumoperitoneum is complete when a pressure of 12 mm Hg is reached.

Operation Techniques The difficulty of a TAPP repair is determined not only by the pathological substrate of the hernia (type, size, hernial sac, scarring, accompanying lipoma) but also by the patient’s physical characteristics (height, distance between umbilicus and pubic bone, weight, pelvic width, local obesity, strength of the abdominal muscles, thickness and elasticity of the abdominal wall, and previous abdominal surgery). After the diagnostic survey, insertion of the working trocars, and positioning of the patient, the operation starts with opening of the peritoneum. The procedure is standardized, regardless of the patient’s physique and hernia type.



Tip

If there are adhesions between the omentum or bowel loops and the hernial sac, these can be left. Division is not necessary and can even be dangerous because of the risk of bowel injury.

Reduction is performed easily “en bloc” with the entire hernial sac later in the operation. The generous peritoneal incision should be curved, starting at the anterior superior iliac spine and continued approximately 3 to 4 cm above all possible hernial orifices as far as the medial umbilical fold to allow wide and clearly visible access to the preperitoneal space (▶Fig. 2.116).

Division of the fold is not usually advisable as there may be bleeding from non-obliterated umbilical vessels. If more room is needed, the incision is continued cranially parallel to the fold. It is important that the subsequent dissection includes the entire inguinal preperitoneal space to enable the mesh to be placed flat and without creases. Dissection can nearly always be performed bluntly in the visceral compartment of the preperitoneal space, maintaining a fine layer of fascia to divide it from the parietal compartment in which the nerves and inguinal vessels course.2 The dissection follows a precise strategy. It is easier to enter the preperitoneal space laterally; the nearly avascular place is reached immediately and within a few minutes, the entire lateral compartment (Bogros) is free (▶Fig. 2.117). It must be noted that it is not the peritoneum that is dissected but the abdominal wall. Once the plane is entered, dissection continues to the medial compartment (of Retzius) over the epigastric vessels located in the center (risk of injury!). If there are no adhesions, e.g., after prostatectomy, the peritoneum and bladder are dissected bluntly from the rectus muscle and pubic bone within a few seconds without a risk of injuring the bladder or peripubic vessels (▶Fig. 2.118). However, rough dissection must be avoided, as this can lead to tearing of these small vessels and unnecessary bleeding. Development of a feeling for tissue is possible even in laparoscopic surgery but must be deliberately learned. When there is a direct hernia, the more or less large fat pad is immediately removed from the extended transversalis fascia at this stage of the operation, but careful electrocautery of blood vessels and lymphatics on the fascia (hernial sac) is advisable to prevent a postoperative seroma (▶Fig. 2.119). A very large direct hernial sac should be inverted and fixed to the Cooper ligament with

2

Opening of the peritoneum

Epigastric vessels Deep inguinal ring Medial umbilical fold

Region of the anterior superior iliac spine

Fig. 2.116  Generous curved incision of the peritoneum, following the black line.

Fig. 2.117  Lateral entry into the preperitoneal space.

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Dissection of the medial compartment

Rectus muscle

Epigastric vessels Bladder

Parietal peritoneum Fig. 2.118  Dissection of the medial compartment.

Fig. 2.119  Dissection of a direct hernial sac.

Deep inguinal ring

Epigastric vessels

Iliopubic tract Hernial sac

Fig. 2.120  Exposure of the deep inguinal ring.

a suture or tacks. The resulting reduction in dead space can significantly reduce the incidence of large postoperative seromas.21 This also results in a degree of abutment for more stable mesh positioning. The deep inguinal ring is exposed only when the lateral and medial compartments are free (▶Fig. 2.120), strictly following the anatomical landmarks (epigastric vessels and superior crus of the transversalis arch) so that the most important step of an indirect hernia operation— mobilization of the sac from the inguinal canal, dissection of the spermatic cord, and parietalization— can start. Isolation of the hernial sac is easier when three conditions are met: •• Fat-free exposure of the deep inguinal ring, i.e., division of all adhesions between the hernia and neighboring structures (epigastric vessels, transversalis loop, iliopubic tract). •• Mobilization of inguinal canal lipomas. A small indirect hernial sac is often reduced with this measure.

peritoneum Fig. 2.121  Lipomas dissected from the inguinal canal are placed on the mesh.

Lipomas must always be dissected to prevent them from being mistaken postoperatively for recurrence or subsequent pain.57 Lipomas do not have to be extracted, which can sometimes be very timeconsuming. If possible, a small vascular pedicle should be left so the lipoma can be placed on the mesh at the end (▶Fig. 2.121). •• Preliminary exposure of the testicular vessels inferolaterally (▶Fig. 2.122), so these can act as a landmark and be followed to the tip of the hernial sac, avoiding injury to them. The spermatic cord is separated from the sac mainly by blunt dissection using the rope ladder technique with two Overholt clamps, coagulating only the very tough adhesions between the sac and the vessels superficially so that atraumatic blunt dissection can continue. When the apex of the sac is reached, dissection by the same method continues in the opposite direction, i.e., from

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2.4  Laparoscopic Techniques

Epigastric vessels

2

Iliopubic tract

Testicular vein Cooper ligament Vas deferens

Fig. 2.122  Preliminary exposure of the testicular vessels.

distal to proximal. This step is called parietalization; all remaining adhesions between the sac, the peritoneum, and the spermatic cord are divided about as far as down to the middle of the psoas. This step is one of the most important in the operation; if adhesions remain, these can cause the mesh to roll up when the peritoneum is closed, resulting in subsequent recurrence. There should be a distance of about 1 to 2 cm between the lower edge of the mesh and the peritoneal reflection (▶Fig. 2.121). If there is no mesh movement when the peritoneum is elevated, parietalization is sufficient. Optimal dissection of the inguinal region should have at least the following boundaries (▶Fig. 2.123): •• The anterior superior iliac spine laterally. •• 2 to 3 cm above the center of the symphysis medially to the opposite side. •• 3 to 4 cm above the deep inguinal ring cranially. •• 2 to 3 cm caudal to the Cooper ligament inferomedially. •• 4 to 5 cm below the iliopubic tract inferolaterally. It is now possible to implant the mesh easily and without creases, overlapping the entire myopectineal orifice by approximately 3 to 5 cm. It should be noted, however, that the bigger the hernia defect, the bigger should be the mesh overlap. Studies have shown that there is a significant associa­ tion between mesh size and the incidence of recurrence.13 A mesh measuring 10 × 15 cm is defined as the minimum size. For larger defects (> 4 cm), a larger mesh (12 × 17 cm) is recommended. However, there are no confirmed data. The mesh should not be slit to create a new deep inguinal ring.12 A slit creates a weak point that can later lead to recurrence. This also involves unnecessary complete mobilization, including posteriorly, of the spermatic cord with destruction of the protective spermatic fascia and resulting

Iliac artery

Fig. 2.123  Complete anatomical dissection of the entire inguinal region.

Iliopubic tract

Genital branch of the genitofemoral nerve

Lateral Femoral branch of the cutaneous genitofemoral nerve femoral nerve

Fig. 2.124  Exposure of the intact preperitoneal fascia, behind which the inguinal nerves and vessels are located.

close contact between the mesh and the vas deferens, which is thus included in the foreign body reaction, and this may result in stenosis later. If the spermatic fascia and the lumbar fascia laterally2 remain intact (▶Fig. 2.124), direct contact between the mesh and nerves is avoided, which is possibly the reason for the lower incidence of chronic postoperative pain1 after TAPP compared with open mesh implantation. The mesh structure with the corresponding foreign body reaction almost certainly influences the incidence of chronic pain. Studies have shown that meshes with reduced material (lightweight) and with large pores  (> 1 mm) and high effective porosity cause less pain, at least in the early postoperative period (up to 4 weeks) than traditional heavyweight mesh (> 90 g/m²).16,17,115 Mesh fixation is not required as the mechanism of action follows Pascal’s physical principle provided that

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Adult Inguinal Hernia the defect is overlapped sufficiently widely. Fixation is intended merely to prevent possible dislocation of the mesh in the immediate early postoperative period, especially when the patient does not wake up gently from the anesthetic but coughs uncontrollably, strains, and moves. It is then understandable that the risk of mesh migration is greater, the larger the hernial defect or the smaller the mesh. According to the evidence to date, the following rules apply for mesh fixation56: •• If the diameter of the hernial orifice is < 1.5 cm (hernia types L1 and M1 in the EHS classification), fixation is unnecessary with a mesh (10 × 15 cm), especially when a mesh with hydrophilic properties is implanted. •• Fixation is optional with hernias types L2 and M2 (defect diameter: 1.5–3.0 cm). A non-invasive technique should be selected for fixation, i.e., ideally with fibrin glue, as the incidence of acute and chronic pain is significantly lower than with fixation using staples or tacks.56 •• Fixation is recommended for large defects > 3 to 4 cm (hernia types L3 and M3), using absorbable tacks for M3 hernias and fibrin glue for L3 hernias are used. The final step in the operation is closure of the peritoneum. An absorbable continuous suture is recommended. Suturing causes less pain compared with closure using clips.57 There should be no gaps in the peritoneal closure as otherwise there is a risk of small bowel obstruction (with gaps > 1 cm). When the trocars are withdrawn, the entry sites must be observed briefly for secondary bleeding.

Learning Curve Results with Simple and Difficult Hernias From our experiences, with over 15,100 operations and 23 staff members, TAPP is also suitable as a training operation. The assistant starts in the second or third year of training at the latest, and a gradual introduction

is recommended.69 The learning process can be supported by training on a simulator (hernia model directly, computer indirectly). The learning curve comprises approximately 50 to 70 operations and nowadays must no longer be to the patient’s disadvantage, the only exception to this being the operation time. A requirement is that the method is established and standardized in the hospital. Autodidactic learning with the inevitably increased risk of complications is no longer permissible today. The results should be documented and analyzed at regular intervals to enable continuous development. TAPP can be successful in principle for nearly every hernia provided the necessary expertise is available (▶Table 2.1). Patients who have had transabdominal radical prostatectomy or women who have had a TVT procedure are a special group. In these patients, extensive scarring may be found in the preperitoneal space with obliteration of the usual tissue planes. Dissection must be predominantly sharp. The operation can be very difficult but is quite feasible compared with TEP. Epigastric vessels and the bladder, in particular, are at a risk of injury. The operation starts in the nonscarred region. The preperitoneal space should be entered from the lateral side and then follows the anatomical structures (epigastric vessels, rectus muscle, symphysis) medially. An obvious learning curve is apparent in our experience with over 200 patients.114 While morbidity was initially high at 15%, it decreased to only 3% in the last 100 cases. The problem with a scrotal hernia is the enormous sac that must be mobilized. This can be complex and very difficult technically due to extensive fat tissue and because the spermatic cord is often displaced. In addition, there is a large wound surface, resulting in a risk of extensive postoperative hematoma. The spermatic cord structures may also be injured, with the risk of postoperative orchitis or testicular atrophy. A further problem is that the hernial orifice is often large (> 4 cm) so a larger mesh (12 × 17 cm)

Table 2.1  TAPP results in different types of hernia (Marienhospital Stuttgart, Germany 04/93–12/07) Primary hernia (incl. bilateral) (n = 13,163)

Recurrence after previous open surgery (n = 1,783)

Scrotal hernia (n = 807)

Hernia after prostate surgery (n = 300)

Recurrence after preperitoneal mesh implantation (n = 162*)

Operation time, min (median)

40

45

60

54

75

Morbidity (%)

2.8

3.5

5.8

8.3

6.8

Reoperation rate (%)

0.4

0.6

0.85

1.0

3.8

Recurrence rate (%)

0.7

1.0

2.2

0.7

0.6

Incapacity for work, d (median)

14

17

17

14

17

Age (median)

60 (17–97)

62 (18–92)

61 (18–97)

69 (52–94)

59 (29–90)

BMI (median)

25

25

25

25

25

* 92 own recurrences, 70 from elsewhere.

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2.4  Laparoscopic Techniques must be used to reduce the risk of recurrence. Among our 807 patients with a scrotal hernia, we reduced the recurrence rate from 4.1% initially to < 1% in this way. Mesh fixation is advisable in these patients. If complete reduction of the sac is too difficult and time-consuming, it can also be divided after impeccable demonstration of the spermatic cord. The sac is then ligated proximally and left open distally. However, in this case, too, the rule is that, if experience is lacking, open surgery should be performed. Recurrences and even rerecurrence after previous open surgery are not a serious obstacle to TAPP. The results of our 1,783 operations for recurrence after previous open hernia surgery are nearly identical to those obtained after primary hernia surgery (▶Table 2.1). On the other hand, TAPP for recurrence after previous preperitoneal mesh implantation is a very difficult and complication-fraught operation. The EHS guidelines99 therefore recommend open reoperation in these cases. The reason is that the scar tissue is further reinforced by the foreign body reaction, resulting from mesh implantation. The tissue planes are abolished and the anatomical structures (epigastric vessels, spermatic cord, bladder) are fused with the mesh, rendering blunt dissection impossible. Nevertheless, we showed in 162 patients that safe operation is possible with appropriate experience, especially as we have the impression that scar formation is much less when modern lightweight large-pored mesh is implanted. The practical procedure is the same as that described for after prostatectomy. Dissection between the mesh and the abdominal wall is recommended, leaving the mesh on the peritoneum. This is not troublesome and final peritoneal closure does not present any problem. Depending on the character of the recurrence and the mesh position, reconstruction can be adapted to the defect, i.e., further complete dissection of the inguinal region is unnecessary when the recurrence is medial and the old mesh is otherwise in perfect position laterally. The new mesh should not be implanted as an IPOM, however, as the risk of re-recurrence is increased on account of insecure fixation. In all these difficult hernia situations, open surgery should always be preferred in the absence of adequate experience.

 Tip When the operation is successful, the patient can benefit from all the advantages of a minimally invasive procedure. It is therefore recommended to start every operation with laparoscopy, in the first place to establish the cause of the recurrence and secondly to assess the difficulties that may be anticipated with the planned operation. Conversion is possible at any time.

Comparison of TAPP with TEP Both techniques are accepted options in the operative treatment of inguinal hernia, though neither TAPP nor TEP has proved superior to date, not least because of insufficient data.71,113,64 Dissection of the inguinal region with mesh implantation is identical with both methods, and only the access differs. Accordingly, with TEP, there exists a greater tendency to vascular injury (0.42 vs. 0.25%) and an increased conversion rate (0.66 vs. 0.16%), whereas a higher rate of bowel injury (0.21 vs. 0.11%) and trocar hernia (0.6% vs. 0.05%) are found more with TAPP.71 It is generally agreed that TAPP is easier to learn and more suitable for difficult hernias (indirect scrotal), especially when incarcerated or strangulated. TEP is virtually impossible in patients who have had transabdominal radical prostatectomy and those with recurrence following preperitoneal mesh implantation. By contrast, direct hernia, especially when bilateral, is an ideal indication for TEP.

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2.4.2  Totally Extraperitoneal Mesh Repair (TEP) Andreas Kuthe

Introduction Today’s videoendoscopic methods of inguinal hernia repair with TAPP and TEP developed around 1990 as part of the boom in laparoscopic surgery. They combined reinforcement of the posterior wall of the inguinal canal, familiar since Bassini7 and necessary to prevent recurrence, using alloplastic mesh according to the Stoppa principle,101 with the new concept of reducing the access through a minimally invasive technique, now further refined by the use of mini-instruments. This demonstrates the paradigm change in hernia surgery: hernia management, prevention of recurrence, pain reduction, patient comfort, aesthetics. Both techniques pursue the same goal of patch placement in the extraperitoneal space to bridge the hernial orifices but they achieve this in different ways: while TAPP is performed la­paroscopically via the abdominal cavity, TEP does not enter the intraperitoneal space, which is not involved in the hernia, but remains strictly extraperitoneal. TEP and TAPP are therefore like nonidentical twins. Begin and Dulucq26 from France and Arregui,6 Ferzli,30 McKernan,65 and Phillips83 from the United States of America are the surgeons associated with the development of TEP.

Operation Techniques The technique we have used and promoted has not altered since we started performing TEP in 1994.58

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Preparation, Arrangement, and Positioning

First Access

The operation is usually performed under general anesthesia, though spinal and epidural anesthesia are possible. Caution is required in patients with pulmonary risk, who may have to be able to hyperventilate in the event of hypercapnia. We give antibiotic prophylaxis despite a lack of evidence,15 as a mesh infection—albeit very rare—can have major consequences for the affected patient. Totally extraperitoneal (TEP) mesh repair does not represent an increased risk for thrombosis,15 but the S3 guideline should be observed. Umbilical disinfection is recommended, and possibly shaving or depilation from the umbilicus halfway down to the symphysis. The patient should have emptied his bladder shortly before surgery and a catheter is not necessary. The patient lies on his back, with the arm on the side of the hernia extended. It is helpful for the patient to be in slightly head-down position and rotated toward the operator. The screen is at the patient’s feet on the side of the hernia, and the operator is at thoracic level on the opposite side with the camera operator behind or (less comfortably) opposite him (▶Fig. 2.125).

The extraperitoneal space is accessed through a transverse curved incision of 1.5 cm at the lower border of the umbilicus on the side of the hernia, exposure and transverse splitting of the anterior layer of the rectus sheath, and bypassing the medial border of the rectus. Umbilical vessels passing to the epigastric vessels are often encountered and must be preserved. Ideally, they should remain on the rectus muscle. They can lead to very unpleasant intraoperative bleeding or to secondary bleeding that may be difficult to find and control. Dissection of the extraperitoneal space can be cameramonitored (0° optic) by means of a dissection balloon, for which the recommendation is grade A15 (▶Fig. 2.126), or with a blunt dissector under visual control. The landmarks are the linea alba, rectus muscle, transversalis fascia, Cooper ligament, and epigastric vessels (▶Fig. 2.127). A Hasson trocar is then introduced and fixed to the anterior layer of the rectus sheath with a suture.

Working Trocars A 5-mm or mini trocar is first inserted under vision at least 5 cm above the pubic bone. Further lateral dissection is performed with dissector and optic (0° works better) posterior to the epigastric vessels until the second working trocar can be introduced (10 mm is standard but 5 mm or mini is also possible). Visual control is important here, too, as injuries of the peritoneum and even of the cecum (on right) or sigmoid (on left) are possible otherwise. It is advisable to insert the second working trocar laterally in the anterior axillary line on the side of the hernia at the level of the umbilicus as this produces convenient triangulation of the trocars. This trocar must be inserted above the iliac spine to allow adequate lateral mesh coverage. An alternative is to introduce it close to the midline between the first working trocar and the pubic bone; this means that all trocars are in one line, which appears more comfortable for the operator but makes dissection more difficult because of the lack of triangulation. In addition, this second trocar may be in the way of good medial patch placement.

Hernia Dissection

Fig. 2.125  Positioning and arrangement for right-sided TEP.

Further dissection of the extraperitoneal space must make room for ideal mesh placement, i.e., the midline must be reached at the pubic bone and dissection must extend beyond the midline above this. The lower border of the pubic bone should be exposed, noting the iliac vein and structures of the obturator foramen. At this point, a medial hernia is easy to dissect bluntly from the transversalis fascia and the insufficient fascia is gathered with a suture to prevent hematoma/

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2.4  Laparoscopic Techniques Fig. 2.126  Dissection balloon after inflation.

2

Inferior epigastric artery and vein

L

Iliopubic tract Genital branch of the genitofemoral nerve Testicular artery and vein

M

Vas deferens

F

External iliac artery and vein Femoral branch of the genitofemoral nerve Lateral cutaneous femoral nerve

Obturator nerve, artery, vein Cooper ligament

L = lateral hernial orifice M = medial hernial orifice F = femoral hernial orifice

Fig. 2.127  Important anatomical structures and landmarks when dissecting the extraperitoneal space for TEP on the right.

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Adult Inguinal Hernia pseudo-recurrence (recommendation grade B15). Turning laterally, the peritoneal sac is mobilized posteriorly at least 5 cm from the inguinal ligament; this is usually possible without sharp dissection.

Tip



Enough room must be created on the psoas and laterally as otherwise the mesh cannot be placed in an ideal position and most recurrences arise from this area. The genitofemoral nerve and lateral cutaneous femoral nerve must be protected and the thin layer of connective tissue covering them should always be preserved. In addition, the femoral nerve passes there but is not visible, as it is variably covered by the psoas muscle; so, caution is necessary when coagulating in this area.

The spermatic cord must now be parietalized to allow the peritoneal sac on it to be mobilized sufficiently in cranial direction. A lateral hernia if present must be dissected. Experience has shown that it is useful to isolate the hernial sac from the spermatic cord close to the deep inguinal ring, approaching from the lateral side, and then mobilize it from the inguinal canal by blunt dissection. However, it can also be divided at the deep ring; this is strongly recommended for larger lateral hernias (grade C).15 The peritoneum can then be closed securely in central direction. A lipoma is often present in the inguinal canal, possibly extending to the scrotum, and must not be overlooked and left there as the

outcome is otherwise unsatisfactory for all concerned. It does not have to be resected but must be mobilized enough to rest later on the mesh with the peritoneum.

Mesh Size and Placement The mesh should be at least 10 × 15 cm (recommendation grade A15). It is placed parallel to the inguinal ligament, half above and half below the iliopubic tract (▶Fig. 2.128). The mesh overlaps the midline above the pubic bone. The inferior border of the pubic bone must also be covered. The upper corner then extends laterally to the iliac spine and the lower corner must be on the psoas muscle, lateral to the spermatic cord. All three hernial orifices (medial, lateral, femoral) are therefore in the center and should be overlapped by the mesh by at least 3 cm on all sides. A larger mesh, up to 15 × 15 cm, is needed for larger hernial openings and a transverse dimension of over 15 cm should be chosen if the pelvis is very wide, though this is very rare. Slitting the mesh is not only unnecessary (recommendation grade B15 but is even dangerous for the spermatic cord vessels and the genitofemoral nerve lying directly beneath the mesh. When CO2 is released, it is possible to check that the mesh is in correct and crease-free position. We release the gas in fractions through the lateral trocar, hold up the lateral border of the mesh with the lateral trocar, and correct the mesh with the medial instrument. The lower border of the mesh must be inspected to ensure that it is not turned up by the peritoneal sac beneath it, the bladder, or a lipoma. Fig. 2.128  Correct mesh placement in TEP on the right.

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2.4  Laparoscopic Techniques

Mesh Fixation Fixation is not usually necessary in TEP15,58 if the mesh is big enough and placed correctly.

Caution



Poor mesh placement cannot be corrected by fixation. Fixation may be useful to correct insufficient overlapping in the case of very large medial hernias or when medial dissection has been inadequate due to adhesions. To reduce chronic postoperative pain, gluing is preferable to use of a stapler or tacks (recommendation grade B15).

Local Anesthesia We always conclude the operation with instillation of 8 mL of 0.5% bupivacaine into the extraperitoneal space in front of the mesh and infiltration of 2 mL in the trocar sites prior to intracutaneous absorbable skin suture. This further reduces the already low postoperative analgesic requirement. In approximately 5% of patients, the obturator nerve is affected, resulting in temporary weakness of the adductors, but this does not prevent immediate mobilization.

Drainage Drainage of the extraperitoneal space is required extremely rarely (recommendation grade B15), e.g., after extensive sharp dissection of extraperitoneal adhesions. Placing a suction drain in the site of the hernial sac or sac remnant after scrotal hernias appears quite reasonable. However, this must not have any contact with the mesh to avoid mesh dislocation when the drain is removed.

Mobilization/Loading The patient can be mobilized as soon as possible after transfer from the recovery room and may be discharged home. After a week, when the wounds have healed, we do not see any further need for physical restriction.

Special Aspects Lipoma While dissection of the transversalis fascia medially provides a clear working area, an additional preperitoneal

lipoma may be found after lateral hernial sac dissection. This must be dissected and mobilized from the inguinal canal but does not have to be resected. If such a lipoma is overlooked, it may give the impression of a hernia postoperatively, possibly with symptoms due to pressure on the nerves coursing through the inguinal canal and with the potential for incarceration. If it is too large to pass through the inguinal canal, it should be resected through a small inguinal access.

2

Female Hernia A lateral hernia is usually found in women, while a femoral hernia is frequent and a medial hernia is quite rare. Parietalization of the round ligament is very difficult and nearly always ends with a substantial injury of the peritoneum which must be sutured securely. Alternatively, the round ligament can be divided at the deep inguinal ring, preferably between clips because of the arteries within it. As the ligament is fixed to the peritoneum, the central segment comes close to the deep ring again as the mesh becomes integrated.

Femoral Hernia A femoral hernia is found more often in female patients, and a femoral hernia in addition to a medial or lateral hernia is not uncommon in either sex. Most often, it is fixed and irreducible. Before reducing it, the medial and lateral margins of the hernia should be exposed, revealing the pubic bone (caution: iliac vein). If the hernial ring has to be extended to allow reduction, this should be done in superomedial direction by incising the inguinal ligament. A branch of the epigastric artery running transversely must be noted to avoid potential bleeding or secondary hemorrhage (see ▶Fig. 2.127).

Bilateral Hernia Additional trocars are not required for repair of the opposite side. The operation should start on the apparently more difficult site. The surgeon changes sides for dissection and mesh placement on the second side. The initial landmarks for the opposite site are the pubic bone and the epigastric vessels and the procedure is continued as normal. Two meshes of appropriate size that overlap in the midline are preferred over implantation of one large mesh as they are easier to position correctly. If positioning is correct, mesh fixation is not required.

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Irreducible Hernia After induction of anesthesia and with good relaxation, manual reduction should always be attempted; if successful, routine TEP is then possible. Nearly 100% of all irreducible hernias can be managed by TEP.62 •• Femoral hernia: See previous text. •• Medial inguinal hernia: Sharp cranial extension of the hernial ring should always allow reduction. •• Lateral inguinal hernia: Extension of the deep inguinal ring is difficult. The hernial sac can be opened anteriorly to allow gradual return of the contents to the abdomen using atraumatic forceps. If necessary, the sac can be excised, protecting the spermatic cord, and the peritoneal defect is closed securely. The greater omentum is nearly always adherent extensively in the sac and difficult to reduce. We resect it through a small inguinal access.

Tip



When a hernia is very large, it can be useful to start with laparoscopy to reduce the hernia contents. The hernial orifice is then repaired with TEP.

Scrotal Hernia As the name indicates, the hernial sac extends as far as or into the scrotum. The vast majority are lateral hernias and the hernial orifice can be very large. If reduction prior to operation is possible, normal TEP is performed; otherwise, see under irreducible hernias. The sac should not be dissected but divided at the deep inguinal ring. As this avoids scrotal manipulation, there is less hematoma formation and a lower risk of ischemic orchitis. The residual scrotal hernial sac leads very rarely to hydrocele and should be left open, but the peritoneal leak must be securely sutured closed.

Strangulated Hernia Strangulated hernia is an emergency as the blood supply to the incarcerated hernia is impaired and the patient’s life is at risk. Taxis should be attempted after induction of anesthesia and is often successful. Over 80% of cases can be treated successfully by TEP.62 •• Successful taxis: Normal TEP can be performed, always followed by laparoscopy to assess the incarcerated tissue and resect it as necessary. •• Unsuccessful taxis: If ileus is present, we would always start with laparoscopy through a paramedian minilaparotomy at the umbilicus and carry out reduction under vision with light pressure from the exterior, assisted if necessary by traction with atraumatic forceps from within. If the groin is not infected,

the hernia can be repaired by TEP (after closure of the posterior layer of the rectus sheath), and resection of incarcerated tissues can then be performed through mini laparotomy distant from the hernia. If ileus is not present, TEP can be performed as described for irreducible hernia, but always followed by laparoscopy to assess the incarcerated tissue.

TEP for Recurrent Hernias •• Previous posterior operation: TEP is not suitable for treatment of recurrence after a previous posterior operation (TAPP, TEP, Stoppa, etc.) as the extraperitoneal route of TEP from the umbilicus is blocked by adhesions and the old mesh. •• Previous anterior operation: TEP produces similarly good results as in a primary operation,93 since, in these cases (Shouldice, Bassini, Lichtenstein, Rutkow, etc.), TEP, like TAPP, goes through pristine tissue and the number and type of previous operations are not so critical. The problem is more with adhesions involving the transversalis fascia and deep inguinal ring. The hernial sac can be extremely fixed where it passes through the abdominal wall so that it makes more sense in many cases to excise it rather than to dissect it and close the peritoneal defect securely.

TEP after Previous Lower Abdominal Surgery Considerable peritoneal adhesions can be expected; so, peritoneal injury is often unavoidable. It is therefore important to install the second working trocar first and then approach the scar. The second working trocar may thus have to be placed in an atypical position. The anatomy can be difficult to identify, and there is a risk of vascular and nerve injury. Anterior procedures are preferable in case of doubt and when adequate experience is lacking.

Appendectomy This, the most frequent previous operation, sometimes presents a real problem with right-sided hernias as adhesions make adequate lateral dissection difficult. Peritoneal tears are common and troublesome especially when only one working instrument is at the site. Dissection should start medially, if necessary placing the second trocar medially also.

Caution



Cecal injury may occur when there is cecal adhesion.

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2.4  Laparoscopic Techniques Dissection from above is an alternative: the posterior layer of the rectus sheath is opened in lateral direction above the scar with the medial instrument to reach the extraperitoneal space and the second trocar is then deployed here so the scar region can be dissected from above with both hands.

ileus due to adhesions to exposed parts of the mesh. Even large peritoneal injuries do not lead to intraoperative conversion if: •• The working pressure is low (10 or ideally only 7 mm Hg). •• The patient is in slightly head-down position (10–20°). •• The patient is well relaxed.

Other Previous Visceral Surgery

Defects over 1 cm in length can, in my opinion, be closed securely by suturing to prevent adhesions to the mesh.

In the great majority of cases, moderate adhesions can be expected as after gynecological procedures (midline laparotomy), depending on the access route of the original operation.

Results

Previous Gynecologic Surgery This usually results in low-grade adhesions in the midline and presents few problems.

Previous Urologic Surgery In my view, cystectomy is a contraindication to TEP as it is hardly possible to dissect the extraperitoneal space. After radical prostatectomy, access medial to the epigastric vessels is very difficult. So the approach must be lateral, but only a surgeon truly versed in TEP will find a safe route to the Cooper ligament. Its lower border is often not free enough for the mesh to overlap here; in this case, the mesh must be fixed.

Caution



Caution is required with the iliac vessels, which are not visible initially. The midline can be reached only by sharp dissection, but this can be less extensive here as the hernias are nearly all lateral; this is supplemented by gluing the mesh medially.

Previous Vascular Surgery Only a very experienced surgeon can perform successful and uncomplicated TEP as the anatomy in the extraperitoneal space can be greatly altered and/or adherent with a particular risk of arterial bleeding.

Previous Trauma Surgery Very severe adhesions can block the extraperitoneal space, mainly after pelvic reconstruction. TEP is not advisable.

Peritoneal Injury Injury of the peritoneum is common during TEP (up to 50% in our experience104) and may lead to sometimes very troublesome capnoperitoneum and postoperative

2

Recurrences after TEP The recurrence rates after TEP do not differ from those after TAPP or the Lichtenstein procedure.99,113 Rates below 1 to 2% are achieved in single specialist series.15,63,104,113 The re-recurrence rate after TEP for recurrence after previous anterior surgery is equally low.93 In our experience, the majority of recurrences are lateral and arise from the posterolateral aspect, usually due to turning up of the posterolateral corner of the mesh. Recurrence is more rarely due to inadequate lateral overlapping of the mesh. Medial recurrence is nearly always due to inadequate medial overlapping of the mesh. To avoid recurrence, therefore, appropriate mesh size and exact mesh placement are enormously important.

Complications Intraoperative Complications

Serious complications such as organ injury, small bowel obstruction, and iliac vessel injury are rare and even less frequent than with TAPP.99,113 Bladder injuries usually occur during adhesiolysis in the midline after previous lower abdominal surgery, and bowel injuries during reduction of irreducible hernias or lateral adhesiolysis (e.g., after conventional appendectomy). Both must be noted at operation and can then be oversewn videoendoscopically; mesh implantation is possible following bladder and small bowel injury. The iliac vein can be mistaken for an irreducible hernia and injured; this is managed through a subumbilical midline access. A major intraoperative peritoneal tear will result in ileus and must be prevented by careful and secure sutured closure. ▶ Hemorrhage. The most frequent cause of hemorrhage is injury of the epigastric vessels and their branches during extraperitoneal dissection. Electrocoagulation or else clipping can provide assistance. Special attention must be paid to a variable vessel passing from the umbilicus to the epigastric vessels. The testicular vessels must also be noted, with cautious mobilization of a lateral lipoma, which may contain the testicular vessels; the obturator vessels must also be noted at the inferior border of the pubic bone, where the obturator nerve is at risk during coagulation.

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Caution



Caution is required when dissecting a femoral hernia, especially when extending the orifice, as variants may pass from the epigastric vessels (corona mortis) medially on the inguinal ligament or posteriorly toward the obturator foramen (see ▶Fig. 2.127). In addition, there are various small unnamed vessels that will bleed, especially when the correct dissection plane is left.

Caution



Caution is required during electrocautery in the vicinity of nerves (see ▶Fig. 2.127).

▶ Nerve injury. This occurs at operation and only becomes apparent postoperatively. It is caused by rough extraperitoneal dissection that leaves the correct plane and in particular by blind electrocautery. The following nerves are at risk, from lateral to medial: lateral cutaneous femoral nerve, genitofemoral nerve, femoral nerve (never visible but close to the surface of the psoas, crossing beneath the inguinal ligament lateral to the external iliac artery), and the obturator nerve (see ▶Fig. 2.127).

Postoperative Complications ▶Secondary hemorrhage. Considerable secondary bleeding may occur from small vessels after both inguinal and extraperitoneal procedures, as these spaces are slow to become tamponade. The very rare104 extraperitoneal secondary hemorrhage requires reoperation in approximately 50% of cases (always possible endoscopically); since the mesh readily becomes dislocated, there is a latent risk of infection, and considerable pain may be present. Intraperitoneal bleeding is possible after a peritoneal tear and can even lead to hemorrhagic shock if it is not recognized. Inguinal secondary hemorrhage leads to a spermatic cord or scrotal hematoma and rarely requires revision.104 ▶ Hematoma/Seroma. In our experience, hematomas/ seromas are the most frequent complications after TEP, occurring in up to 6% of cases depending on definition and routine use of postoperative ultrasound.104 Their location can be scrotal as well as inguinal and preperitoneal. Good and open patient management combined with adequate anti-inflammatory and analgesic therapy help during the initial period and revision is hardly ever necessary. In rare cases, when a seroma in the spermatic cord is under pressure and causing pain, aspiration can provide relief. An extraperitoneal seroma rarely needs to be aspirated to prevent mesh dislocation. Weeping must always be anticipated following seroma aspiration.

▶ Ischemic orchitis. Ischemic orchitis is less often compared with open procedures (0.1% in our experience,7,63,99) as the pampiniform plexus can hardly be altered. However, caution is required when dissecting a lateral hernial sac far into the inguinal canal. Interference with the arterial blood supply of the testis is unlikely even if the spermatic artery is divided in the extraperitoneal space due to the additional supply via the superficial epigastric artery and the artery along the vas deferens.

Pain Postoperative pain merits a chapter of its own (see section ▶5.3). It occurs significantly more rarely after TEP and TAPP, the two endoscopic procedures, than after open procedures;63,99,113 depending on definition, the rates are below 1 to 6%. For the affected patient, however, a real problem can develop, albeit rarely. Since acute pain, in our view, plays a part in triggering the onset of chronic pain, we start analgesic and anti-inflammatory treatment intraoperatively, combined with local anesthesia and immediate mobilization. During dissection, it is imperative to be aware of the correct plane so the local nerves are not denuded and then come in direct contact with the mesh. If the mesh must be fixed, gluing is clearly preferable to tack or staple fixation as regards postoperative pain.15 A postoperative pain syndrome must be addressed promptly. Our best experience has been with osteopathic therapy and acupuncture.

TEP: Indications and Contraindications In 2001 and 2002, we treated 1,085 inguinal and femoral hernias in the Clementinenhaus Hospital in Hannover, 1,059 (97.6%) of them with TEP. This leaves 26 cases: •• Seven young patients had a sutured repair (no indication for mesh implantation). •• Three patients refused mesh implantation and underwent Shouldice repair. •• Four patients were not suitable for general anesthesia or spinal/epidural anesthesia and were managed with anterior operations. •• Five patients had TAPP operation for recurrence after endoscopic hernioplasty. •• Seven patients with previous lower abdominal surgery underwent an anterior repair procedure. The patient’s sex and the type, position, size, and reducibility of the hernia play no part in the indication for TEP when the operator has the necessary experience; the contraindications include young age, the patient’s wishes, suitability for anesthesia, and previous lower abdominal surgery. I regard two other factors as contraindications; these are existing infection/contamination and uncontrollable coagulopathy: •• Mesh repair should not be performed if there is a large bowel lesion or inguinal infection due to

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2.4  Laparoscopic Techniques strangulation, and the same applies for existing infection in the lower abdomen and for potentially contaminated procedures necessary at the same time, such as appendectomy, colon resection, or cholecystectomy. •• Patients with coagulopathies that can be corrected by replacement can be treated with TEP as can patients on aspirin. Patients on vitamin K antagonist therapy, in our opinion, can be operated on with low-molecularweight heparin (LMWH) bridging. Caution is required in the case of thrombocytopenia and thrombopathy with prolonged bleeding time; treatment with clopidogrel and other newer anticoagulants that cannot be interrupted is a contraindication, in our view.

2.4.3 Minitechnique Henning Niebuhr

Introduction As in other standard operations performed laparoscopically, endoscopic hernia surgery endeavors to minimize access trauma. The technique for achieving this minimization by means of instruments, reduced to a diameter of 2 mm, is described in this section. The aims of instrument miniaturization are: •• Delicate dissection. •• Reduction of negative postoperative sequelae. •• Aesthetic advantages due to reduced scarring. The procedure was already described in 1998.48 The long time to maturation of the instrument technology has so far prevented it from becoming widespread.

Robust instruments have been developed and available for about 4 years, so, the technique can now be used routinely and in large numbers.

Instruments

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Different groups of materials are available for instrument construction, two of which are described here: •• Steel. •• Titanium/ceramic. The design of the steel instruments is based on that of the familiar 5-mm instruments, especially with regard to handle design. The smallest possible steel instruments have a diameter of 3 mm. Further miniaturization does not appear possible on account of the shear forces that lead to bending. The outer diameter of the trocars used is 3.5 mm. The total length of the incisions for TAPP repair is therefore 17 mm. Instruments made of titanium and ceramic using a two-component technique are different. In this case, the outer diameter is 2 mm and the bending strength is high. The outer diameter of the trocars is 2.8 mm. The total length of the incisions for TAPP repair is 15.6 mm.

Operation Techniques After creating the pneumoperitoneum via a Veress needle, three trocars are placed, one with a diameter of 10 and two with a diameter of 2.8 mm. The optic is introduced through the 10-mm umbilical trocar (▶Fig. 2.129). The incision for the optic trocar is made transversely in the lower circumference of the umbilicus. The skin here can later be closed invisibly with an intracutaneous absorbable suture. The skin incisions for the two working trocars are made with the “Skinpic” (▶Fig. 2.130). This achieves a very Fig. 2.129  Instruments.

Fig. 2.130  Skinpic.

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Adult Inguinal Hernia small skin opening through which the bluntly rounded mini obturators with the trocars attached flush slide into the abdomen by bluntly pushing apart the subcutaneous tissue, fascia (muscle), and peritoneum without cutting, screwing, or tearing. Through the two trocars (each 2.8 mm) introduced laterally just medial to the anterior superior iliac spine, the peritoneum above the hernia is incised transversely over a distance of about 5 cm with a high-strength 2-mm dissector and a corresponding 2-mm scissors (Alphadur titanium ceramic 2-mm instruments, Gimmi, Tuttlingen, Germany). The hernial sac is then dissected from the spermatic cord with 2-mm dissectors and the 2-mm scissors until it has been fully mobilized. The hernial orifice in the transversalis aponeurosis is then apparent. After extensive dissection of the spermatic cord and its structures from the peritoneum, a sufficiently large  (10 × 15 cm) mesh with slightly rounded corners can now be placed safely over the spermatic cord, the vessels, and the hernial orifices (▶Fig. 2.131). The same rules apply as described in section ▶2.4.1. The delicate 2-mm microtechnique allows dissection close to the peritoneum to spare neural structures. When a large medial hernia is present, the rolled-out transversalis fascia is dissected gradually and is then “flattened” and sutured with polyglactin. The peritoneum must be mobilized extensively off the vas deferens, the vessels, and the spermatic fascia over the psoas to prevent the lower edge of the mesh from rolling up. The peritoneum is finally closed with a conventional 3/0 polyglactin continuous suture using the 2-mm needle holder and a corresponding dissector (▶Fig. 2.132).

The individually trimmed mesh and the suture material are introduced through the 10-mm umbilical trocar. The residual suture material is buried through the 10-mm trocar by pushing the needle holder backward and pushing it through after removal of the valve head of the 10-mm trocar (▶Fig. 2.133). Incision or fixation of the mesh is not necessary as it is pressed onto the transversalis fascia in the tailor-made preperitoneal space by the closed peritoneum and the viscera that “lean” on it, once the pneumoperitoneum is released, just like in the TEP procedure. The pressure on the mesh following release of the pneumoperitoneum leads through the expressed fibrin to rapid adhesion of the mesh to its surroundings so mesh displacement is largely excluded. Very large medial hernias are an exception, where leveling suture of the rolled out transversalis fascia is indicated to ensure that the mesh remains in place and to avoid mesh bulking in the hernial orifice. Moreover, in this case, the mesh should be secured temporarily medially with a 3/0 polyglactin suture. If the mesh were to be fixed, a tacker or fibrin glue would have to be introduced through the 10-mm trocar (Use of a 5-mm trocar in the umbilicus is theoretically possible but does not appear rational, as the mesh and suture must be introduced through it). To carry out this maneuver under optical control, insertion of a 2-mm (needlescope) optic into one of the two 2.8-mm trocars is necessary and possible. Fascial closure at the umbilical trocar incision may be required in individual cases. The operation concludes with a continuous, buried intracutaneous absorbable suture of the umbilical incision. The 2.8-mm stab wounds do not require treatment (▶Fig. 2.134).

Fig. 2.131  Mesh inserted.

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2.4  Laparoscopic Techniques Fig. 2.132  Peritoneal suture.

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Fig. 2.133  Needle transfer.

Fig. 2.134  Postoperative result.

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Adult Inguinal Hernia [88] Rives J, Lardennois B, Flament JB, Convers G. The Dacron mesh sheet, treatment of choice of inguinal hernias in adults. Apropos of 183 cases [Article in French] Chirurgie. 1973; 99(8): 564–575 [89] Robbins AW, Rutkow IM. The mesh-plug hernioplasty. Surg Clin North Am. 1993; 73(3):501–512 [90] Röder W, Weigel TF, Isemer FE. Ein Konzept zur Senkung postoperativer Schmerzen nach Leistenhernienoperation. Langenbecks Arch Chir. 1994; 379(2):80–83 [91] Rutkow IM, Robbins AW. Hernioplastik mit der Netzplombe. Chirurg. 1997; 68(10):970–976 [92] Santoro E, Agresta F, Aloisi P, et al. Is minilaparoscopic inguinal hernia repair feasible? A preliminary experience. J Laparoendosc Adv Surg Tech A. 2005; 15(3):294–297 [93] Scheuerlein H, Schiller A, Schneider C, Scheidbach H, Tamme C, Köckerling F. Totally extraperitoneal repair of recurrent inguinal hernia. Surg Endosc. 2003; 17(7):1072–1076 [94] Schultz L, Graber J, Pietrafitta J, Hickok D. Laser laparoscopic herniorraphy: a clinical trial preliminary results. J Laparoendosc Surg. 1990; 1(1):41–45 [95] Schumpelick V. Präperitoneale Reparation mit Netzplastik nach Nyhus. In: Schumpelick V, ed. Hernien. 4th ed. Stuttgart: Thieme; 2000: 205 [96] Schumpelick V, Treutner KH, Arlt G. Klassifikation von Inguinalhernien. Chirurg. 1994; 65(10):877–879 [97] Schumpelick V, Kasperle R, Stumpf M. Operationsatlas Chirurgie. 4th ed. Stuttgart: Thieme; 2013 [98] Simmermacher RKJ, Duyn EB, Devers GJ, et al. Preperitoneal mesh in groin hernia surgery. A randomized clinical trial emphasizing the surgical aspects of preperitoneal placement via laparoscopic (TEP) or grid-iron (Ugahary) approach. Hernia. 2000; 4: 296–298 [99] Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009; 13(4):343–403 [100] Singh K, Arregui M. Intraperitoneal onlay mesh (IPOM) for inguinal hernia repair—still a therapeutic option. In: Bittner R, Arregui ME, Bisgaard T, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia. International Endohernia Society (IEHS). Surg Endosc 2011; 25: 2829–2831 [101] Stoppa R, Petit J, Henry X. Plastic des hernies de l’aine par voie mediane sousperitoneal. Acta Chiropt. 1972; 5:488 [102] Stoppa R, Petit J, Henry X. Unsutured Dacron prosthesis in groin hernias. Int Surg. 1975; 60(8):411–412

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3

Chapter 3 Special Hernias

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3 3.1

Female Hernias

172

3.2

Sportsman’s Groin

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3.3

Sliding Hernia

177

3.4

Recurrent Hernia

180

3.5

Umbilical Hernia

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3.6

Femoral Hernia

192

3.7

Rare Hernias

208

3.8

Spigelian Hernia

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3.9

Internal Hernias

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Special Hernias

3  Special Hernias 3.1  Female Hernias Georg Arlt Only about 5 to 8% of all hernias in the inguinal region occur in women;5,48,77 approximately 20 to 30% are femoral hernias and the other two-thirds are predominantly indirect inguinal hernias. Direct inguinal hernias are rare in women.127 In major clinical studies, direct inguinal hernias amount to only a little over 10%. Unlike indirect hernias, the incidence of bilateral direct inguinal hernia is comparatively higher in women at 40 to 50%.48 The incidence and distribution of female groin hernias differ completely from male hernias, primarily because of the anatomical differences. The female pelvis is shallower and wider and the area of the muscle-free Hesselbach triangle is correspondingly smaller. Moreover, the structures that pass through the inguinal canal are rather narrow and string-like. These factors make women less prone to develop an inguinal hernia but promote the development of femoral hernias. Although direct inguinal hernias are rare, when they occur, they are very frequently bilateral, indicating a systemic disorder, e.g., collagen metabolism. Data regarding the timing of operation in pregnant women are very sparse. There are no publications about a particular risk of incarceration during pregnancy or problems during childbirth. In advanced pregnancy, the enlarged uterus covers the hernial orifice and so possibly protects against incarceration. The current recommendation is to observe a hernia diagnosed during pregnancy and perform elective surgery following delivery.13

3.1.1  Operation Tactics The choice of access and operative procedure for female hernias in the inguinal region is currently undecided. Good results with long-term recurrence rates of 2.5 to 4% up to 10 years have been described for open transinguinal repair of a groin hernia, using both sutured and mesh methods.5,122 Recurrent hernias, especially when observed in the early postoperative period, are found much more often in the femoral region in women. This suggests that they are not genuine recurrent hernias but rather an initially overlooked primary femoral hernia. In a clinical study of the groin region, about 20% of femoral hernias were overlooked.102 In addition to clinical examination, ultrasonography can help to distinguish preoperatively between an indirect inguinal and a femoral hernia and should therefore be employed readily. Moreover, intraoperative assessment by palpation of the femoral compartment in women is an essential component of a successful open operation. If no evidence for a femoral hernia is found during surgery of an indirect inguinal hernia, a sutured repair with

complete closure of the deep inguinal ring can be used. When an additional defect in the femoral compartment is found, TIPP repair (See section ▶2.3.2) or a modification of the Lichtenstein repair is the option during open surgery. Mesh repair should be the standard treatment of the rare direct female inguinal hernia. All potential hernial orifices are treated by endoscopic TEP repair, thus eliminating the problem of an overlooked femoral hernia. This argument is used to promote TEP as the most suitable method of inguinal hernia repair in women.102 However, mesh repair is often not necessary for an isolated indirect inguinal hernia, especially in younger women,122 and can therefore be regarded as “overtreatment.”

3.1.2  Operation Techniques The operation technique differs from the procedure in men as round ligament of the uterus is in the inguinal canal instead of the spermatic cord. Injuries of the round ligament are not dangerous and it can be divided and resected without significant consequences. When the hernia is indirect, the sac is treated and the femoral compartment is then explored digitally through the expanded deep inguinal ring (▶Fig. 3.1). Sutured repair, e.g., by the Shouldice method (see section ▶2.2.2.4), can then be carried out, especially in younger patients. Unlike in men, the deep inguinal ring is closed completely. The proximal stump of the round ligament can be included in the lateral part of the Shouldice suture (▶Fig. 3.2). When the hernia is direct, the posterior wall of the inguinal canal may have to be incised to allow palpation of the femoral orifice. Mesh repair is recommended, e.g., with the Lichtenstein procedure. Unlike the operation in men (see section ▶2.3.1), the mesh is not slit laterally. If a femoral hernia is found in addition during open surgery, TIPP repair can be used without slitting the mesh laterally (see section ▶2.3.2) or the Lichtenstein repair can be modified by fixing the medial part of the mesh to the Cooper ligament rather than to the inguinal ligament (▶Fig. 3.3). Suture of the mesh starts as usual over the pubic bone, without picking up the periosteum. From there, the suture passes from medial to lateral between the Cooper ligament and the inferior border of the mesh as far as the femoral vein. The suture ascends here to the base of the inguinal ligament and continues beyond the deep inguinal ring, as in men. The mesh is fixed cranially by the usual method of tying it loosely to the internal oblique muscle. At the deep inguinal ring, the proximal stump of the round ligament can be fixed to the mesh. The operative technique of laparoscopic (TAPP) or endoscopic (TEP) inguinal hernia repair in women does not differ from that in men (see section ▶2.4.1 and ▶2.4.2). In case of doubt, the round ligament can be divided at the level of the deep inguinal ring to optimize mesh position.

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3.1  Female Hernias Fig. 3.1  Exploration of the femoral compartment through the deep inguinal ring.

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Fig. 3.2  The Shouldice repair of an indirect inguinal hernia in women. The round ligament is included in the lateral region of the suture.

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Special Hernias Fig. 3.3  Lichtenstein repair of a combined hernia with a femoral hernial orifice. Schematic cross-section of mesh position medial to the femoral vein.

3.2  Sportsman’s Groin Ulrike Muschaweck and Christoph Peter Schuhmacher Sportsman’s groin (sportsman’s hernia) is an interesting condition common in top athletes, which has received much attention only in the past 10 years. It is defined by chronic and usually exercise-related pain in the groin region. In our routine practice, we prefer the term sportsman’s groin to sportsman’s hernia, because patients with this syndrome rarely have a genuine hernia but rather have weakness of the posterior wall of the inguinal canal with nerve irritation. The term “soft groin” is often used to describe this condition but this rather general diagnosis does not adequately reflect the complexity of the disorder. This section presents the typical symptoms, the required diagnostics, and recommended treatment of sportsman’s groin. Pain in the groin region is not rare; the annual incidence reported in active footballers is 8 to 15%.26 This is easily understandable because of the stress on this region of the body, especially in athletes. The muscles of the anterior abdominal wall play a key part in stabilizing the pelvis. Considerable forces act on muscle origin and insertion sites during eccentric rotating movements, running and sprinting, and on impact and rotation of the upper body. In addition, the multilayered nature of the matrix of muscles and tendons causes these structures to slide over each other. Important sensory nerves, the ilioinguinal nerve and the genital branch of the genitofemoral nerve, pass through this sliding matrix. The abductors and adductors of the thigh act as antagonists of the abdominal muscles in stabilizing the pelvis and must always be considered when the cause of groin pain is sought, especially in athletes. The pubic bone, where the abdominal muscles are inserted, is especially important. This is not a classic inguinal hernia but rather a circumscribed weakness of the posterior wall of the inguinal canal, which leads to circumscribed protrusion. Since

there is no hernia, the term “sportsman’s hernia” or “sports hernia” should be avoided. The leading problem resulting from this site of lower resistance is sudden irritation of the genital branch of the genitofemoral nerve, which then becomes chronic. The typical pain is burning, stabbing, and/or radiating to the inner thigh, testis, and scrotum, and also to the back. The circumscribed expansion of the inguinal canal also leads to medial and cranial retraction of the rectus muscle. This causes increased tension on the pubic bone with a sustained increase in stress on the fanlike muscle insertion, resulting in sometimes burning pain in the pubic bone, known as “osteitis pubis” or “pubalgia.” This painful stimulus produces reflex tension of the rectus and therefore further tension on the pubic bone. The dull pain at rest and sudden shooting pains with exercise are very troublesome for top athletes and can drastically reduce their performance. There is also a mental component. By trying to avoid the symptoms, the athlete is much more cautious and limited in his mobility and radius of action. Consequently, his form falls off. Besides the acute and readily explained pain in the groin area, further differential diagnoses should be considered when the details of the pain are less obvious.41

3.2.1 History Knowing the history is the first important step in establishing the correct diagnosis. Essential points in the history are the time of onset of the groin pain, prior trauma, or wrong movements during training, and the pediatric history in case of any previous damage, such as the Perthes disease or hip dysplasia. In the trauma history, a distinction should be made between impact injury, extreme movements (shooting at goal, skiing injury etc.), dislocations, and chronic overuse. For example, the type of sport can provide important evidence about the nature of the strain. Golfers are exposed to rotation of the pelvis with the leg fixed, skiers

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3.2  Sportsman’s Groin are more at risk of sudden extreme movements or collisions, and footballers are subject to recurrent twisting and shooting stresses and stresses on the adductor muscles. The characteristics of pain can help lead to the right diagnosis: •• Is the pain load-dependent? •• Is it unilateral or bilateral? Can the pain be provoked? •• Does it occur when the patient is lying or standing?

3

A typical and therefore indicative pain as the cause of sportsman’s groin has a burning and sometimes sporadic character radiating to the inside of the thigh, into the scrotum, and to the back. Infiltration of a local anesthetic at the pain point may sometimes help to elucidate the cause of an insertion tendinopathy.

3.2.2 Diagnosis Clinical Examination Operation must always be preceded by an accurate record of the symptoms. Athletes typically report a sudden, shooting, sharp, and sometimes burning pain in the groin region, radiating to the inside of the thigh, perineum, and scrotum. The typically unilateral pain can be provoked by sit-ups and sudden movement with torsion of the hip region. It is particularly typical that the pain sensation also occurs with the same intensity after adequate rest. Examination reveals a tender inguinal canal on standing and especially with the Valsalva maneuver, and the pubic bone is often tender too. An actual hernial orifice is not palpable as with a typical inguinal hernia. The clinical examination always includes the musculoskeletal system and palpation of the abdomen. The musculoskeletal structures to consider in the differential diagnosis are: •• The sacroiliac joint. •• The hip: ○○ Osteoarthritis. ○○ Coxa vara, coxa valga. ○○ Slipped epiphysis and snapping hip. •• The muscles of the pelvic region, especially the adductors, which can be affected by insertion tendinopathies on the pubic bone. From the neurological point of view, it is important to identify or exclude the ilioinguinal nerve entrapment syndrome. A slightly flexed and internally rotated hip is a frequent clinical sign. Pressure injury of the genital branch of the genitofemoral nerve and/or ilioinguinal nerve often produces sensory deficits in the groin itself and on the inside of the thigh. Radiation of the pain along the spermatic cord (spermatic cord neuralgia) as far as the testis is a typical symptom of such nerve irritation. Radicular syndromes due to degenerative disease of the spine or intervertebral discs can also involve the groin in the area of pain radiation, usually unilaterally. Radiography may aid diagnosis.

Fig. 3.4  Dynamic ultrasound scan with typical appearance of the bulge, which is diagnostic of sportsman’s groin.

Ultrasonography In addition to an accurate history and physical examination, ultrasonography plays a very important role. The sliding layers in the groin region can be examined and the local bulge (▶Fig. 3.4) of the posterior wall of the inguinal canal during static and dynamic examination (when the patient strains) can be detected.80 This finding is diagnostic in conjunction with the clinical symptoms. Correctly performing and interpreting an ultrasound of the groin requires much experience and practice.

Magnetic Resonance Imaging and Computed Tomography Computed tomography (CT) is rarely required to diagnose sportsman’s groin. Magnetic resonance imaging (MRI) plays a pivotal role in its diagnosis. For patients with a normal clinical examination and unclear ultrasound findings, MRI of the region including the spine is indicated, especially to detect conditions of bone and cartilage that cannot be seen directly on conventional X-ray. MRI may show, for example, an avulsion fracture or insertion tendinopathy (“conjoint tendinopathy”), that is, conditions that necessitate mainly conservative management.55 However, the protrusion of the posterior wall of the inguinal canal can never be seen on MRI, as the examination is performed with the patient lying down and the circumscribed defect is too small.

Herniography Herniography is still quite widely used in the Anglophone countries.29 In our experience, however, it can hardly be recommended on account of the radiation exposure and the test can easily be replaced by ultrasonography performed by an experienced examiner.

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Special Hernias Table 3.1  Randomized studies on the treatment of sportsman’s groin Author

Patients

Operation method

Result

42

68

–

Comparison of active vs. conventional PT: considerably better results after active PT

Ekstrand et al26

66

Open repair, neurectomy

4 groups (OP, NSAID, IT, and PT); only the operated patients showed a significant and long-term improvement in pain

Paajanen et al82

60

TEP

Better freedom from pain in the operation group 1–12 months after surgery

Hölmich et al

Abbreviations: OP, operation; NSAID, nonsteroidal anti-inflammatory drugs; IT, individual therapy; PT, physical therapy; TEP, totally extraperitoneal mesh repair.

Table 3.2  Results with the minimal repair technique in 132 patients 4 weeks after surgery (89 athletes, 43 ordinary patients) Result within 28 days of operation

Athletes

Ordinary patients

p-Value

Resumption of sport (%)

85/86 (98.8%)

39/42 (92.8%)

0.330

Time to resumption (d)

7 (4–14)

8.5 (6.25–14.0)

0.002

Full resumption of sport (%)

72/86 (83.7%)

25/42 (59.5%)

0.004

Time to full resumption of sport (d)

14 (10–28)

21 (14–28)

0.056

Complete elimination of pain (%)

68/86 (79.1%)

33/42 (78.6%)

1.00

Time to complete elimination of pain (d)

13 (7–28)

14 (5.25–28.0)

0.860

Very good patient satisfaction (%)

86/86 (100%)

41/42 (97.6%)

0.328

Mean pain score (0–10) on day 28

0.5 (0–2)

1 (0–2.75)

0.064

3.2.3 Treatment Unlike the treatment of inguinal hernia, which does not include any conservative component, sportsman’s groin is always treated individually, considering all therapeutic modalities. Many of the affected patients are treated exclusively conservatively for a long time.29 The achievable rates of freedom from pain until the next playing season125 are unsatisfactory at only 41%. There are hardly any randomized studies in the literature addressing the question of optimal therapy (▶Table 3.1). It can be deduced from the available studies that operative therapy appears to be superior to conservative therapy alone or physical therapy. In the absence of ultrasound evidence of abdominal wall instability, some research groups recommend invasive abdominal wall procedures such as anterior pelvic floor repair or adductor tenotomy. In addition, procedures such as neurectomy on its own in the inguinal canal and transabdominal preperitoneal (TAPP) mesh repair are used (for a summary, see31 and70). Laparoscopic TAPP is used to treat sportsman’s groin especially in America. Our research group has developed the minimal repair technique to treat sportsman’s groin and has used it in over 3,500 patients since 2002. It is used in all athletes in whom posterior weakness of the inguinal canal can be demonstrated clinically and on ultrasound and in whom a purely bony or ligamentous origin of the pain is unlikely. The minimal repair mechanism involves refixation of the rectus muscle with a resulting reduction in the tension on the pubic bone (see operation techniques in section ▶2.2.2). When adductor problems are also present, we recommend physical therapy in addition.

Neurectomy is combined only as needed (macroscopic abnormality or unfavorable anatomical course), usually by resection of the genital branch of the genitofemoral nerve, and occasionally of the ilioinguinal nerve. In case of doubt, we currently tend to resect a nerve in the painful groin region rather than leave it. With the minimal repair technique, we deliberately decide against mesh implantation. In our view, the size of the defect in the posterior wall of the inguinal canal, which is not more than 2 to 3 cm in most patients, does not require mesh. Moreover, an implanted mesh graft would interfere with the muscular sliding of the athlete’s abdominal wall or even abolish it. The most important result for all affected patients is rapid resumption of their high-performance sport. We investigated this in a recently published study and we found that 83.7% of the athletes were able to return fully to their sport after a median 14 days (range: 10–28 days) with an outstanding improvement in their symptoms (▶Table 3.2). Patient satisfaction is excellent. The flow sheet in ▶Fig. 3.5 summarizes our recommended treatment. An important aspect of rehabilitation is a training plan tailored to the patient’s sport. We support the patient’s wish for early exercise: sports such as jogging, cycling, and training can start between days 2 and 5, increasing to full loading between days 6 and 10. The aim is defined as full loading after 14 days.

3.2.4 Summary Sportsman’s groin is a new challenge for the hernia surgeon as sports challenges in adolescence are growing

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3.3  Sliding Hernia

History

Trauma? Pain character? Ultrasonography No bulge Atypical pain characteristics

and professional sportsmen (footballers, ice hockey players) are suffering increasingly often from inguinal pain syndromes that cannot be managed conservatively. Careful clinical examination and ultrasonography by an experienced examiner can regularly demonstrate weakness of the posterior wall of the inguinal canal. The minimal repair technique is a gentle operative therapy with excellent short- and long-term results and high patient satisfaction.

3

3.3  Sliding Hernia

Bulge Burning pain Radiation to thigh

MRI NAD

Re-evaluation

Pathology Yes

if necessary Conservative: NSAIDs Physiotherapy

Minimal repair, possibly neurectomy No

Improvement after 3 weeks?

Fig. 3.5  Recommended treatment sequence in performance athletes with groin pain.

Volker Schumpelick The presence of a sliding hernia must be suspected if a greatly thickened hernia swelling is found when the external oblique aponeurosis is divided. The hernial sac is dissected in the usual way. It is not necessary to open the sac prior to complete dissection. Adhesions to the spermatic cord can usually be divided readily. The sac of an indirect hernia should be dissected as far as the deep inguinal ring and that of a direct hernia to beneath the level of the transversalis fascia. If a sliding hernia is suspected based on the consistency of the hernial sac, the sac is opened between clamps on the anterior wall (▶Fig. 3.6). It must be ensured that only the anterior peritoneal layer is divided; so, no part of the bowel is injured. Opening the sac of small medial sliding hernias can be omitted when the bladder forms part of the wall. In these cases, a superficial purse string suture suffices to bury the sac. Fig. 3.6  Sliding hernia. It is repaired by creating a new peritoneal ring, incising the free peritoneum.

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Special Hernias In the case of larger sliding hernias, the sac must be opened at the lateral and medial border of the sliding component as far as the deep inguinal ring (▶Fig. 3.7). This enables the sac contents to be reduced. Reperitonealization should not be attempted because of the risk of injury.

After complete excision of the wall of the hernia bearing the bowel, the free peritoneal margins behind the loop of bowel are sutured to create a new deep inguinal ring (interrupted 2/0 silk or PDS suture; ▶Fig. 3.8). The hernia contents can then be reduced. Fig. 3.7  Sliding hernia. Counter-incision to create a free leaf of peritoneum.

Fig. 3.8  Sliding hernia. The peritoneal leaf behind the hernial sac is folded and sutured to create a new peritoneal funnel.

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3.3  Sliding Hernia After complete reduction, the peritoneum is closed by an additional purse string suture in the newly created peritoneal funnel (▶Fig. 3.9).

Another technique for burying the sac is resection of the free peritoneal covering to leave a narrow margin, which is closed by an internal purse string suture (▶Fig. 3.10).

Fig. 3.9  Sliding hernia. The sac is buried in the newly created inguinal ring by an external purse string suture.

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Fig. 3.10  Sliding hernia. Repair by an internal purse string suture to bury the hernia contents.

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Special Hernias

Fig. 3.11  Sliding hernia. Repair by an external purse string suture. After inspection, the sac is closed and buried by an external purse string suture.

The hernia swelling is buried beneath the deep inguinal ring by an external purse string suture (▶Fig. 3.11). It can be assumed overall that complete reduction and adequate closure of the hernial orifice are more important than anatomical restoration of the peritoneal covering. Reduction using the Hoguet maneuver has proved effective for medial sliding hernias and sliding femoral hernias. This can convert the hernia to a lateral inguinal hernia, which can be repaired as described above.

3.4  Recurrent Hernia Karsten Junge “The most common cause of recurrent hernia is poor technique by the surgeon at the first operation.” (Lloyd M. Nyhus 1989) “It is the pathological changes in collagen that set the stage for the development of a recurrent hernia.” (R. Bendavid 2004)

3.4.1  General Remarks/ Epidemiology The touchstone of every hernia repair procedure is the recurrence rate. Therefore, critical examination of the employed method can only be achieved by consistent follow-up of one’s own patients. According to the literature, excellent recurrence rates can be achieved in specialized centers with nearly all inguinal hernia repair

procedures. A meta-analysis of prospective randomized studies that included all procedures showed that open or laparoscopic mesh procedures have an advantage over sutured methods.65 However, the recurrence rate varied considerably among the individual studies. These results are supported by large population-based analyses, e.g., the Danish Hernia Database, which show significantly lower reintervention rates for primary operations using mesh implantation.106 Thus, as in incisional hernia repair, mesh implantation appears at least to postpone the onset of a recurrent hernia.28 Since recurrent hernias will never be entirely a thing of the past, they demand detailed consideration.

3.4.2  Risk Factors For a long time, it was generally assumed that poor surgical technique is the primary cause of hernia recurrence.1 It is also certain that inadequate technique (e.g., insufficient mesh size in TEP/TAPP, failure to expose and double the entire transversalis fascia in the Shouldice procedure) predisposes to recurrence. However, scientific insights today suggest that impaired collagen metabolism and other endogenous or exogenous factors are also of great importance with regard to the development of a recurrent inguinal hernia.46,51,96 The endogenous risk factors can include the patient’s age, while smoking and various medications are among the exogenous risk factors.115 Lau et al. describe a potential genetic component in a study of 1418 men in whom a positive family history causes an eightfold increase in the risk of having an inguinal hernia.54

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3.4  Recurrent Hernia

3.4.3  Forms and Location Genuine recurrences must be distinguished from false ones. While a genuine recurrence develops at the operation site, a false recurrence appears in immediate proximity or is an additional hernia (e.g., femoral hernia) overlooked at the initial operation. As with primary hernias, recurrent hernias can be classified as direct, indirect, and combined. Protrusion of an elastic mesh through the former hernial orifice after preperitoneal repair of large defects without closure of the orifice can be defined as bulging. Recurrence can be expected with up to 50% of incisional hernias if mesh procedures are not used. They are usually located at the center of the repair and only rarely at

the periphery. Recurrent hernias after technically insufficient operations using mesh appear in typical locations (▶Fig. 3.12). For instance, pseudorecurrence is found after inadequate excision and stabilization of the previous laparotomy scar (▶Fig. 3.12a), marginal recurrence in the absence of cranial and caudal overlapping (▶Fig. 3.12b), the typical subxiphoid cranial recurrence when the subxiphoid space is not dissected (▶Fig. 3.12c), and central recurrence (▶Fig. 3.12d) when the anterior layer of the rectus sheath is not closed sufficiently. Recurrent inguinal hernias include indirect hernias (▶Fig. 3.13) and different forms of direct hernias (medial, suprapubic, intermediate, complete, ▶Fig. 3.14, ▶Fig. 3.15, ▶Fig. 3.16, ▶Fig. 3.17).

Fascial scar

3

Pseudo-recurrence

Incisional hernia

Fascial scar

Marginal recurrence

Incisional hernia

Fascial scar

Cranial recurrence

Incisional hernia

Fascial scar Incisional hernia

Central recurrence

Fig. 3.12  Location of typical recurrent hernias due to technical errors during the previous operation.

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Special Hernias Fig. 3.13  Indirect recurrent hernia.

Fig. 3.14  Direct (medial) recurrent hernia.

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3.4  Recurrent Hernia Fig. 3.15  Direct (suprapubic) recurrent hernia.

3

Fig. 3.16  Direct (intermediate) recurrent hernia.

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Special Hernias Fig. 3.17  Direct (complete) recurrent hernia.

Asymptomatic or minimally symptomatic

Inguinal hernia

After previous anterior operation Consider ‘watchful waiting’

Elective surgery

Symptomatic

Strangulated

Emergency surgery (consider sutured procedure if infection risk)

Recurrent hernia

Primary bilateral hernia

Mesh procedure recommended: laparoscopic (TEP/TAPP) or Lichtenstein

Primary unilateral hernia

Mesh procedure recommended: Lichtenstein or laparoscopic (TEP/TAPP)

After previous posterior operation

Mesh procedure recommended: Lichtenstein

Mesh procedure recommended: (laparoscopic TEP/TAPP) or Lichtenstein

Fig. 3.18  Choice of procedure to treat inguinal hernia.

3.4.4  Choice of Procedure The European Hernia Society guidelines on choice of procedure recommend a change of access route when treating a

recurrent hernia. The approach to recurrent hernias following previous anterior repair should be laparoscopic and posterior if possible, and an anterior approach should be used for recurrences after previous posterior surgery (▶Fig. 3.18).

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3.4  Recurrent Hernia Table 3.3  Choice of procedure to treat recurrent hernia according to a survey of Scottish surgeons Laparoscopic repair n (%)

Open repair n (%)

Referral for laparoscopic repair n (%)

Not sure n (%)

Recurrent hernia after open repair

48 (38.7)

33 (26.6)

38 (30.6)

5 (4.1)

Recurrent hernia after laparoscopic repair

10 (8.2)

74 (60.7)

25 (20.5)

15 (10.6)

Previous procedure method

Access for revision

Anterior Lichtenstein

Transinguinal anterior or posterior

Posterior TAPP, TEP

Posterior open: Wantz, Stoppa

Anterior Lichtenstein

Posterior endoscopic or open

Posterior TAPP, TEP

Anterior Lichtenstein

3

Yes

Recurrence after mesh implantation

Mesh-related complications

No

Fig. 3.19  Choice of procedure to treat recurrent inguinal hernia depending on the presence of mesh-related complications and type of previous surgery.

The guidelines of the Danish Hernia Database published in 2011 also include a change of access route in their recommendations.97 This procedure has become partly established clinically. In a survey of compliance with National Institute of Clinical Excellence (NICE) guidelines from 2004 recommending a laparoscopic approach for recurrent hernia, Shaikh110 found in 2011 that the access route for recurrent hernia repair had already changed (▶Table 3.3). There are no comparative studies on the change of access route. Apart from the actual recurrence, however, chronic pain and a foreign body sensation are often the primary indication for revision of a previous inguinal hernia repair using mesh. In these patients, additional neurectomy and/or mesh removal may be indicated for pain therapy. For these revision operations, Schwab and Klinge in 2007 proposed the algorithm shown in ▶Fig. 3.19, which corresponds to the EHS proposal in the absence of mesh-related complications but suggests repeating the primary access route when mesh revision is indicated.107 All mesh implantation procedures can be used to manage a recurrent incisional hernia after primary sutured repair. For recurrences following mesh implantation, Conze, Binnebösel, and Klinge21 suggest the following algorithm for managing a recurrent incisional hernia.

The authors regard repair by retromuscular sublay mesh augmentation as the reference procedure, and recurrence after inlay or onlay incisional hernia repair is treated by sublay with a lightweight mesh. After sublay repair with lightweight mesh, the previous repair is extended and after previous surgery using heavyweight mesh, this is exchanged for lightweight mesh or the procedure is changed to laparoscopic IPOM. After a previous laparoscopic IPOM procedure, the mesh can be either refixed or extended or the mesh can be explanted, with a switch to open sublay repair (▶Fig. 3.20). Overall, there is no gold standard procedure for repairing recurrent inguinal and incisional hernias. The choice of procedure must be guided by the patient and the hernia itself.

3.4.5 Preparation The diagnosis is made preoperatively by clinical examination, ultrasonography of the groin or abdominal wall to determine the defect size, and Doppler ultrasound of the testicular vessels in the case of recurrent inguinal hernia. Detailed knowledge of the previous operation can considerably simplify the procedure (type, size of the implanted mesh, location of the mesh materials, mesh fixation, location of the spermatic cord, ▶Fig. 3.21).

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Special Hernias

Inlay

Sublay with PPLW

Onlay

Sublay with PPLW

Recurrence after mesh implantation

PPHW

Exchange with PPLW Lap. IPOM

Sublay PPLW

Extension with PPLW Refixation or extension

Lap. IPOM Explantation and sublay Fig. 3.20  Choice of procedure to treat recurrent inguinal hernia depending on the type of previous surgery and mesh material. PPHW: heavyweight polypropylene PPLW: lightweight polypropylene

Fig. 3.21  Recurrent hernia. Scarred spermatic cord moved to subcutaneous position after previous Bassini–Kirschner operation.

3.4.6  Dissection and Repair Because of the large number of possible previous operations including their technical variants (mesh type and size, mesh location, mesh fixation) for both inguinal and incisional hernias, a general detailed description of the dissection and repair of a recurrent hernia is not feasible and the repair must be guided by the

patient and the hernia. The aim must be long-term stabilization of the groin or abdominal wall with alloplastic mesh material.

3.4.7 Complications Compared with the primary operation, significantly in­creased complication rates are found, both intraoperative

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3.5  Umbilical Hernia (nerve, vas, and bowel injury) and early and late postoperative (hematoma, wound infection, chronic pain, re-recurrence).

3.5  Umbilical Hernia Ulla Volmer and Georg Arlt

3.5.1  Epidemiology and Pathogenesis Five percent of all hernias are umbilical hernias.105 There is a high incidence in premature infants and babies with birth defects with a birth weight below 1,500 g. With a few exceptions, healing to a stable umbilical scar can be expected by the age of 2 years following obliteration of the umbilical vessel.38,39 Surgical treatment is not required in 98% of cases.104,126 Unlike omphalocele, a congenital malformation of the abdominal wall with protrusion of abdominal viscera, the abdominal wall is otherwise well developed with an umbilical hernia. In adults, development of an umbilical hernia is promoted by risk factors such as pregnancy, obesity, disorders of connective tissue metabolism due to endogenous (genetic) and exogenous (smoking, corticosteroids) factors, hepatic cirrhosis, and malignant disease. Spontaneous healing cannot be assumed apart from in pregnant women, in whom recovery of the abdominal wall can be anticipated after delivery. In adulthood, the incarceration rate is up to 30% with mortality of 10 to 15%.104

3.5.2  Diagnosis and Classification A palpable, painless protrusion in the umbilical region is typical. In many patients, the umbilical hernia has been present for years without significant changes and with only slight symptoms. If it increases rapidly in size, intra-abdominal pathology must be excluded. Clinical examination should be supplemented by ultrasonography of the abdominal wall. The ultrasound scan should extend over the entire midline from the xiphoid to 3 cm below the umbilicus. It allows assessment of the linea alba for other gaps and the presence of rectus diastasis. Classification follows EHS criteria (European ­ Hernia Society). Hernias are classified as small up to 2 cm, medium defects of 2 to 4 cm, and large defects with a diameter over 4 cm. Small umbilical hernias are further classified as minimal defects below 0.5 cm.

3.5.3 Indications Incarceration and persistent symptoms are absolute indications. Diagnosis after the age of 6 years with minor symptoms is a relative indication. Surgery in infancy should be performed only in exceptional cases, e.g., because of recurrent incarceration. The choice of an appropriate operative procedure is crucial for the recurrence rate and complications. Fascial suture of large hernias on its own

leads to recurrence rates of 20 to 45%, but with small defects up to 2 cm recurrence occurs in only 4.1 to 6.6% of cases.103 Surgical treatment is not necessary for asymptomatic umbilical hernias < 0.5 cm. Only recurrent symptoms justify repair of small umbilical hernias. Spitzy sutured repair generally suffices for fascial defects < 2 cm. The recurrence rate increases markedly with 2 to 4 cm umbilical hernias and mesh insertion is recommended. This can be by preperitoneal umbilical mesh plasty (PUMP), retromuscular mesh in the classic onlay technique, or intraperitoneal technique (open IPOM) in an open operation, or by a laparoscopic procedure (lap. IPOM). Mesh repair is regarded as obligatory for umbilical hernias with a defect greater than 4 cm. There are no limits to laparoscopic and open IPOM insertion as regards hernia size. PUMP repair is limited by the preperitoneal space that can be dissected roughly 2 to 3 cm in all directions from the fascial border. Defects greater than 4 cm may not be suitable for PUMP repair and require retromuscular mesh placement, such as midline incisional hernias.

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3.5.4 Complications With open repair, impaired wound healing due to infection and disturbed blood supply is caused by division of the base of the umbilicus. Perioperative antibiotic prophylaxis is often recommended but is not evidence-based. As regards the impaired perfusion of the umbilical skin, this should be minimized by an appropriate incision with little or no dissection of the sac from the skin. Bowel injuries are rare but have been described with both open and laparoscopic procedures and must be included in the informed consent. Intra- and postoperative bleeding results from the anatomy of the abdominal wall with vessels in the median umbilical fold. Umbilical hernias in patients with cirrhosis and ascites present particular challenges. The tendency to incarceration is greater and skin ulceration and postoperative ascites leaks occur more often. Besides attempting to correct the cirrhosis preoperatively to reduce ascites, an abdominal drain is recommended for 10 to 14 days until the wound heals.

3.5.5  Operation Technique The Spitzy semicircular infraumbilical incision, the Drachter semicircular left lateral incision, and the vertical transumbilical incision can be considered for open operation (▶Fig. 3.22). The latter provides almost “scarfree” repair69 but should be used only when the skin has no deep and inaccessible creases and can be disinfected reliably because of the potential risk of infection. If the umbilical skin is inflamed or necrotic, the umbilicus is excised and the procedure concludes with reconstruction of an umbilical depression. Following the skin incision, dissection continues down to the fascia, and the hernial sac is bypassed at fascial level, detached or ideally divided at the base of the umbilicus, and buried with a purse string suture (▶Fig. 3.23, ▶Fig. 3.24).

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Special Hernias Fig. 3.22  Incisions. a  Spitzy inferior incision. b  Drachter lateral incision. c  Transumbilical incision.

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Fig. 3.23  Dissection of the sac, bypassing of the neck of the sac at fascial level with the Overholt forceps.

Fig. 3.24  Division of the sac at the umbilicus and closure with a purse string suture.

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3.5  Umbilical Hernia Alternatively, a circular opening is made in the sac at fascial level, the contents are reduced, and the peritoneum is sutured after mobilization from the posterior layer of the rectus sheath (e.g., 2/0 or 3/0 PGA).

Spitzy Repair Hernias up to 2 cm are closed, preferably transversely, by a continuous suture of the fascial margins (e.g., polypropylene 0 or 2/0). The peritoneum should be dissected from the posterior layer of the rectus sheath to ensure that the suture is placed under vision and interposition of the peritoneum in the fascial defect is avoided (▶Fig. 3.25). Both permanent (polypropylene) and slowly absorbable (PDS) sutures can be used. An alternative is the Mayo “vestover-pants” repair with a transverse row of U sutures to close the fascia (▶Fig. 3.26). However, better long-term results have not been achieved with the overlapping fascia. In any case, tension-free approximation of the fascial edges is desirable. In case of doubt, alloplastic material must be used. The operation concludes with fixation of the base of the umbilicus at fascial level (▶Fig. 3.27) and intracutaneous suture (▶Fig. 3.28).

Preperitoneal Umbilical Mesh Plasty Preperitoneal umbilical mesh plasty (PUMP) repair is suitable for 2 to 4 cm fascial defects. The advantages are that the technique is easy to learn and uses an individually tailored, economical flat mesh; direct contact

Fig. 3.25  Fascial closure with a transverse continuous edge-toedge suture.

between mesh and bowel is reliably avoided. After treating the hernial sac and peritoneal defect, the peritoneum is dissected bluntly from the edges of the defect in all directions for a distance of 3 cm (▶Fig. 3.29). A circular or oval implant at least 6 cm in diameter is cut from a lightweight large-pored mesh and two to three fixing sutures (e.g., PGA 2/0) are placed in it (▶Fig. 3.30). The mesh is then spread out flat in the preperitoneal space and fixed by loose sutures through the posterior wall of the fascia (▶Fig. 3.31). The fascia is closed transversely with a continuous suture (e.g., polypropylene 0 or 2/0). The operation concludes with fixation of the base of the umbilicus and skin suture. Lateral dissection of the peritoneum from the posterior layer of the rectus sheath may not be possible with very large umbilical defects. In these cases, the defect can be closed with a retromuscular graft, similar to midline incisional hernia repair. If rectus diastasis is also present, repair of the midline up to the xiphoid is recommended. Laparoscopic umbilical hernia repair is similar to midline incisional hernia repair. Prefabricated mesh is available for open intraperitoneal placement as an alternative to preperitoneal mesh implantation. The operation technique is relatively easy, as the grafts are placed in the free abdominal cavity and dissection of the peritoneum is not necessary. However, these implants come with the risks of direct mesh-bowel contact, represent a large foreign body burden, and are relatively expensive.

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Fig. 3.26  Fascial doubling using the Mayo “vest-over-pants” U suture technique.

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Special Hernias Fig. 3.27  The base of the umbilicus is pushed down with the index finger and fixed to the fascia with 1 to 2 interrupted 2/0 PGA sutures.

Fig. 3.28  Skin closure with interrupted intracutaneous sutures.

Fig. 3.29  Preparation of the mesh bed, dissecting the peritoneum from the linea alba and posterior layer of the rectus sheath for 3 cm around the fascial defect.

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3.5  Umbilical Hernia Fig. 3.30  Placement of PGA fixing sutures in the individually tailored mesh prior to implantation.

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Fig. 3.31  Placement of the mesh in the preperitoneal space. It is fixed by a transfascial suture in the midline and two sutures to the posterior wall of the rectus sheath on right and left.

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3.6  Femoral Hernia Volker Schumpelick “Radical operation of femoral hernias is far less popular with the public than that of inguinal hernias.” (G. Lotheissen, 1898)

3.6.1  Basic Principles General Remarks Femoral hernia is an often overlooked entity in the femoral canal. Roughly 40% of femoral hernias are already incarcerated when they are diagnosed.109 They are easily overlooked especially in obese patients or are mistaken for deep inguinal lymph nodes.

The Hernial Orifice The femoral canal is the hernial orifice. The upper opening of the canal is the femoral ring, which is 1 to 3 cm wide. Anteriorly, the femoral ring is formed by the iliopubic tract and the inguinal ligament (▶Fig. 3.32). The posterior boundary is the superior pubic ramus and the medial boundary is formed where the inguinal canal meets the lacunar ligament. The femoral canal is bounded laterally by the femoral vein. It is funnel shaped and runs parallel to the femoral vein to the saphenous opening, which is roughly 2 cm inferior to the femoral ring. This opening is up to 1 cm wide and is bounded by the lacunar ligament medially, the pectineal fascia posteriorly, extensions of the inguinal ligament anteriorly, and by the vein laterally. The femoral canal is usually filled by loose fat and connective tissue and by deep inguinal lymph nodes (the Rosenmüller node). The cribriform fascia is in front of it, and pectineus and the fascia lata are behind it. The most common form of femoral hernia is located medial to the femoral vein. In rare cases, femoral hernias can also develop lateral, anterior, or posterior to the vein.

Pathogenesis Congenital femoral hernias are rare and the acquired form predominates. According to McVay’s anatomical studies, increased intra-abdominal pressure forces preperitoneal fat into the femoral canal, preparing a path for the hernia (▶Fig. 3.32). Causative factors for primary hernias include repeated pregnancy, obesity, and ageassociated collagen weakness, while secondary femoral hernias develop especially after inguinal hernia surgery. The reason for this may be failure to identify the hernia at the first operation or development as a consequence of the operation. The repair method used in the previous operation is critical for the postoperative form. Naturally, procedures that shift the inguinal ligament and transversalis fascia anteriorly (e.g., Bassini, Shouldice) present a greater risk. When the suture is under great tension,

Fig. 3.32  Mechanism of femoral hernia development in crosssection. a  Original condition. b  Expansion of the femoral canal. c Herniation.

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3.6  Femoral Hernia there is a risk of opening the femoral canal and therefore the hernial opening to an unphysiologic width. Sixty percent of femoral hernias are on the right side, and they are bilateral in 20% of cases.22 Women are affected more often, both absolutely and relatively. Repeated pregnancies appear to promote the development of a femoral hernia.

with the crural approach, possibly in the form of spinal anesthesia. General anesthesia is the method of choice if incarceration is present with a possible need for laparotomy and when laparoscopy is planned.

Diagnosis

3.6.4  Operation Tactics

Like inguinal hernia, femoral hernia is a clinical diagnosis. Ultrasonography, CT, or herniography are reserved for exceptional cases. The diagnosis is often made too late, and one in every three to four femoral hernias is already incarcerated when first diagnosed.89,109 This explains the high mortality. Incarcerated femoral hernia is an important and often the unrecognized cause of intestinal obstruction especially in elderly women. The differential diagnosis includes other swellings in the groin region, the most important of which is inflammation of the lymph node in the fossa ovalis.

Surgery can be open or laparoscopic. The latter is the procedure of choice today but the open technique should be familiar even if it is used only rarely. TAPP and TEP are the laparoscopic procedures of choice but plug and patch can also be used. Open surgery is guided by the statistical and anatomical situation (▶Fig. 3.33). Fifty-three percent of men with a femoral hernia also have an ipsilateral inguinal hernia, usually direct.35 Only 12% of women have an ipsilateral inguinal hernia, predominantly indirect. Most of these ipsilateral inguinal hernias in women are small, contain mainly fat, and hardly require operation. In view of these figures, femoral hernia repair through a crural access usually suffices in women. In men, the inguinal region must be revised in every case because of the high incidence of additional inguinal hernia. The operation tactic must also distinguish between primary and secondary hernias and between emergency (40%) and elective surgeries.

3.6.2 Indications ▶ Absolute indication. Any incarcerated femoral hernia— any diagnosed femoral hernia with general and local operability. ▶ Relative indication. Any femoral hernia with limited operability. ▶ Contraindications. General or local inoperability.

3.6.3  Preparation, Anesthesia, and Positioning ▶ Preparation. See section ▶2.3.5. ▶ Anesthesia. General or local anesthesia, depending on experience. Local anesthesia is effective especially

▶ Positioning. Supine with the hips extended and the buttocks slightly elevated.

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We generally recommend crural closure of the femoral hernia for secondary forms when inguinal hernia repair is sufficient. This distinction applies for the primary form. In an emergency, the simplest form of repair (usually combined inguinal and crural) should be preferred. Recurrent

Fig. 3.33  Overt femoral hernia in crosssection.

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Special Hernias femoral hernias should be managed through simultaneous inguinal and crural exposure. In principle, there are four methods of surgical femoral hernia repair:35 •• Crural access, without opening the external oblique aponeurosis (most frequent procedure in women). •• Crural access, opening of the inguinal canal and inspection of the posterior wall without the need for repair (primary procedure in men). •• Crural access, opening of the external oblique aponeurosis, repair of the posterior wall of the inguinal canal if there is an inguinal hernia (procedure for small combined hernias). •• Crural and inguinal access, opening of the external oblique aponeurosis and posterior wall of the inguinal canal, closure of the femoral hernial orifice from above and below, then closure of the posterior wall of the inguinal canal (procedure for large combined hernias, recurrence, and incarceration). This classification applies especially to elective surgery. With incarceration, the simplest and safest method is the best one.

3.6.5  Forms of Repair Sutured repair is mentioned for the sake of completeness though an alloplastic mesh repair is generally used nowadays, through laparoscopic TAPP and TEP and with the plug and patch procedure. Accordingly, the different historical suture methods are described here as the basis for hernia surgery.

Crural Access (Fabricius 1892, Bassini 1893, Salzer 1921). The crural access is also called the inferior or direct access.

The skin incision is made over the hernia swelling, obliquely or parallel to the femoral vessels. Direct access can also be obtained through a low inguinal incision.34 The advantages of the crural access are the low postoperative impairment and the good visibility of the fossa ovalis. The crural approach is not recommended for combined hernias or incarcerated hernias, which require an inguinal procedure in addition. Exclusively crural access is used mainly for uncomplicated femoral hernias in women. We prefer crural access through an inguinal incision. The forms of repair are the Fabricius (▶Fig. 3.34), Kummer (▶Fig. 3.35a), B ­ assini (▶Fig. 3.35b), Salzer (▶Fig. 3.35c), and umbrella (▶Fig. 3.36) procedures.

Inguinal Access (Lotheissen 1898, von Moschcowitz 1908). The access is as for inguinal hernia, splitting the transversalis fascia. The good overview of the femoral canal is an advantage, allowing reduction of incarcerated femoral hernias. Inguinal access is the standard access in men, to enable the important inspection of the inguinal hernial orifices. The disadvantages can be the greater operation trauma and the need to repair the posterior wall of the inguinal canal if it is opened. In any case, the inguinal access should be used for recurrence, incarceration, and combined hernias. Possible forms of repair include the Moschcowitz procedure (▶Fig. 3.37a) in combination with the Bassini inguinal hernia repair, the Lotheissen repair (▶Fig. 3.37b), and the two-row inguinal and crural closure in conjunction with the Shouldice inguinal hernia repair (▶Fig. 3.38). In recent years, femoral hernia closure with plastic mesh has become popular compared with direct sutured repair. This can be carried out in the form of transinguinal preperitoneal patch (TIPP, ▶Fig. 3.39a), Fig. 3.34  Cross-section of the Fabricius crural femoral hernia repair.

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3.6  Femoral Hernia Fig. 3.35  a–c. a  Cross-section of the Kummer crural femoral hernia repair. b  Cross-section of the Bassini crural femoral hernia repair. c  Cross-section of the Salzer crural femoral hernia repair.

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attaching the mesh to the Cooper ligament, or by the Lichtenstein method (▶Fig. 3.39b), in which the patch is fixed to the Cooper ligament with a few sutures. Another possibility is implantation of an umbrella-shaped mesh,

which is fixed crurally through the femoral canal to sit over the inguinal end of the canal like an umbrella. TEP or TAPP performed under general anesthesia is a good alternative (see sections ▶2.4.1 and ▶2.4.2).

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Special Hernias Fig. 3.36  Cross-section of crural femoral hernia repair with an umbrella prosthesis in cross-section.

Fig. 3.37  a and b. a  Cross-section of inguinal femoral hernia repair by the Moschcowitz procedure with the Bassini closure of the inguinal canal. b  Cross-section of inguinal femoral hernia repair by the Lotheissen method.

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3.6  Femoral Hernia Fig. 3.38  a and b. a  Two-row sutured closure of the femoral canal. b  Cross-section of the additional closure of the inguinal canal.

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Preperitoneal Access (Henry 1936, Nyhus 1959). A horizontal incision above the inguinal ligament provides extra- or preperitoneal exposure of the femoral hernial orifice. The preperitoneal access has advantages, especially for recurrent hernias or after extensive

previous surgery. The disadvantages are severe operation trauma and the relaxation medication required for the operation. The preperitoneal access is therefore used especially for recurrent hernias. The preperitoneal access is always useful for large hernias requiring alloplastic cover by polypropylene mesh. It is performed nowadays as TEP (see section ▶2.4.2).

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Special Hernias Fig. 3.39  a and b. a  Cross-section of inguinal femoral hernia repair by TIPP. b  Cross-section of inguinal femoral hernia repair by the Lichtenstein method.

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3.6.6  Operation Techniques

Management of the Sac

Crural Access

The sac is opened, the contents are reduced, and the sac is transfixed at its base and excised (▶Fig. 3.42). The femoral hernial orifice can now be exposed. It is bounded laterally by the femoral vein, medially by the lacunar ligament, superiorly by the inguinal ligament, and inferiorly by the Cooper ligament. There are different methods of closing the femoral hernial orifice.

Skin Incisions The skin incision is made medial to the femoral vessels, vertically or obliquely over the hernia swelling projected over the femoral canal (▶Fig. 3.40). A low inguinal incision can also be used when a combined procedure is planned.

Exposure of the Hernial Sac

Fabricius Repair

After incising the femoral fascia, the sac is isolated and dissected free of fat on all sides (▶Fig. 3.41). As with a direct hernia, parts of the bladder may be attached to the sac and they are dissected sharply with precise hemostasis. Blunt dissection increases the risk of opening the bladder. Dissection of the sac neck must proceed until the parietal layer of the peritoneum is visible.

The femoral vein is held laterally by a vein retractor or small swab. Interrupted sutures are first placed in the superior pubic (Cooper) ligament from medial to lateral with a sharp semicircular needle, below the elevated inguinal ligament, and fixed with clamps (▶Fig. 3.43). In deep wounds, these sutures can also be placed with a Reverdin needle. If suture tension is high, the inguinal

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3.6  Femoral Hernia

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Fig. 3.41  Exposure of the hernial swelling in the femoral canal. Fig. 3.40  Crural incision or low inguinal skin incision (see ▶Fig. 3.59).

Fig. 3.42  After reduction of the hernia contents the sac is closed from the crural side by a transfixion ligature.

ligament can be detached from or notched at the pubic tubercle in the original method. A 2/0 nonabsorbable suture (polypropylene) is used.

Fig. 3.43  Fabricius repair. Interrupted sutures between the superior pubic (Cooper) ligament and the inguinal ligament. The femoral vein is protected by holding it laterally with a Langenbeck retractor.

Fabricius Closure

Kummer Repair

The sutures are then passed through the inguinal ligament from medial to lateral, where they should include the transversalis fascia. The width of the vascular opening is checked with a fingertip while the sutures are tightened and tied (▶Fig. 3.44).

In the Kummer modification, the entire abdominal wall muscle is drawn in funnel shape into the inguinal canal (▶Fig. 3.45, ▶Fig. 3.46). This is based on the tactic of closing not just the femoral hernia but also the femoral canal over a long distance.

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Special Hernias Fig. 3.44  Completed Fabricius repair.

Fig. 3.45  Kummer repair: U-sutures between the iliopectineal fascia and Cooper ligament and the lower abdominal wall.

Caution

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There is a risk of injuring the spermatic cord with this method. It should therefore be used only in women.

If the tension of the sutures between the inguinal ligament and the Cooper ligament is too great or even insurmountable, closure of the hernia by direct suture should not be forced but rather a Bassini or mesh repair should be performed.

Kummer Closure See ▶Fig. 3.46.

Fig. 3.46  Completed Kummer repair.

Bassini Repair The first suture (2/0 polypropylene) picks up the inguinal ligament and lacunar ligament medially and then the pectineal fascia broadly. The sutures are continued laterally at intervals of approximately 0.5 cm (▶Fig. 3.47). Narrowing of the femoral vein must be carefully avoided; the palpating finger constantly checks the patency of the vascular lacuna.

Salzer Repair A semicircular flap of fascia is first cut out of the pectineal fascia with a scalpel. The base of the flap is sutured to the Cooper ligament to provide firm fixation (▶Fig. 3.48).

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3.6  Femoral Hernia

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Fig. 3.47  Bassini repair.

Fig. 3.48  The hernial orifice is covered by a flap of the iliopectineal fascia in the Salzer method. The Salzer flap is sutured to the Cooper ligament.

Fig. 3.49  Fixation of the Salzer flap to the inguinal ligament.

Salzer Closure The flap is then reflected and stitched to the anterior surface of the inguinal ligament (▶Fig. 3.49). It is fixed to the inguinal ligament by interrupted sutures on the free inferior border. It can be additionally fixed to the projecting leaf of the femoral fascia (▶Fig. 3.49).

Umbrella Patch Repair There has been no shortage of attempts to close femoral hernias through the crural route using patches, plaques, or alloplastic material. These techniques have the advantage

Fig. 3.50  Preperitoneal umbrella mesh repair to close the femoral hernial orifice at the operation site.

that they do not narrow the walls of the femoral canal by sutures but this can be closed without tension with an alloplastic mesh. While plaques often dislocate and are at risk of recurrence, we have adopted the principle of implantation of a circular mesh in the shape of an umbrella, which is pushed folded through the femoral canal to preperitoneal position, where it is opened by crural traction. The polypropylene mesh can be handcrafted and should have a diameter of at least 5 cm. It is fixed to the ligamentous structures of the femoral canal (▶Fig. 3.50).

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Inguinal Access Skin Incisions The skin and subcutaneous incisions are the same as for an inguinal hernia (▶Fig. 3.51). After dividing the external oblique aponeurosis, the spermatic cord or round ligament is exposed by a combination of blunt and sharp

dissection and snared with rubber tubing. When the cremaster is large, it is split longitudinally and muscle fibers are resected. The posterior wall of the inguinal canal is now exposed. It is inspected for an additional indirect or direct inguinal hernia.

Splitting of the Transversalis Fascia The transversalis fascia is then split obliquely from the deep inguinal ring to the pubic tubercle (▶Fig. 3.52). The epigastric vessels are protected carefully. If they are injured, they are doubly ligated and divided.

Exposure of the Hernial Sac

Fig. 3.51  Oblique or horizontal incision for inguinal access. 1 Iliohypogastric nerve. 2 Ilioinguinal nerve.

After splitting the transversalis fascia, the neck of the sac becomes visible medial to the femoral vein (▶Fig. 3.53). The hernia can usually be reduced by cautious pressure on the swelling from the crural end and traction on the neck (▶Fig. 3.54). If the hernial ring is too tight, the opening is extended by a medial incision (1–2 cm) in the iliopubic tract or lacunar ligament. If the bladder is attached medially to the sac, it should be dissected off sharply. Following reduction, the sac is pulled back and thereby converted to a direct or indirect sac, as in the Hoguet maneuver. The sac is then managed in the usual way.

Fig. 3.52  Splitting of the transversalis fascia.

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3.6  Femoral Hernia Fig. 3.53  Exposure of the hernial sac in the femoral canal from the inguinal aspect.

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Fig. 3.54  Femoral hernial sac after inguinal dislocation.

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Management of the Hernial Sac After opening and reducing the hernial contents, the sac is closed as proximally as possible with a purse string suture or transfixion ligature and divided, and the stump is buried. If reduction of the sac is unsuccessful because of strong adhesions to its surroundings, it is opened at its base and the contents are managed under direct vision (▶Fig. 3.55). If the sac appears livid and necrosis of incarcerated bowel is suspected, the sac should remain closed initially. Transperitoneal exposure of the neck of the sac is advisable by wide incision of the parietal peritoneum, extending the incision into the rectus muscle for herniolaparotomy. The sac should be removed without opening it only after resection of the incarcerated bowel segment. The details of dealing with incarcerated bowel can be found in section ▶5.2.

The sutures are continued laterally as far as the femoral vein, which is held laterally with a Langenbeck retractor. The sutures are tied from medial to lateral according to the increasing tension on them. At the McVay “transition stitch,” i.e., projected over the femoral vessels, the Cooper ligament can no longer be used to accept the sutures because of excessive tension. Here the abdominal muscle is attached to the iliopubic tract or femoral vascular sheath. After the final suture, the femoral and inguinal canals are closed.

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Tip

Fixation to the Cooper ligament results in a concave depression of the abdominal wall medially, which is prone to hematoma development. Careful hemostasis is therefore necessary, possibly with a vacuum drain for approximately 48 hours. A relieving incision of the rectus sheath is essential.

Lotheissen/McVay Repair Before closing the hernial orifice, the Cooper ligament (superior pubic ligament) must be clearly exposed. Minor vessels such as an aberrant obturator artery or vein are ligated and divided. Starting at the lacunar ligament, four to five nonabsorbable (2/0 polypropylene) interrupted sutures are placed (▶Fig. 3.56). These fix the transversalis fascia and transversus abdominis to the Cooper ligament. The most medial stitch picks up the inguinal falx. The sutures should be no more than 0.6 cm apart and should take plenty of tissue.

Moschcowitz Repair After exposing the femoral hernia and managing the sac, repair is performed from the inguinal side by approximating the inguinal ligament to the Cooper ligament. The inguinal ligament and iliopubic tract are fixed to the Cooper ligament with five sutures (2/0 polypropylene), starting medially at the pubic tubercle and continuing as far as the femoral vein at intervals of approximately 0.6 cm; they are then fixed in the same order (▶Fig. 3.57).

Fig. 3.55  Dislocation of the hernia contents after inguinal opening of the femoral hernial sac.

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3.6  Femoral Hernia Fig. 3.56  Lotheissen/McVay femoral and inguinal hernial orifice repair.

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Fig. 3.57  Moschcowitz femoral hernia repair.

The posterior wall of the inguinal canal is then reconstructed by fixation of the abdominal wall to the inguinal ligament using the Bassini method or in layers as in the Shouldice repair.

Two-Row Repair As in the Shouldice procedure for inguinal hernia, the femoral canal is closed by approximation of the Cooper

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Special Hernias Fig. 3.58  Femoral hernia closure by a continuous suture from the inguinal side.

Fig. 3.59  Inferior displacement of the inguinal skin incision for crural access.

ligament to the transversalis fascia or the back of the inguinal ligament by a double-row continuous suture; if there is enough suturable substance in the femoral canal, the femoral hernial orifice is closed by a two-row continuous suture (2/0 polypropylene or PDS). If necessary, the first suture can be placed from the inguinal side

(▶Fig. 3.58), and the second from the crural side after pulling the inguinal incision inferiorly (▶Fig. 3.59, ▶Fig. 3.60). After testing the femoral hernia repair (▶Fig. 3.61), the posterior wall of the inguinal canal is closed in layers using the Shouldice method (▶Fig. 3.62) (see also section ▶2.2.2.4).

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3.6  Femoral Hernia Fig. 3.60  Crural closure of the hernia by a continuous suture after previous inguinal sutured closure.

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Fig. 3.61  Examination of the femoral hernia closure from the inguinal side.

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Special Hernias Fig. 3.62  Closure of the inguinal canal by the Shouldice fascial doubling.

Alloplastic Repair The unsatisfactory recurrence rates after femoral hernia repair by simple suture, especially in the case of larger hernias, justify the use of alloplastic mesh. This can be placed by the crural route or equally well inguinally. In many cases, laparoscopic TAPP and TEP are the methods of first choice today. In our experience, the inguinal approach with transinguinal preperitoneal patch (TIPP, section ▶2.3.2) and the modified Lichtenstein repair have proved effective. In the latter, as in TIPP, the inferior edge of the mesh is fixed to the Cooper ligament, while the upper edge normally lies on the muscle. We regard transinguinal preperitoneal patch (TIPP) as the more physiological procedure as the mesh is covered by fascia and muscle on all sides. The TIPP, TAPP, and TEP are used regularly as well (see sections ▶2.4.1 and ▶2.4.2). It would appear that the pendulum is swinging toward the laparoscopic operations as the procedures of first choice.

3.7  Rare Hernias Christian Peiper and Ralph Lorenz

3.7.1  Lumbar Hernia Location Herniation between the 12th rib, erector spinae muscle, iliac crest, and external oblique muscle (▶Fig. 3.63):

•• Superior lumbar hernia (Grynfeltt): upper costolumbar triangle between the 12th rib, the lateral border of latissimus dorsi, and sacrospinalis, •• Inferior lumbar hernia (Petit): lower iliolumbar triangle between the external oblique muscle, the lateral border of latissimus dorsi, and the iliac crest.

Symptoms Most lumbar hernias develop postoperatively, e.g., after surgery on the kidney or bone harvesting from the iliac crest. They must be distinguished from postoperative relaxation of the abdominal wall due to denervation, where there is no risk of incarceration. Pelvic fracture or destruction is a common cause of inferior lumbar hernia. Primary lumbar hernia is rare and may be congenital or occur spontaneously. The hernia can contain preperitoneal fat, colon or small bowel, and the kidney. Accordingly, it may interfere with bowel or urinary tract voiding.30

Operation Techniques Open or laparoscopic repair is possible. Implantation of plastic mesh to reinforce the abdominal wall is regularly required. The patient lies on the opposite side in slightly headdown position. •• Open procedure: after a skin incision over the hernial swelling (▶Fig. 3.64), the sac is mobilized and reduced and the preperitoneal space is exposed.

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3.7  Rare Hernias Fig. 3.63  Anatomical location of superior (left) and inferior (right) lumbar hernia.

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Fig. 3.64  Skin incision over the maximum protrusion of the lumbar hernia in the line of the muscle fibers.

The mesh is fixed there on the peritoneum, and the hernial orifice can be closed over this with nonabsorbable sutures.18 •• Minimally invasive: videoendoscopically controlled surgery can be transabdominal and extraperitoneal30 or retroperitoneoscopic.37 In each case, the mesh should be fixed on the muscle. Because of the posterolateral site of the hernia, intraperitoneal mesh placement (IPOM) does not guarantee adequate overlap.

3.7.2  Supravesical Hernia Synonym: suprapubic hernia.

Location This always arises from the supravesical fossa, which is on either side of the median umbilical ligament (obliterated urachus) and is bounded by the bladder and medial umbilical ligament (obliterated umbilical vessels;

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Special Hernias Fig. 3.65  Anatomical locations of supravesical hernias. a Median. b Transrectal. c Pararectal. d Lateral.

▶Fig. 3.65). In fact, the lateral border of the rectus sheath can act as a simpler landmark.112 External and internal supravesical hernias can be distinguished as follows:113 •• External hernias can extend through the abdominal wall to the subcutaneous tissue in median, transrectal, pararectal, or lateral location. In the latter, the medial umbilical ligament separates a lateral supravesical hernia from a medial inguinal hernia. •• Internal supravesical hernias also originate in the supravesical fossa, but instead of outward, they extend inward in pre-, para-, retro-, or supravesical direction.112

Symptoms External supravesical hernias present as a bulge medial to the superficial inguinal ring, while internal hernias are diagnosed when they displace the bladder and possibly cause urological symptoms. Supravesical incarceration of a loop of small bowel is not rare.45

Operation Techniques Depending on the location, an external supravesical hernia is repaired by an open or minimally invasive mesh-based method such as direct inguinal hernia. Internal supravesical hernias can be repaired by direct nonabsorbable suture following laparotomy and reduction of the hernia contents. This is also possible laparoscopically.36 Mesh-assisted repair is possible116 but problematic because of the location.

3.7.3  Obturator Hernia Location An obturator hernia passes through the obturator foramen together with the obturator vessels and obturator nerve, following a 2 to 4 cm channel between the pectineus, adductor longus, and obturator externus muscles on the inside of the thigh (▶Fig. 3.66). The sac passes either through the obturator externus or on its upper border (▶Fig. 3.67a and b). The obturator membrane can be penetrated caudally or cranially (▶Fig. 3.67b and c). Typical signs of compression can develop because of the proximity of the sac to the obturator nerve.

Symptoms There is no external bulge. The Howship-Romberg sign, produced by irritation of the obturator nerve on hip extension, abduction, or internal rotation and consisting of pain or paresthesias in the area supplied by the cutaneous branch of the obturator nerve on the inside of the thigh, is pathognomonic.63,130 Underweight women in their 60s and 70s are mainly affected (“little old lady’s hernia”), and the diagnosis is often made only when it becomes incarcerated. The hernia can occasionally be palpated as a swelling on vaginal or rectal examination (▶Fig. 3.68). Computed tomography is helpful when the situation is unclear.

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3.7  Rare Hernias Fig. 3.66  Anatomical course of the obturator vessels and nerve in the obturator foramen.

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D

E

F

Fig. 3.67  Relation between obturator hernia, obturator nerve, and obturator externus at the obturator foramen. a  The hernia passes through obturator externus. b  The hernia and nerve emerge over the obturator muscle. c  The nerve emerges above and the hernia below obturator externus.

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Special Hernias Fig. 3.68  Palpable bulge in the obturator foramen on vaginal or rectal examination, with pain radiation along the obturator nerve (the Romberg sign).

Operation Techniques

Location

Because of the high rate of incarceration, surgery is indicated when the hernia is diagnosed. In the elective situation, an open or laparoscopic preperitoneal approach is possible. Incarceration requires a transperitoneal procedure to allow assessment of the hernia content. Reduction must be extremely cautious to avoid injuring the obturator vessels and nerve. If there is no peritonitis, the hernia should be repaired using plastic mesh.1 In the presence of inflammation, direct suture is better but this can be difficult and often results in weak reconstruction with an increased risk of recurrence.121

The hernial orifice is the greater sciatic foramen through which the sciatic nerve passes. It can be further classified as (▶Fig. 3.69): •• Suprapiriform hernia (superior gluteal hernia) (60%). •• Infrapiriform hernia (inferior gluteal hernia) (30%).

3.7.4  Sciatic Hernia Synonyms: pelvic hernia, gluteal hernia, Verdier hernia, ischiocele, ischiadic hernia.

Herniation through the lesser sciatic foramen is very rare (10%) and is called a spinotuberous hernia (supraspinous gluteal hernia).

Symptoms A chronic persistent irreducible hernia can cause sciatica due to its anatomical proximity to the nerve and be misconstrued as a disc prolapse. CT or MRI can distinguish it from local soft tissue tumors. If bowel, ureter, or bladder is incarcerated, corresponding symptoms of stenosis will occur.

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3.7  Rare Hernias Fig. 3.69  Anatomical location of the different forms of sciatic hernia. 1 Suprapiriform hernia. 2 Infrapiriform hernia. 3 Spinotuberous hernia.

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Operation Techniques

Location

Because of the close proximity between the hernia, sciatic nerve, pudendal nerve, internal pudendal artery, inferior gluteal artery, and superior gluteal artery, reduction and repair must be performed cautiously to avoid injuring these structures. External repair from a gluteal approach is possible in principle but does not appear promising for the above reasons. After transabdominal exposure of the hernia by open or laparoscopic surgery and reduction in the Trendelenburg position, the defect should be repaired with mesh.56 After opening the peritoneum, some authors use a plug to close the canal in the sciatic foramen.8 This can be held in place by a polypropylene mesh or endogenous tissue, e.g., parts of the ligament of the ovary.128 Sutures should only be placed under vision because of the proximity of nerves and vessels.

The pelvic floor is formed by the levator ani and coccygeus muscles and their fasciae. Hernias can emerge through the pelvic diaphragm in all regions (▶Fig. 3.70). Anterior and posterior hernias are distinguished depending on the position of the hernia relative to the transverse perineal muscle and the sacrospinous ligament (▶Fig. 3.71). Anterior pelvic floor hernias are classified as labial hernia, pudendal hernia and vaginolabial hernia. These pelvic floor hernias are manifested in perirectal or retrorectal location between levator ani and coccygeus. They also occur in men (▶Fig. 3.72). Perineal incisional hernias occur postoperatively after perineal prostatectomy and abdominoperineal excision of the rectum.

3.7.5  Perineal Hernia Synonyms: pelvic floor hernia, Garengeot hernia.

Symptoms An external bulge can be seen in the perineum, which is reducible and has an obvious cough impulse if it is a hernia. Posterior pelvic floor hernias often cause discomfort on sitting as the bulge emerges below the gluteal muscle (▶Fig. 3.71, ▶Fig. 3.72). Ultrasound and/or CT can confirm the diagnosis.

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Special Hernias Fig. 3.70  Left side: anatomy of the pelvic floor.   1 Symphysis.   2 Deep transverse perineal muscle.   3 Obturator canal.   4 Obturator canal.   5 Anal canal.   6 Levator ani.   7 Coccygeus.   8 Piriformis.   9 Sacrum. 10 Fifth lumbar vertebra.Right side: forms of pelvic floor hernias. 11 Paravesical hernia. 12 Retrovesical hernia. 13 Obturator hernia. 14 Ischiorectal hernia. 15 Spinotuberous hernia. 16 Infrapiriform hernia. 17 Suprapiriform hernia.

Fig. 3.71  Location of anterior (top; labial hernia, pudendal hernia, and vaginolabial hernia) and posterior (bottom) pelvic floor hernias in women.

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3.7  Rare Hernias Fig. 3.72  Location of posterior perineal hernia in men.

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Operation Techniques In principle, a transabdominal, perineal, or combined access can be used. Transabdominal laparoscopic meshassisted repair is currently used most widely for both primary and secondary perineal hernias.91,93 In the combined procedure, the perineal part of the operation is used either for plastic reconstruction of tissue dilated by large hernias90 or for optimized fixation of the mesh from the abdominal and perineal side.99 Purely perineal access appears useful only for very small hernias but is also used because it causes less trauma. Major defects of the pelvic floor as a result of surgery, e.g., after cylindrical abdominoperineal excision of the rectum, can be covered by gluteal musculofascial flaps, rectus abdominis muscle flaps, or free latissimus dorsi flaps.78 Whether biological mesh can reinforce or replace these reconstructions is the subject of ongoing studies.20

3.7.6  Interparietal Hernias Location Interparietal hernias arise from a direct or indirect inguinal hernia. The sac then runs atypically between the individual layers of the abdominal wall. They are classified as: •• Preperitoneal hernias (20%). •• Interstitial hernias (60%; Goyrand).

•• Hernias between the transversalis fascia and transversus abdominis. •• Hernias between the transversus abdominis and internal oblique. •• Hernias between the internal oblique and the aponeurosis of the external oblique. •• Extra-aponeurotic (inguinoparietal or superficial) hernias (20%; Küster; ▶Fig. 3.73). •• Bilocular hernias, combination of inguinal and femoral hernia (Holthouse). •• Krönlein hernia: bi- or multilocular interparietal hernia with indirect inguinal hernia or with femoral hernia and medial sac position. Secondary interparietal hernias have been described after retromuscular mesh-assisted incisional hernia repair. 16

Symptoms According to the inguinal hernia and atypical sac position.

Operation Techniques Primary interstitial hernias of the inguinal region are repaired according to inguinal hernia repair principles following mobilization of the atypically located hernial sac.

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Special Hernias Fig. 3.73  Different possible locations of interparietal hernias in the inguinal region. (The spermatic cord passes to the left.) a Preperitoneal. b  Deep interstitial. c  Superficial interstitial. d  Extra-aponeurotic (superficial).

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3.8  Spigelian Hernia

3.8  Spigelian Hernia

3.8.3  Results and Complications

Marc Miserez

Since recurrence rates are lower after sutured repair of a spigelian hernia than after suture of inguinal or incisional hernias,53,117 this is a good option for small hernias (< 2 cm) without risk factors such as smoking, obesity, heavy physical work, or known disorder of collagen metabolism. Nevertheless, we believe that mesh repair further reduces the risk of recurrence without increasing perioperative morbidity due to wound complications, chronic pain, and adhesions if the mesh is inserted extraperitoneally with no or minimal fixation, preferably through an extraperitoneal endoscopic approach.71

3.8.1  Definition, Anatomy, and Incidence Protrusion of local preperitoneal fat or of a peritoneal hernial sac through a defect in the spigelian aponeurosis is called a spigelian hernia.117 The spigelian aponeurosis consists of the fascia of the transversus abdominis muscle, bounded laterally by the semilunar line and medially by the lateral border of the rectus muscle.114 The semilunar line extends from the ninth rib to the symphysis. The name of the hernia derives from Adriaan van den Spieghel who first described it in the 17th century.124 The spigelian hernia typically consists of interstitial herniation through the aponeurosis of the transversus abdominis and internal oblique muscles, while the superficial aponeurosis of the external oblique is usually preserved because of its thickness.67 The spigelian hernia site of predilection is where the semilunar line crosses the lateral border of the lower limit of the posterior layer of the rectus sheath, possibly because the internal oblique is more muscular than aponeurotic there.94 Spigelian hernias are rare overall, with a prevalence of 0.12 to 2% of all hernias.22,81,86 The diagnosis is often made only when they become incarcerated, with reported rates of up to 24%.117 The usually small fascial defect (below 2 cm in diameter) may be the cause of the high rate of incarceration. Most patients are between 60 and 80 years old, more females than males (ratio 1.4:1), and the hernia occurs more often on the right side (ratio 1.2:1).

3.8.2  Diagnosis and Choice of Procedure Diagnosis is sometimes difficult, given the low incidence and vague clinical symptoms. A bulge in the right or left lower abdomen during the Valsalva maneuver provides the first indication. An ultrasound and/or CT scan is usually necessary.10 In view of the high incarceration risk, surgery is absolutely indicated even in asymptomatic cases. This applies particularly for physically active patients with a small hernial orifice. A diagnostic flow chart was developed for spigelian hernias that includes laparoscopy to confirm the diagnosis, establish the location and size, possibly reduce the hernia, and detect any other intra-abdominal or abdominal wall pathology.53,67 Herniation of preperitoneal fat is missed laparoscopically; in these cases, an endoscopic extraperitoneal or primary open procedure is necessary for diagnosis. General anesthesia is required for laparoscopic or endoscopic access. Open surgery can also be performed under local or regional anesthesia.

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3.8.4  Operation Techniques We recommend a 5-mm, 30° optic through a port in the left upper abdomen (Palmer point) for standard diagnostic laparoscopy. This allows a better overview of the spigelian belt than the umbilical access. If the first trocar is placed in infraumbilical position, we recommend an incision in the posterior and anterior rectus sheath while retracting the rectus muscle laterally.68 After closing the posterior layer, the procedure could then be continued as a totally extraperitoneal mesh repair (TEP) operation. The diagnostic laparoscopy is followed by repair using either an open or laparoscopic/endoscopic approach. Based on the best available evidence and our personal conviction, we recommend the following treatment.67 As with incisional hernia repair,14 tension-free mesh implantation should guarantee a low recurrence rate. Experience to date shows that this also applies for smaller defects of 10 cm2 or less.114 We and others therefore regard extraperitoneal mesh placement (TEP technique) as the procedure of first choice as a large mesh is implanted through a minimally invasive approach.59,71,120 This requires a surgeon experienced in TEP repair of inguinal hernias and a defect that is well below the umbilicus and allows exposure of the preperitoneal space. Apart from two details, the access resembles TEP repair. Firstly, we recommend using a 5-mm, 30° optic with three trocars in the midline so the camera position can be changed (▶Fig. 3.74). In standard inguinal hernia TEP, we place one trocar laterally at the anterior superior iliac spine,68 but this is too close to the spigelian hernia defect. In addition, the lower part of the posterior layer of the rectus sheath must often be incised at the lateral border of the semilunar line to have enough room for a mesh overlap of 3 to 5 cm (▶Fig. 3.75). A transabdominal preperitoneal mesh repair (TAPP) approach can also be chosen, as in the laparoscopic inguinal hernia repair64,83 (▶Fig. 3.76). This provides a larger working space while still allowing preperitoneal mesh placement after incising the peritoneum. Intraperitoneal onlay mesh (IPOM) is also possible3,71

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Special Hernias Fig. 3.74  Position of the trocars for endoscopic totally extraperitoneal mesh repair (TEP) of a right-sided spigelian hernia.

(▶Fig. 3.77). In this case, adequate mesh fixation is necessary. The laparoscopic technique is valuable, especially in obese patients. On the other hand, the transabdominal approach is associated with the risk of bowel injury, especially when extensive adhesiolysis is necessary. If incarceration has occurred, reduction of the hernia contents laparoscopically can be very difficult and sometimes impossible.119,129 Conversion to open repair is then necessary, possibly with partial bowel resection through the hernial orifice or an extended trocar access, e.g., at the umbilicus. For open repair, a horizontal skin incision is usually made over the hernia, splitting the external oblique aponeurosis in the line of its fibers (▶Fig. 3.78, ▶Fig. 3.79). A flat mesh can then be placed preperitoneally or between the external and internal oblique muscles, though preperitoneal dissection, especially above the semilunar line, is much more difficult (▶Fig. 3.80). When the mesh is placed in preperitoneal or intermuscular position, the

lateral border of the rectus sheath must often or always be incised to ensure that the mesh extends adequately and overlaps behind the rectus muscle19 (▶Fig. 3.81). Mesh fixation is not necessary when there is an adequate overlap of 3 to 5 cm.60 The external oblique aponeurosis is then closed. Besides this open sublay mesh procedure, other methods described include open intraperitoneal mesh placement (open IPOM) and the use of specially prefabricated mesh grafts.15,44,61 Sutured repair is carried out through the same access as open mesh repair. After appropriate dissection, the peritoneal sac is closed with an absorbable purse string suture and the defect is repaired with two continuous sutures (preferably 2/0 polypropylene). The first deep suture closes the aponeurosis of the transversus abdominis and internal oblique muscles, and the second suture closes the external oblique aponeurosis87 (▶Fig. 3.82). There have been isolated descriptions of laparoscopic sutured repair.10,76

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3.8  Spigelian Hernia Fig. 3.75  The TEP repair of a right-sided spigelian hernia. Note the incision of the lower part of the posterior layer of the rectus sheath at the lateral border for several centimeters in cranial direction. TEP, totally extraperitoneal mesh repair.

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Fig. 3.76  Laparoscopic transabdominal preperitoneal mesh repair (TAPP) of a right-sided spigelian hernia.

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Special Hernias Fig. 3.77  Laparoscopic intraperitoneal onlay mesh repair of a right-sided spigelian hernia.

Fig. 3.78  Transverse skin incision over a right-sided spigelian hernia.

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3.8  Spigelian Hernia Fig. 3.79  Exposure of a right-sided spigelian hernia after incision of the external oblique aponeurosis.

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Fig. 3.80  Open preperitoneal mesh repair of a right-sided spigelian hernia.

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Special Hernias Fig. 3.81  Open intermuscular mesh repair of a right-sided spigelian hernia. Note the incision of the lateral border of the rectus sheath to allow the mesh to extend and overlap adequately behind the rectus muscle.

Fig. 3.82  Sutured repair of a right-sided spigelian hernia: the defect is closed with two continuous sutures. The first deep suture is placed in the aponeurosis of the transversus abdominis and internal oblique, and the second suture in the aponeurosis of the external oblique.

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3.9  Internal Hernias

3.9  Internal Hernias

3.9.3 Diagnosis

Volker Schumpelick and Uwe Klinge

Clinically, these hernias may be nonspecific, but symptoms of mechanical obstruction are more often present. The diagnosis is suggested on plain X-ray of the abdomen and/ or blockage of Gastrografin transit.6,24 Mechanical ileus is seen on ultrasound. An internal hernia is most often diagnosed at operation, i.e., at the incarceration stage. Paraduodenal hernias at the duodenal flexure are the most important form of internal hernia. Men in the fourth to sixth decades are affected most often.7 The mesentericoparietal fossa is the main opening (▶Fig. 3.83), with nine possible variants, the most important of which are: •• Left mesentericoparietal hernia (Treitz-Brösicke hernia), which extends in the venous recess into the descending mesocolon (▶Fig. 3.84). This, the most common (75%) form, is characterized by a hernial ring that contains the left colic artery and inferior mesenteric vein. •• The right mesentericoparietal hernia without malrotation (Treitz-Neumann hernia) in the Waldeyer fossa is the second most frequent paraduodenal hernia. In this case, the duodenojejunal flexure is in normal position and the sac extends into the ascending mesocolon, framed by the superior mesenteric artery (▶Fig. 3.85). •• The third form of paraduodenal hernia is the right mesentericoparietal hernia with malrotation.123 The duodenojejunal flexure is absent and the entire small intestine is behind the ascending colon. Because the ileocolic artery runs on the anterior wall of the hernial sac (▶Fig. 3.86), the right colon must be mobilized and moved to the left side to avoid bowel necrosis.9

[ ]

Definition

An internal hernia is the protrusion of viscera into congenital or acquired openings in the abdominal cavity. True and false internal hernias are distinguished depending on whether a peritoneal sac is present.

3.9.1 Anatomy The first report of an internal hernia came from Hensing in 1742.7,50 In subsequent years, numerous other hernias were discovered, the most common and well known being the Treitz hernia, called so because of the first description by Treitz in 1857 of a hernia at the duodenojejunal flexure.7,123 Postoperative hernias arise from incomplete and omitted closure of mesenteric or omental openings, as parastomal herniation between a stoma and the lateral abdominal wall, or as a retroanastomostic hernia following Billroth II gastrojejunostomy.25 This is also called a Petersen hernia after the surgeon who first described it (1900).108 These hernias are false hernias as they lack a peritoneal covering.

3.9.2 Incidence Internal hernias are found in 0.2 to 0.9% of autopsies25 (▶Table 3.4). They cause 4% of cases of mechanical intestinal obstruction92 and account for 1% of hernias.32 They are among the most dangerous forms of hernia, with mortality rates of up to 80%.11 Table 3.4  The most frequent internal hernial orifices Orifice

Frequency (%)

Paraduodenal

53

Ileocecal

13

Foramen of Winslow

8

Mesosigmoid

6

Mesentery

8

Broad ligament

8

Supravesical

7

Postoperative

5

Caution

3



There is a risk of vascular injury when the hernial ring is divided without a clear view of the anatomy. Paracecal hernias that project into the superior, inferior, or retrocecal recess are rarer than paraduodenal hernias (▶Fig. 3.87). Reduction often occurs spontaneously with the start of anesthesia. A hernia in the foramen of Winslow is another variant17,25,32 (▶Fig. 3.88). Here, the hernial ring consists of the hepatoduodenal ligament with the common bile duct, hepatic artery, and portal vein. Dissection from the hernial ring must be extremely careful to avoid damaging the vascular structures. Manual reduction is often facilitated by splitting the gastrocolic ligament to make an opening in the bursa.

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Special Hernias

Fig. 3.83  Anatomy and openings of paraduodenal hernias. x1 Superior duodenal fossa. x2 Inferior duodenal fossa. x3 Paraduodenal fossa. x4 Mesentericoparietal fossa. 1 Inferior mesenteric vein. 2 Left colic artery. 3 Inferior mesenteric artery. 4 Ureter.

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3.9  Internal Hernias

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Fig. 3.84  Anatomy and opening of a left mesentericoparietal (Treitz-Brösicke) hernia. 1 Inferior mesenteric vein. 2 Left colic artery.

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Special Hernias

Fig. 3.85  Anatomy and opening of a right mesentericoparietal hernia without malrotation, i.e., Treitz-Neumann hernia in the Waldeyer fossa. 1 Superior mesenteric artery. 2 Inferior mesenteric vein.

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3.9  Internal Hernias

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Fig. 3.86  Anatomy and opening of a right mesentericoparietal hernia with malrotation. 1 Ileocolic artery.

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Special Hernias Fig. 3.87  Anatomy and openings of paracecal hernias. x1 Superior ileocecal recess. x2 Inferior ileocecal recess. x3 Retrocecal recess.

Fig. 3.88  Anatomy and opening of a hernia through the foramen of Winslow.

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3.9  Internal Hernias

3.9.4 Indications ▶ Absolute. Incarceration. ▶ Relative. Persistent symptoms, suspected diagnosis, intraoperative finding.

3.9.5 Anesthesia General anesthesia.

3.9.6 Position Supine.

3.9.7 Access Midline or transverse incision depending on suspected location.

3.9.8 Complications Peritonitis, obstruction due to adhesions, recurrence.

3.9.9 Results Good if bowel vitality is preserved, mortality rates up to 80%.

3.9.10  Operation Techniques The operative technique consists of freeing the herniated segment of bowel from the hernial ring without damaging its vital structures. This applies especially for hernial rings in the vicinity of blood vessels such as left and right mesentericoparietal hernias and hernias through the foramen of Winslow, where vascular integrity must be carefully preserved. After the bowel has been released and has recovered its vitality, the hernial opening is closed or plugged with omentum.

Further Reading [1] Amid PK. The Lichtenstein repair in 2002: an overview of causes of recurrence after Lichtenstein tension-free hernioplasty. Hernia. 2003; 7(1):13–16 [2] Ammar SA. Management of complicated umbilical hernias in cirrhotic patients using permanent mesh: randomized clinical trial. Hernia. 2010; 14(1):35–38 [3] Appeltans BM, Zeebregts CJ, Cate Hoedemaker HO. Laparo­ scopic repair of a Spigelian hernia using an expanded polytetrafluoroethylene (ePTFE) mesh. Surg Endosc. 2000; 14(12):1189 [4] Bátorfi J, Kelemen O, Vizsy L, Simon E, Bálint A, Pósfai G. Transabdominal preperitoneal herniorraphy: technique and results. Acta Chir Hung. 1997; 36(1–4):18–21 [5] Bay-Nielsen M, Kehlet H. Inguinal herniorrhaphy in women. Hernia. 2006; 10(1):30–33 [6] Bell-Thomson J, Vieta JO, Yiavasis AA. Paraduodenal hernias. Am J Gastroenterol. 1977; 68(3):254–259 [7] Berardi RS. Paraduodenal hernias. Surg Gynecol Obstet. 1981; 152(1):99–110

[8] Bernard AC, Lee C, Hoskins J, et al. Sciatic hernia: laparoscopic transabdominal extraperitoneal repair with plug and patch. Hernia. 2010; 14(1):97–100 [9] Bertelsen S, Christiansen J. Internal hernia through mesenteric and mesocolic defects. A review of the literature and a report of two cases. Acta Chir Scand. 1967; 133(5):426–428 [10] Bittner JG, IV, Edwards MA, Shah MB, MacFadyen BV, Jr, Mellinger JD. Mesh-free laparoscopic spigelian hernia repair. Am Surg. 2008; 74(8):713–720, discussion 720 [11] Brigham RA, Fallon WF, Saunders JR, Harmon JW, d’Avis JC. Paraduodenal hernia: diagnosis and surgical management. Surgery. 1984; 96(3):498–502 [12] Bruns W, Dudda W, Wenzel E. Spätergebnisse der Herniotomie nach Lotheissen-McVay 20 Jahre postoperativ. Langenbecks Arch Chir. 1996; 381(5):263–266 [13] Buch KE, Tabrizian P, Divino CM. Management of hernias in pregnancy. J Am Coll Surg. 2008; 207(4):539–542 [14] Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004; 240(4):578–583, discussion 583–585 [15] Campanelli G, Pettinari D, Nicolosi FM, Avesani EC. Spigelian hernia. Hernia. 2005; 9(1):3–5 [16] Carbonell AM. Interparietal hernias after open retromuscular hernia repair. Hernia. 2008; 12(6):663–666 [17] Carlisle BB, Killen DA. Spontaneous transverse mesocolic hernia with re-entry into the greater peritoneal cavity: report of a case with review of the literature. Surgery. 1967; 62:268–273 [18] Cavallaro G, Sadighi A, Miceli M, Burza A, Carbone G, Cavallaro A. Primary lumbar hernia repair: the open approach. Eur Surg Res. 2007; 39(2):88–92 [19] Celdrán A, Señaris J, Mañas J, Frieyro O. The open mesh repair of Spigelian hernia. Am J Surg. 2007; 193(1):111–113 [20] Christensen HK, Nerstrøm P, Tei T, Laurberg S. Perineal repair after extralevator abdominoperineal excision for low rectal cancer. Dis Colon Rectum. 2011; 54(6):711–717 [21] Conze J, Binnebösel M, Klinge U. Redo following mesh repair. In: Schumpelick V, Fitzgibbons RJ, eds. Recurrent Hernia—Prevention and Treatment. Heidelberg: Springer; 2007 [22] Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011; 2(1):5 [23] Dalinka MK, Wunder JF, Wolfe RD. Internal hernia through the mesentery of a Meckel’s diverticulum. Radiology. 1970; 95(1):39–40 [24] Davis R. Surgery of left paraduodenal hernia. Am J Surg. 1975; 129(5):570–573 [25] Du Toit DF, Pretorius CF. Left paraduodenal hernia with acute abdominal symptoms. A case report. S Afr Med J. 1986; 70(4):233–234 [26] Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries in male soccer players. Scand J Med Sci Sports. 1999; 9(2):98–103 [27] Faust H, Kuthe A, Saemann T, et al. Die endoskopische extraperitoneale Patch-Plastik von Leisten- und Femoralhernien ohne Naht oder Klammerfixation des Polypropylen-Patches. In: MIC in der Hernienchirurgie. Langenbecks Arch Chir 1996; 113 (Suppl. II, (Kongreßbd.): 603–605 [28] Flum DR, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time? A population-based analysis. Ann Surg. 2003; 237(1):129–135 [29] Fon LJ, Spence RA. Sportsman’s hernia. Br J Surg. 2000; 87(5):545–552 [30] Gagner M, Milone L, Gumbs A, Turner P. Laparoscopic repair of left lumbar hernia after laparoscopic left nephrectomy. JSLS. 2010; 14(3):405–409 [31] Garvey JF, Read JW, Turner A. Sportsman hernia: what can we do? Hernia. 2010; 14(1):17–25 [32] Ghahremani GG. Internal abdominal hernias. Surg Clin North Am. 1984; 64(2):393–406

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Special Hernias [33] Gianetta E, de Cian F, Cuneo S, et al. Hernia repair in elderly patients. Br J Surg. 1997; 84(7):983–985 [34] Glassow F. Recurrent inguinal and femoral hernia. BMJ. 1970; 1(5690):215–216 [35] Glassow F. The surgical repair of inguinal and femoral hernias. Can Med Assoc J. 1973; 108(3):308–313 [36] Gorgun E, Onur E, Baca B, Apaydin B, Yavuz N, Sirin F. Laparoscopic repair of an internal supravesical hernia: a rare hernia causing small bowel obstruction. Surg Endosc. 2003; 17(4):659 [37] Grauls A, Lallemand B, Krick M. The retroperitoneoscopic repair of a lumbar hernia of Petit. Case report and review of literature. Acta Chir Belg. 2004; 104(3):330–334 [38] Hall DE, Roberts KB, Charney E. Umbilical hernia: what happens after age 5 years? J Pediatr. 1981; 98(3):415–417 [39] Halpern LJ. Spontaneous healing of umbilical hernias. JAMA. 1962; 182:851–852 [40] Heithold DL, Ramshaw BJ, Mason EM, et al. 500 total extraperitoneal approach laparoscopic herniorrhaphies: a single-institution review. Am Surg. 1997; 63(4):299–301 [41] Hölmich P, Dienst M. Differentialdiagnose von Hüft- und Leistenschmerzen. Symptome und körperliche Untersuchungstechnik. Orthopade. 2006; 35(1):8–15, 10–15 [42] Hölmich P, Uhrskou P, Ulnits L, et al. Effectiveness of active physical training as treatment for long-standing adductorrelated groin pain in athletes: randomised trial. Lancet. 1999; 353(9151):439–443 [43] Huhn U, Arlt G, Kersten CC. The PUMP repair—open preperitoneal umbilical mesh plasty. Hernia. 2009; 13(Suppl. 1):70 [44] Iversen E, Lykke A, Hensler M, Jorgensen LN. Abdominal wall hernia repair with a composite ePTFE/polypropylene mesh: clinical outcome and quality of life in 152 patients. Hernia. 2010; 14(6):555–560 [45] Jan YT, Jeng KS, Liu YP, Yang FS. Internal supravesical hernia. Am J Surg. 2008; 196(4):e27–e28 [46] Junge K, Klinge U, Rosch R, et al. Decreased collagen type I/III ratio in patients with recurring hernia after implantation of alloplastic prostheses. Langenbecks Arch Surg. 2004; 389(1):17–22 [47] Kald A, Anderberg B, Smedh K, Karlsson M. Transperitoneal or totally extraperitoneal approach in laparoscopic hernia repair: results of 491 consecutive herniorrhaphies. Surg Laparosc Endosc. 1997; 7(2):86–89 [48] Kark AE, Kurzer M. Groin hernias in women. Hernia. 2008; 12(3):267–270 [49] Khoury N. A randomized prospective controlled trial of laparoscopic extraperitoneal hernia repair and mesh-plug hernioplasty: a study of 315 cases. J Laparoendosc Adv Surg Tech A. 1998; 8(6):367–372 [50] Kiviniemi H, Rämö J, Pokela R, Lepojärvi M, Ståhlberg M. Herniation through the foramen of Winslow. A case report. Acta Chir Scand. 1984; 150(6):501–502 [51] Klinge U, Junge K, Mertens PR. Herniosis: a biological approach. Hernia. 2004; 8(4):300–301 [52] Koch G, Eichfuß HP, Farthmann E, et al. Äußere und innere Brüche. Med Welt. 1978; 29:61–70 [53] Larson DW, Farley DR. Spigelian hernias: repair and outcome for 81 patients. World J Surg. 2002; 26(10):1277–1281 [54] Lau H, Fang C, Yuen WK, Patil NG. Risk factors for inguinal hernia in adult males: a case-control study. Surgery. 2007; 141(2):262–266 [55] LeBlanc KE, LeBlanc KA. Groin pain in athletes. Hernia. 2003; 7(2):68–71 [56] Losanoff JE, Basson MD, Gruber SA, Weaver DW. Sciatic hernia: a comprehensive review of the world literature (1900–2008). Am J Surg. 2010; 199(1):52–59 [57] Lukaszczyk JJ, Preletz RJ, Morrow GJ, Lange MK, Tachovsky TJ, Krall JM. Laparoscopic herniorrhaphy versus traditional open repair at a community hospital. J Laparoendosc Surg. 1996; 6(4):203–208 [58] Lytle WJ. The internal ring. Br J Surg. 1945; 128:29 [59] Mainik F, Flade-Kuthe R, Kuthe A. [Combined endoscopic treatment of Spigelian hernia: laparoscopy—total extraperitoneal patch plasty - laparoscopy] Chirurg. 2011; 82(10):932–935, 934–935

[60] Malazgirt Z, Derviso, ğ, lu A, Polat C, Guneren E, Guven H, Akpolat T. Preperitoneal mesh repair of spigelian hernias under local anesthesia: description and clinical evaluation of a new technique. Hernia. 2003; 7(4):202–205 [61] Malazgirt Z, Topgul K, Sokmen S, et al. Spigelian hernias: a prospective analysis of baseline parameters and surgical outcome of 34 consecutive patients. Hernia. 2006; 10(4):326–330 [62] Malycha P, Lovell G. Inguinal surgery in athletes with chronic groin pain: the ‘sportsman’s’ hernia. Aust N Z J Surg. 1992; 62(2):123–125 [63] Mantoo SK, Mak K, Tan TJ. Obturator hernia: diagnosis and treatment in the modern era. Singapore Med J. 2009; 50(9): 866–870 [64] Martell EG, Singh NN, Zagorski SM, Sawyer MA. Laparoscopic repair of a spigelian hernia: a case report and literature review. JSLS. 2004; 8(3):269–274 [65] McCormack K, Scott NW, Go PM, Ross S, Grant AM; EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2003(1):CD001785 [66] Meyers MA. Paraduodenal hernias. Radiologic and arteriographic diagnosis. Radiology. 1970; 95(1):29–37 [67] Miserez M, Schreinemacher MHF. Spigelian Hernias: Diagnosis and Treatment. In: Jacob BP, Ramshaw B, eds. The SAGES Manual of Hernia Repair. New York: Springer Science+Business Media; 2013: 567–582 [68] Miserez M. Totally extraperitoneal endoscopic inguinal hernia repair (TEP) in 10 steps; Available at: http://www.websurg.com/ doi-vd01en2755.htm (accessed December 22, 2012) [69] Mislowsky A, Hemphill A, Nasrallah DV. A scarless technique of umbilical hernia repair in the adult population. Hernia. 2008; 12(6):627–630 [70] Morales-Conde S, Socas M, Barranco A. Sportsmen hernia: what do we know? Hernia. 2010; 14(1):5–15 [71] Moreno-Egea A, Carrasco L, Girela E, Martín JG, Aguayo JL, Canteras M. Open vs. laparoscopic repair of spigelian hernia: a prospective randomized trial. Arch Surg. 2002; 137(11): 1266–1268 [72] Munshi IA, Wantz GE. Treatment of recurrent and prevascularized femoral hernias by reinforcement of the visceral sac using a giant prosthesis [Article in French] Chirurgie. 1996; 121(5):321–324; discussion 324–325 [73] Munshi IA, Wantz GE. Management of recurrent and perivascular femoral hernias by giant prosthetic reinforcement of the visceral sac. J Am Coll Surg. 1996; 182(5):417–422 [74] Muschaweck U, Berger L. Minimal Repair technique of sportsmen’s groin: an innovative open-suture repair to treat chronic inguinal pain. Hernia. 2010; 14(1):27–33 [75] National Institute for Clinical Excellence. Technology appraisal guidance no 83: Guidance on the use of laparoscopic surgery for inguinal hernia. London: NICE; 2004 uptake report [76] Ng WT, Kong CK, Kong KC. Facilitation of open Spigelian hernia repair by laparoscopic location of the hernial defect. Surg Endosc. 2004; 18(3):561–562 [77] Nilsson E, Kald A, Anderberg B, et al. Hernia surgery in a defined population: a prospective three year audit. Eur J Surg. 1997; 163(11):823–829 [78] Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis. 2009; 11(8):806–816 [79] Nussbaumer P, Blessing H. Endoscopic pre-peritoneal prolene mesh-plasty for management of inguinal and femoral hernias [Article in German] Swiss Surg. 1997; 3(3):121–124 [80] Orchard JW, Read JW, Neophyton J, Garlick D. Groin pain associated with ultrasound finding of inguinal canal posterior wall deficiency in Australian Rules footballers. Br J Sports Med. 1998; 32(2):134–139 [81] Paajanen H, Ojala S, Virkkunen A. Incidence of occult inguinal and Spigelian hernias during laparoscopy of other reasons. Surgery. 2006; 140(1):9–12, discussion 12–13

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3.9  Internal Hernias [82] Paajanen H, et al. Laparoscopic surgery for chronic groin pain in athletes is more effective than non-operative treatment. Surgery. 2011; 150:99–107 [83] Palanivelu C, Vijaykumar M, Jani KV, Rajan PS, Maheshkumaar GS, Rajapandian S. Laparoscopic transabdominal preperitoneal repair of spigelian hernia. JSLS. 2006; 10(2):193–198 [84] Pans A, Desaive C, Jacquet N. Use of a preperitoneal prosthesis for strangulated groin hernia. Br J Surg. 1997; 84(3):310–312 [85] Pardieck DA. Laparoscopic inguinal hernia repairs in men in a community hospital setting using the TAPP approach. JSC Med Assoc. 1998; 94(8):345–350 [86] Patle NM, Tantia O, Sasmal PK, Khanna S, Sen B. Laparoscopic repair of spigelian hernia: our experience. J Laparoendosc Adv Surg Tech A. 2010; 20(2):129–133 [87] Pélissier E, Ngo P. Traitement chirurgical des hernies de Spiegel. In: Techniques Chirurgicales—Appareil digestif. Paris; EMC (Elsevier Masson SAS, Paris) 2010; 40–151:1–6 [88] Shaffner LdeS, Pennell TC. Congenital internal hernia. Surg Clin North Am. 1971; 51(6):1355–1359 [89] Ponka JL. Hernias of the abdominal wall. Philadelphia, PA: Saunders; 1980 [90] Gómez Portilla A, Cendoya I, Uzquiza E, et al. Giant perineal hernia: laparoscopic mesh repair complemented by a perineal cutaneous approach. Hernia. 2010; 14(2):199–201 [91] Portilla AG, Martín E, de Lecea CM, et al. Recurrent postoperative perineal hernia: laparoscopic redo mesh repair. Hernia. 2010; 14(5):535–537 [92] Pritchard GA, Price-Thomas JM. Internal hernia of the transverse colon. A new syndrome. Dis Colon Rectum. 1986; 29(10):657–658 [93] Rayhanabad J, Sassani P, Abbas MA. Laparoscopic repair of perineal hernia. JSLS. 2009; 13(2):237–241 [94] Read RC. Observations on the etiology of spigelian hernia. Ann Surg. 1960; 152:1004–1009 [95] Robbins AW, Rutkow IM. Mesh plug repair and groin hernia surgery. Surg Clin North Am. 1998; 78(6):1007–1023, vi–vii [96] Rosch R, Junge K, Lynen P, et al. Hernia—a collagen disease? Eur Surg. 2003; 35:11–15 [97] Rosenberg J, Bisgaard T, Kehlet H, et al; Danish Hernia Database. Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults. Dan Med Bull. 2011; 58(2):C4243 [98] Rutkow IM, Robbins AW. The mesh plug technique for recurrent groin herniorrhaphy: a nine-year experience of 407 repairs. Surgery. 1998; 124(5):844–847 [99] Salum MR, Prado-Kobata MH, Saad SS, Matos D. Primary perineal posterior hernia: an abdominoperineal approach for mesh repair of the pelvic floor. Clinics (Sao Paulo). 2005; 60(1):71–74 [100] Sanchez-Bustos F, Ramia JM, Fernandez Ferrero F. Prosthetic repair of femoral hernia: audit of long term follow-up. Eur J Surg. 1998; 164(3):191–193 [101] Schmidt P, Antal A. The totally extraperitoneal mesh repair (TEP) laparoscopic hernia repair. Acta Chir Hung. 1997; 36(1–4):320–322 [102] Schouten N, Burgmans JP, van Dalen T, et al. Female ‘groin’ hernia: totally extraperitoneal mesh repair (TEP) endoscopic repair seems the most appropriate treatment modality. Hernia. 2012; 16(4):387–392 [103] Schumacher OP, Peiper C, Lörken M, Schumpelick V. Langzeitergebnisse der Nabelhernienreparation nach Spitzy. Chirurg. 2003; 74(1):50–54 [104] Schumpelick V, Arlt G, Klinge U. Versorgung von Nabelhernie und Narbenhernie. Dtsch Ärztebl. 1997; 94A:3471–3476 [105] Schumpelick V. Nabelhernie. In: Schumpelick V, ed. Hernien. 4th ed., Stuttgart: Thieme; 2000: 350 [106] Schumpelick V, Klinge U, Rosch R, et al. How to treat the recurrent incisional hernia: open repair in the midline In: Schumpelick V, Fitzgibbons RJ, eds. Recurrent Hernia—Prevention and Treatment. Heidelberg: Springer; 2007 [107] Schwab R, Klinge U. Principle actions for re-recurrences. In: Schumpelick V, Fitzgibbons RJ, eds. Recurrent Hernia—Prevention and Treatment. Heidelberg: Springer; 2007

[108] Sebesta DG, Robson MC. Petersen’s retroanastomotic hernia. Am J Surg. 1968; 116(3):450–453 [109] Seidel W, Spelsberg F, Niedring O, Zenker R. Die Indikation zur operativen Versorgung der Leisten- und Schenkelhernien. Dtsch Med Wochenschr. 1972; 97(25):963–967 [110] Shaikh I, Olabi B, Wong VM, Nixon SJ, Kumar S. NICE guidance and current practise of recurrent and bilateral groin hernia repair by Scottish surgeons. Hernia. 2011; 15(4):387–391 [111] Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009; 13(4):343–403 [112] Skandalakis JE, Gray SW, Burns WB, Sangmalee U, Sorg JL. Internal and external supravesical hernia. Am Surg. 1976; 42(2):142–146 [113] Skandalakis JE. Internal supravesical hernias. In: Skandalakis JE, ed. Hernia: Surgical anatomy and technique. New York, NY: McGraw-Hill Inc; 1989: 292 [114] Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Spigelian hernia: surgical anatomy, embryology, and technique of repair. Am Surg. 2006; 72(1):42–48 [115] Sorensen LT, Friis E, Jorgensen T, et al. Smoking is a risk factor for recurrence of groin hernia. World J Surg. 2002; 26(4):397–400 [116] Sozen I, Nobel J. Inguinal mass due to an external supravesical hernia and acute abdomen due to an internal supravesical hernia: a case report and review of the literature. Hernia. 2004; 8(4):389–392 [117] Spangen L. Spigelian hernia. World J Surg. 1989; 13(5):573–580 [118] Stoppa R, Van Hee R. Surgical management of groin hernias. State of the art in 1996. Acta Chir Belg. 1998; 98(3):136–138 [119] Subramanya MS, Chakraborty J, Memon B, Memon MA. Emergency intraperitoneal onlay mesh repair of incarcerated spigelian hernia. JSLS. 2010; 14(2):275–278 [120] Tarnoff M, Rosen M, Brody F. Planned totally extraperito­ neal laparoscopic Spigelian hernia repair. Surg Endosc. 2002; 16(2):359 [121] Tchanque CN, Virmani S, Teklehaimanot N, et al. Bilateral obturator hernia with intestinal obstruction: repair with a cigar roll technique. Hernia. 2010; 14(5):543–545 [122] Thairu NM, Heather BP, Earnshaw JJ. Open inguinal hernia repair in women: is mesh necessary? Hernia. 2008; 12(2):173–175, discussion 217 [123] Turley K. Right paraduodenal hernia: a source of chronic abdominal pain in the adult. Arch Surg. 1979; 114(9):1072–1074 [124] van den Spieghel A. Opera Quae Extant Omnia. Amsterdam: Johannes Blaeu; 1645 [125] Verrall GM, Slavotinek JP, Fon GT, Barnes PG. Outcome of conservative management of athletic chronic groin injury diagnosed as pubic bone stress injury. Am J Sports Med. 2007; 35(3):467–474 [126] Walker SH. The natural history of umbilical hernia. A six-year follow-up of 314 Negro children with this defect. Clin Pediatr  (Phila). 1967; 6(1):29–32 [127] Weber A, Valencia S, Garteiz D, et al. Epidemiology of hernia in the female. In: Bendavid R, Abrahamson J, Arregui M, Flament J, Phillips E, eds. Abdominal Wall Hernias. Heidelberg: Springer; 2001: 613–619 [128] Witney-Smith C, Undre S, Salter V, Al-Akraa M. An unusual case of a ureteric hernia into the sciatic foramen causing urinary sepsis: successfully treated laparoscopically. Ann R Coll Surg Engl. 2007; 89(7):W10–2 [129] Yau KK, Siu WT, Chau CH, Yang GP, Li MK. A laparoscopic approach for incarcerated Spigelian hernia. J Laparoendosc Adv Surg Tech A. 2005; 15(1):57–59 [130] Yau KK, Siu WT, Chau CH, Yang PC, Li MK. Laparoscopic management of incarcerated obturator hernia. Can J Surg. 2005; 48(1):76–77 [131] Zhang H, Cong JC, Chen CS. Ileum perforation due to delayed operation in obturator hernia: a case report and review of literatures. World J Gastroenterol. 2010; 16(1):126–130

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Chapter 4 Incisional Hernias

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4 4.1 General Principles

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4.2

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Open Technique

4.3 Laparoscopic Repair of Incisional Hernias

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Prevention of Incisional Hernias

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Incisional Hernias

4  Incisional Hernias 4.1  General Principles

4.1.4 Indications

Joachim Conze

▶ Absolute indications. Incarceration, intestinal strangulation, or perforation of the bowel in the sac.

4.1.1 Definition Incisional hernias arise at the site of a previous laparotomy incision. They consist of a hernial orifice and peritoneal sac.

4.1.2 Diagnosis Clinical examination to palpate the hernia usually suffices. In obese patients and/or when the defect is small, ultrasound of the abdominal wall is the standard method of detection. The width of the defect is the most important aspect. CT or MRI is indicated only with large loss-of-domain hernias. Preoperative lung function tests may be appropriate depending on defect size and/or respiratory impairment.

4.1.3 Classification The European Hernia Society (EHS) classification is shown in ▶Table 4.1.

Table 4.1  The EHS Incisional Hernia Classification

▶ Relative indications. Persistent symptoms, sustained incapacity for work, social deprivation, increase in size. The interval since the last operation should be more than 6 months to allow adequate fascial strength to be regained. ▶ Contraindications. Peritoneal carcinomatosis, general inoperability, especially respiratory impairment, absent consent.

4.1.5  Preoperative Preparation and Informed Consent Uninfected skin is desirable for elective surgery and pressure ulcers should be treated conservatively in the first instance. An enema is given the night before the operation. Orthograde bowel washout is not indicated. The patient should be given a careful explanation of possible risks and complications.90 These include: •• Wound seroma. •• Wound infection (5–15%). •• Foreign body sensation. •• Bowel injury (~ 2%). •• Chronic pain (~5–15%). •• Recurrence (2–10%).

4.1.6 Anesthesia

Hernia

Characteristics

Medial

Subxiphoid

M1

O

General anesthesia.

Epigastric

M2

O

Umbilical

M3

O

4.1.7 Position

Infraumbilical

M4

O

Suprapubic

M5

O

Subcostal

L1

O

Femoral hernia

L2

O

Iliac

L3

O

Lumbar

L4

O

Recurrent incisional hernia?

Yes O

No O

Length (cm)

–

Width (cm)

–

Width (cm)

W1 < 4 cm O

W2 ≥ 4–10 cm O

W3 ≥ 10 cm O

Lateral

Abbreviation: EHS, European Hernia Society.

The patients’s position depends on the location, slightly hyperextended during dissection and neutral position during repair.

4.1.8  Operation Tactics Numerous repair procedures are available to the surgeon. They differ basically as follows: •• With mesh augmentation, the abdominal wall is reinforced (▶Fig. 4.2). •• With mesh bridging, the abdominal wall is partially replaced (▶Fig. 4.66). Access can be open or laparoscopic. In an open repair, the mesh can be inserted as an onlay on the fascia, as

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4.2  Open Technique

Augmentation Onlay

Fig. 4.1  Forms of incisional hernia repair. a  Mesh augmentation. b  Mesh bridging.

Retromuscular Preperitoneal IPOM

a Defect bridging

4 Onlay Retromuscular Preperitoneal

b

IPOM

Fig. 4.2  Retromuscular mesh augmentation.

a sublay (retromuscular) on the posterior layer of the rectus sheath, in preperitoneal position between fascia and peritoneum, or as an intraperitoneal onlay mesh (IPOM, ▶Fig. 4.1).

4.2  Open Technique

4.1.9  Perioperative Management

Joachim Conze

Time out. Perioperative antibiotics, e.g., 1.5 g cefuroxime, and 0.5 g metronidazole, if appropriate, 30 minutes before skin incision; the old incision may be marked and an adhesive drape can be applied.

In a sublay repair, the anterior abdominal wall is reinforced with mesh behind the rectus muscle medially or between the external and internal oblique muscles. The aim should always be augmentation of the abdominal wall, i.e., fascial closure should be achieved (▶Fig. 4.2). If

4.2.1  Open Sublay (Retromuscular Augmentation)

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Incisional Hernias it is not possible to approximate the fascial edges without tension after dissection of the retromuscular mesh site, separation of the abdominal wall components should be attempted (section ▶4.3.8). If fascial closure is still not possible, mesh bridging should be considered.

provides better vision, prevents further fascial defects from being missed, and avoids iatrogenic bowel injury during dissection of the mesh site. The entire fascial scar is incised under vision (▶Fig. 4.3).

Opening of the Hernial Sac, Local Adhesiolysis, and Exploration of the Abdomen

Operation Techniques See also Conze et al, 2010.22

Excision of the Entire Skin Scar, Dissection of the Hernial Sac, and Exposure of the Fascial Defect The entire length of the existing skin scar is excised. The hernial sac is dissected gradually from the subcutaneous tissue as far as the edge of the fascial defect. This is then exposed circumferentially and the sac is opened. This

After dissecting the sac from the subcutaneous tissue, it is incised and the abdomen is opened, preserving the sac. This can be resected later. This ensures that enough tissue is available to close the posterior abdominal wall incision. Local adhesions to the anterior abdominal wall are then divided (▶Fig. 4.4). Adhesions between loops of intestine should be divided only if they give rise to clinical symptoms. The abdominal contents are then covered with a moist towel. Fig. 4.3  a–d a  Excision of the skin and subcutaneous tissue. b  Dissection down to fascia. c  Circumferential exposure of the fascial edges. d  Dissection of the sac and fascial edges. They are divided from the subcutaneous tissue by sharp dissection (cross-section).

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4.2  Open Technique Fig. 4.4  Opening the abdomen and local adhesiolysis.

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Fig. 4.5  Dissection of the anterior fascia.

Dissection of the Anterior Fascia Epifascial dissection of the anterior fascia should be sparing and not exceed 5 mm (▶Fig. 4.5). This facilitates subsequent dissection of the mesh site and later fascial closure.

Incision of the Rectus Sheath The rectus sheath is incised and entered from the medial side (▶Fig. 4.6).

Tip



Ensure that as much as possible of the anterior rectus sheath is preserved to provide adequate tissue for subsequent suture placement for closing the fascia. A vertical incision provides access to the vertical fibers of the rectus muscle. This muscle serves as a guide for further incision.

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Fig. 4.6  Medial incision of the rectus sheath, opening the retromuscular space.

Fig. 4.7  Dissection plane on the posterior layer of the rectus sheath above the arcuate line.

Dissection of the Retromuscular Mesh Site Leaving the belly of the muscle on the anterior fascia, the posterior layer of the rectus sheath can now be dissected largely bluntly as far as its lateral border. The epigastric vessels and segmental perforating vessels should be preserved when possible (▶Fig. 4.7). Below the arcuate line, the posterior layer of the rectus sheath merges with the

anterior layer so dissection here is preperitoneal. In the case of medial lower abdominal defects, this allows seamless dissection into the retrosymphyseal space (▶Fig. 4.8). Depending on the extent of the fascial defect, this can necessitate detachment of the posterior layer of the rectus sheath from the xiphoid process cranially. The retroxiphoid space is reached to allow adequate mesh overlapping (▶Fig. 4.9).

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4.2  Open Technique

RM

RM Xi

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LA

Fig. 4.8  Dissection plane at the symphysis; dissection is continued in the preperitoneal space between the bladder and symphysis (space of Retzius).

Fig. 4.9  Dissection plane at the xiphoid; the retroxiphoid space is reached by detaching the posterior layer of the rectus sheath from the xiphoid.

[PDS] 2). The peritoneum is approximated below the arcuate line (▶Fig. 4.11).

Tip



If low-tension approximation is not possible because of the width of the defect, parts of the hernial sac can be used for this. Protruding parts of the sac are only resected thereafter.

Fig. 4.10  Exposure of the fatty triangle by incision of the posterior layer of the rectus sheath on both sides of the linea alba.

Incision of the Posterior Layer of the Rectus Sheath on Both Sides of the Linea Alba to Expose the Fatty Triangle To enable sufficient mesh to be placed in the midline behind the linea alba, a vertical incision is made in the posterior layer of the rectus sheath on both sides of the linea alba. This exposes the yellowish preperitoneal fatty triangle. The incision should be at least 5 cm long (▶Fig. 4.10). When the fascial defect is proximal to the arcuate line, this dissection must also be continued caudally to ensure adequate mesh overlapping (inferior fatty triangle).

Closure of the Abdomen/Suture of the Posterior Wall (Peritoneum) When dissection is concluded, the abdomen is closed by a continuous suture of the posterior layer of the rectus sheath with absorbable material (e.g., polydioxanone

The aim of this suture is creation of a natural tissue barrier to avoid direct contact between the mesh and the abdominal viscera.

Measurement of the Mesh Site and Mesh Placement After meticulous hemostasis, the mesh site is measured and a mesh graft is cut to size. When placing the mesh, it must lie flat without creases and overlap the closed defect by at least 5 to 6 cm in all directions (▶Fig. 4.12). Depending on which mesh type is used, the greatest elasticity should be in the direction of the muscle fibers. In retromuscular mesh augmentation, the mesh reinforces the abdominal wall and does not replace it. Nonabsorbable, large-pored mesh with a reduced surface is used for augmentation.

Mesh Fixation Only with Bridging Techniques using Transfascial Interrupted Sutures Mesh fixation is not required for retromuscular mesh augmentation. The anterior fascial closure acts as an

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Fig. 4.11  Continuous suture of the posterior rectus sheath, if necessary using parts of the hernial sac.

abutment for the intra-abdominal pressure which holds the mesh in position. To facilitate crease-free mesh placement, the proximal edge of the mesh can be fixed to the linea alba with an absorbable interrupted suture. This can make it easier to spread out a larger mesh. If it is impossible to create an appropriate thrust bearing because of the width of the defect and a bridging repair

must be performed, the mesh must be fixed to the anterior fascia with transfascial sutures. These are placed in a circle at intervals of 3 to 4 cm. To avoid further retraction of the fascial edge, it is stitched to the mesh with a continuous nonabsorbable suture (e.g., Prolene 2/0); this is the bridging technique (▶Fig. 4.13).

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4.2  Open Technique Fig. 4.12  Insertion of the mesh into the prepared retromuscular site.

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Fig. 4.13  Mesh placement with transfascial mesh fixation in the bridging technique for large fascial defects.

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Continuous Fascial Closure of the Anterior Rectus Sheath The anterior rectus sheath is closed with a continuous nonabsorbable suture to reconstruct the linea alba  (e.g., 2/0 Prolene; ▶Fig. 4.14). It must be carefully ensured that only the fascial edge is included in the suture. The stitches are placed 5 to 8 mm from the edge of the fascia and at intervals of 3 to 5 mm (“small stitch– small bite”). The ratio between the suture length and wound length should be 4:1.58 Tension-free approximation of the fascial edges is essential so the sutures do not tear out.

Subcutaneous Suture, Reattachment of the Umbilicus if Necessary, and Skin Closure The subcutaneous wound area is irrigated with warm saline. The detached umbilical column is fixed to the midline of the fascia with an absorbable suture (e.g., PDS 2/0). Wound drains are placed only after more extensive epifascial dissection. The subcutaneous tissue and skin are closed with staples or a continuous intracutaneous suture (e.g., Monocryl 4/0; ▶Fig. 4.15). The operation concludes with a sterile wound dressing. Fig. 4.14  Closure of the anterior fascia with a continuous nonabsorbable suture.

Fig. 4.15  Subcutaneous wound approximation, drainage, and skin closure.

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4.2  Open Technique

Relevant Anatomy, Dangers, and Tricks •• The epigastric vessels and their perforating branches always run within the rectus sheath at the lateral border. These should be protected during dissection of the mesh site (▶Fig. 4.16). •• If extension of the retromuscular layer into the lateral compartment of the abdominal wall lateral to the rectus sheath is necessary for mesh insertion, this can be achieved by a vertical incision at the lateral border of the rectus sheath. •• Since the neurovascular structures run mainly between the internal oblique and transversus muscles, the lateral mesh position should be between the internal oblique and external oblique muscle.

•• Postoperative hematoma: surgical evacuation of the hematoma. •• Mesh infection: antibiotic therapy, interventional drain insertion or VAC therapy, mesh explantation if necessary.

Postoperative Care ▶ Medical care. The vacuum drains are removed when the amount is < 10-20 mL/d. The patient should be provided with an information leaflet on gradual resumption of physical effort.

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▶ Diet. This depends on the extent of adhesiolysis and postoperative resumption of bowel activity. Liquid diet is usually well tolerated on the first postoperative day.

Management of Special Complications

▶ Bowels. If resumption of bowel evacuation is sluggish, an enema should be given from postoperative day 3.

•• Injury of the epigastric artery: ligature. •• Transmural bowel injury: bowel suture and generous irrigation.

▶ Mobilization. Mobilization is possible immediately on arrival on the ward with nursing support. ▶ Physical therapy. Physical therapy depends on the extent of the repair and pre-existing comorbidity, especially respiratory therapy. ▶ Incapacity for work. Two to three weeks.

4.2.2  Open Onlay (Epifascial Mesh Augmentation) Joachim Conze

Operation Technique The operation technique is shown schematically in ▶Fig. 4.17. Fig. 4.16  When dissecting the mesh site, the perforators should be protected.

Fig. 4.17  Schematic diagram of onlay mesh augmentation.

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Excision of the Entire Skin Scar, Dissection of the Hernial Sac, and Exposure of the Fascial Defect The entire length of the existing skin scar is excised sparingly. The hernial sac is dissected gradually from the subcutaneous tissue as far as the edge of the fascial defect.

Opening of the Abdominal Cavity If Necessary and Local Adhesiolysis The sac is opened only if it is irreducible or compromised hernia contents are suspected (ischemia, necrosis, etc.). After managing the contents, the sac is closed again with a continuous suture (▶Fig. 4.18).

Dissection of the Anterior Fascia Starting from the medial fascial border, the layer between the subcutaneous tissue and anterior fascia is dissected for 5 cm in all directions around the fascial edge (▶Fig. 4.19). Careful hemostasis must be ensured.

Continuous Fascial Closure with Relaxing Swing Door Incision If Required The medial fascial edges are approximated with a continuous nonabsorbable monofilament suture (e.g., Prolene 2/0; ▶Fig. 4.20). If direct fascial approximation is not possible, a “swing door” incision can be made: the anterior layer of the Fig. 4.18  Opening the sac and dissecting its contents. After reducing the contents, the sac is excised.

Fig. 4.19  The peritoneum/sac is then closed with a continuous absorbable suture. An epifascial suture line of 5 cm is dissected in all directions.

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4.2  Open Technique rectus sheath is incised over its entire length 1 to 2 cm lateral to the fascial defect, and the medial part is turned inward to achieve tension-free fascial closure (▶Fig. 4.21).

Measurement of the Mesh Site and Mesh Placement and Fixation The mesh should overlap the fascial suture by 5 cm in all directions. After measuring, an appropriate mesh is cut

to size and placed over the fascial suture. Since a corresponding mesh thrust bearing is lacking, mesh fixation is highly important. This can be done with nonabsorbable interrupted or continuous sutures (e.g., with Premilene/ Prolene 2/0). The stitches should be less than 1 cm apart (▶Fig. 4.22). ▶Fig. 4.23 shows the epifascial mesh position after swing door incision.

Fig. 4.20  Continuous fascial closure with nonabsorbable suture.

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Fig. 4.21  Swing door incision to reduce tension on the fascial suture.

Fig. 4.22  Epifascial (onlay) mesh placement and fixation with interrupted sutures.

Fig. 4.23  Cross-section of the epifascial mesh position after swing door incision.

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Drainage, Reattachment of the Umbilicus if Necessary, Skin Closure The extended epifascial dissection produces a large wound cavity, which often leads to wound seromas. Subcutaneous vacuum drains are placed on the mesh. The umbilicus should be reattached to the fascia through the mesh. This can be achieved with an absorbable suture (e.g., PDS 2/0). The operation concludes with approximating subcutaneous sutures and skin closure.

Relevant Anatomy, Dangers, and Tricks •• The blood supply of the subcutaneous tissue and skin can be injured during dissection of the epifascial mesh site, leading to necrosis of the wound edges. Especially after previous pararectal incisions, the blood supply of the skin bridge between the two incisions may be impaired. •• Mesh fixation is more difficult when the fascial defects extend to adjacent bony structures. Fixation that includes periosteum should be avoided because of the possibility of postoperative pain. •• Adequate soft tissue cover of the mesh must always be ensured to avoid possible mesh infection. Early VAC therapy may be necessary with concomitant conditioning of the overlying soft tissues.

Management of Special Complications •• Transmural bowel injury: bowel suture and generous irrigation. •• Postoperative hematoma: surgical evacuation of the hematoma. •• Mesh infection: antibiotic therapy, early VAC therapy, mesh explantation if necessary. •• Wound seroma: observation, sterile aspiration if extensive. Surgical management, possibly with VAC therapy, of persistent loculated seromas with corresponding symptoms is reasonable after 3 to 6 months.

Postoperative Care ▶ Medical care. The vacuum drains are removed when the discharge is less than 10 to 20 mL/d. The patient should be provided with an information leaflet on gradual resumption of physical efforts. ▶ Diet. This depends on the extent of adhesiolysis and postoperative resumption of bowel activity. Liquid diet is usually well tolerated on the first postoperative day. ▶ Bowels. If resumption of bowel evacuation is delayed an enema should be given from postoperative day 3. ▶ Mobilization. Mobilization is possible immediately on arrival in the ward with nursing support.

▶ Physical therapy. Physical therapy depends on the extent of the repair and pre-existing comorbidity, especially respiratory therapy. ▶ Incapacity for work. Two to three weeks.

4.2.3  Open Intraperitoneal Onlay Mesh Technique Frank P. Müller

Introduction In the open intraperitoneal onlay mesh (IPOM) repair, the mesh is placed intra-abdominally on the peritoneum, allowing technically simple and tension-free repair of the fascial defect. As in the open onlay and retromuscular mesh repair procedures, an intra-operative decision can be made regarding augmentation or defect bridging depending on fascial tension. While the fascia is closed over the mesh in the case of augmentation, bridging is used to repair an abdominal wall defect of variable size. The IPOM procedure can be performed both laparoscopically and via open surgery. The procedure shown here is the open method. Especially in patients with a high-risk profile, open IPOM repair to correct an incisional hernia is a simple and safe operation for the multimorbid patient. Postoperative transfer to the intensive care unit, sometimes with a need for prolonged ventilation, can often be avoided as this technique offers a tension-free procedure with a short operating time.41 The most serious complications after ventral hernia repair with intraperitoneal mesh are fistulas and adhesions with their sequelae.56 These complications have been observed especially when heavyweight and smallpored mesh has been used, and they have also been described with extraperitoneal mesh implantation.25,102 In the past few years, further modifications of mesh for intraperitoneal placement for incisional hernia repair have been introduced, which appear to have significant advantages compared with expanded polytetrafluoroethylene (e-PTFE) mesh. These new types of meshes prevent intestinal adhesions because of specially altered surface properties or because they use new antiadhesive polymers. Apart from their increased antiadhesive properties, the new-generation meshes for IPOM meet all the criteria of modern lightweight and large-pored mesh types. The flexibility of the “newer” IPOM meshes compared with e-PTFE mesh is of great importance when repairing large incisional hernia defects. It must be stressed, however, that the ideal mesh for intraperitoneal placement has not yet been found, and many authors reject intraperitoneal mesh placement. In addition, this type of mesh is much more expensive than the mesh used for extraperitoneal augmentation. Open IPOM repair developed from the inlay technique. The latter had a high recurrence rate of over 40% and is

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4.2  Open Technique no longer used nowadays to treat incisional hernia.1 A sufficiently wide contact area between mesh and tissue is important to enable broad fibrocollagenous healing.

Operation Techniques

sac. The fascial edges are exposed (▶Fig. 4.3). The sac is opened and its contents are reduced. Complete adhesiolysis of the small and large intestine is performed only when the adhesions are extensive and there is a history of chronic abdominal pain or symptoms of bowel obstruction. The sac is resected.

▶Fig. 4.24 shows a large incisional hernia.

Dissection of the Mesh Site

Preparation and Access The operation area is prepared extensively and calculated antibiotic prophylaxis is given.28 Good skin disinfection, if necessary using adhesive drapes, is important to avoid later mesh infection (▶Fig. 4.25 and ▶Fig. 4.26). During implantation, the mesh should not come in contact with the skin to avoid contamination.

Operation Steps The entire skin scar is excised and dissection continues through the subcutaneous tissue as far as the hernial

With incisional hernias in the upper abdomen, the falciform ligament and round ligament of the liver are divided at the level of the fascia. When the hernia is in the lower abdomen, the prevesical space is exposed after division of the medial folds to allow mesh placement behind the symphysis. The required mesh overlap of at least 3 to 5 cm69 in craniocaudal direction is possible only in this way (▶Fig. 4.27, ▶Fig. 4.28, and ▶Fig. 4.29). Mobilization of the left or right colon may be necessary to achieve an adequate overlap laterally.

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Fig. 4.24  Large incisional hernia. a  Frontal view. b  Lateral view.

a

b

Fig. 4.25  Intraoperative use of adhesive drapes to reduce the rate of impaired wound healing and mesh infection.

Fig. 4.26  Careful skin disinfection to reduce the rate of impaired wound healing and mesh infection.

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Incisional Hernias Fig. 4.27  Open intraperitoneal onlay mesh technique with fascial closure (augmentation). The mesh overlaps by at least 3 to 5 cm in all directions. The mesh is pressed against the abdominal wall by intra-abdominal pressure. This promotes ingrowth of the mesh into the peritoneum/abdominal wall.

Fig. 4.28  Double-crown fixation principle.

a

b

Mesh Selection Following preparation, the mesh size is determined by measuring the hernial orifice in two places with a flexible tape measure. The size of the defect is estimated roughly beforehand to have suitable mesh sizes available (see ▶Fig. 4.24). The mesh must project beyond the hernial orifice by at least 3 cm in all directions (see ▶Fig. 4.27 and ▶Fig. 4.28). Suitable meshes range from ePTFE (expanded polytetrafluoroethylene), coated meshes, combined meshes (e.g., polypropylene and ePTFE) to inert materials such as polyvinylidene fluoride and biological meshes. It is important for all mesh used intraperitoneally to minimize adhesions to the bowel as far as possible

and, on the other hand, to ensure good incorporation in the abdominal wall. In abdominal wall bridging, the mesh must be stable enough to prevent a bump or pseudohernia.

Mesh Placement and Fixation The mesh is placed intraperitoneally without tension and with the required overlap in all directions (▶Fig. 4.30). The mesh should be separated from the bowel by the greater omentum to diminish the development of adhesions to the bowel. Compared with all other procedures, mesh placement is very easy in a relaxed patient.

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4.2  Open Technique Fig. 4.29  Preparation of the abdominal cavity with resection of the sac, adhesiolysis, and adequate mobilization of the abdominal wall in all directions, if necessary with division of the round ligament of the liver and division of the median and medial umbilical folds when dissecting the prevesical space.

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Fig. 4.30  Intraperitoneal mesh placement and fixation with interrupted sutures to the peritoneum and posterior rectus fascia at intervals of at least 3 cm.

The fixing sutures should include not only the peritoneum but also the posterior rectus fascia. This is the only way to ensure adequate mesh fixation until fibrocollagenous incorporation of the mesh takes place (▶Fig. 4.30). To

facilitate this, the sutures can be prepared in the mesh at intervals of roughly 3 cm before intraperitoneal placement. Use of absorbable or nonabsorbable tacks can shorten the operation time for open mesh fixation (▶Fig. 4.31).

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Incisional Hernias As in the laparoscopic procedure, mesh fixation uses the “double-crown technique,” i.e., at least two fixing sutures are required (▶Fig. 4.32).16

Augmentation or Bridging Fascial closure over the mesh may be omitted to reduce tension and the risk of an abdominal compartment syndrome. In this case, the edge of the fascia or hernial sac should then be fixed to the mesh with continuous or interrupted nonabsorbable sutures (▶Fig. 4.32). This “topstitched seam” prevents further retraction of the fascial border and reduces the exposed mesh surface.

According to the literature, laparoscopic incisional hernia repair requires closure of the orifice.18 This can also be achieved in the open IPOM repair, e.g., by combining intraoperative mesh positioning with swing-door incisions105 or component separation.76 However, this requires more extensive dissection. The advantages have not yet been demonstrated in the literature.

Abdominal Wall Closure Finally, the skin and subcutaneous tissue are closed over the mesh. At the same time, the scar can be revised and Fig. 4.31  Mesh fixation is also possible with tacks.

Fig. 4.32  In abdominal wall replacement, the hernia edges are fixed to the mesh with interrupted sutures. A nonabsorbable suture is generally used. Mesh fixation therefore uses the “double-crown technique.”

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4.2  Open Technique overstretched, followed by the excision of the excess skin, if necessary (▶Fig. 4.33). Placement of drains is controversial.22 In over 60% of cases of open incisional hernia repair, drains are inserted with the aim of diverting wound secretions to reduce complications such as seroma, hematoma, or infection. A recent Cochrane database analysis showed that drains did not significantly reduce the complication rate after open incisional hernia repair and there was no difference whether or not a drain was used.34 The author tries to avoid use of drains as these are a potential source of infection.

Postoperative Care An abdominal bandage is routinely worn for at least 10 days. Adequate analgesia is required.

Advantages and Disadvantages The advantages of open IPOM repair are obvious: there is no learning curve, as with laparoscopic procedures. “See one, do one, teach one” applies to open IPOM incisional hernia repair more than to any other technique. This also explains the short operation times.5 Intraperitoneal mesh placement is simple and shows good results in the literature41 (▶Fig. 4.34). The time-consuming division of adhesions during laparoscopic hernia repair, with the serious complications reported in the literature, such as thermal bowel injury and unrecognized iatrogenic enterotomy, is not mentioned in the literature in association with the open technique.14,55 Enterotomy is an important complication of laparoscopic incisional hernia repair with mortality of up to 7.3%.54

The possibility of revising the old scar and excising excess skin and subcutaneous tissue is a particular advantage of the open methods (see ▶Fig. 4.33). The postoperative cosmetic result from the patient’s point of view is a clear advantage compared with laparoscopic IPOM repair. The disadvantage of open IPOM repair is the supposedly higher wound infection rate compared with the laparoscopic technique.21,31,32,87 Compared with other open methods such as the sublay technique or the Ramirez repair, access trauma is much less with the open IPOM technique. The infection risk therefore falls; retrospective studies have shown a low infection rate to date with the open IPOM method (between 2 and 8% after follow-up of up to 52 months). There are still no randomized studies.2,9,21,41 Chronic pain after open incisional hernia operations is described 10–20% of cases.64,69 The suggested etiology includes: •• Fixation. •• Foreign material. •• Mesh infections. •• Adhesions between the bowel and the mesh. •• Mesh positioning.

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Summary Open IPOM repair is an important addition to the range of surgical options for incisional hernia treatment. It should be a part of the hernia surgeon’s armory. The classical indication is repair of laparostomy and large incisional hernias in which the abdominal muscles have retracted so far that approximation of the midline is no longer possible even using component separation techniques.9

Fig. 4.33  With the intraperitoneal onlay mesh technique, plastic reconstruction of the scar and excess soft tissue can be carried out. This provides a postoperative result that is very satisfactory for the patient.

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a

b

c

d

e

Fig. 4.34  Reconstruction of a giant incisional hernia. a  Preoperative anterior view, previous laparostomy with split skin graft. b  Preoperative lateral view. c  Postoperative anterior view after reconstruction with the open intraperitoneal onlay mesh technique. d  Postoperative oblique view. e  Postoperative lateral view.

4.3  Laparoscopic Repair of Incisional Hernias 4.3.1  General Principles Dieter Berger Repair of incisional hernia basically consists of implantation of a nonabsorbable mesh to augment the abdominal wall. In the open procedures, mesh can be placed on the external oblique aponeurosis (onlay), behind the rectus muscles (sublay), and intraperitoneally (IPOM). Intraperitoneal onlay mesh repair can be performed laparoscopically and was first described in 1993.53

In essence, following complete division of adhesions to the anterior abdominal wall, the hernial orifice is not closed but is covered with a broadly overlapping nonabsorbable mesh licensed for intraperitoneal use. The crucial differences from the conventional technique are as follows: •• The original laparotomy scar is not touched. •• The layers of the abdominal wall are not separated. •• There is no additional tension, as the hernial orifice is not closed. •• Wide overlapping is possible in nearly every hernia location. A reduced rate of wound complications can be expected after laparoscopic procedures because there is less trauma to the abdominal wall. This has been confirmed in many studies and meta-analyses.7,14,72 Open surgery of

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4.3  Laparoscopic Repair of Incisional Hernias incisional hernias after transverse laparotomy by means of sublay augmentation holds the danger of denervation of the rectus muscles in the affected segments, as dissection must proceed beyond the lateral rectus sheath. Intraperitoneal mesh repair can always avoid this “ground disturbance.”

Indications Clear indications for a laparoscopic procedure are apparent from a comparison of the conventional and laparoscopic approaches: •• Patients with a high risk of infection,12 for instance, after deep wound infections following the index operation, obesity, or comorbidity or comedication that causes an additional risk of infection. •• Incisional hernia after transverse laparotomy. •• Subxiphoid and suprapubic hernias, which are often poorly accessible for anatomical reconstruction because of their proximity to the bony attachments of the abdominal wall. •• Recurrent hernias after conventional and especially retromuscular mesh augmentation.

Contraindications Several previous conventional operations are not a contraindication to a laparoscopic procedure, as it is not possible to predict the extent of the adhesions. Clear contraindications are as follows: •• Impossibility of achieving an adequate overlap of at least 5 cm. •• Portal hypertension presents a particular problem for laparoscopic division of adhesions and must be regarded as a contraindication. •• Abdominal wall paresis, specifically after flank access, cannot be permanently stabilized laparoscopically.62 •• When access to the abdominal cavity is not possible even at minilaparotomy, this requires immediate conversion. •• In very rare cases, laparoscopic adhesiolysis is not possible. However, this situation also presents a particular challenge in open surgery.

Operation Techniques Both open and laparoscopic incisional hernia repairs are usually performed with single-shot antibiotic prophylaxis. A transurethral catheter should be placed when dissection in the prevesical space is necessary, that is, for lower abdominal hernias and after primary access that extends far below the umbilicus. Orthograde bowel preparation is not necessary and an enema on the morning of the operation is sufficient.

Patient, Surgeon, and Video Tower Positioning Patients with hernias after midline or transverse operations should be in supine position on a vacuum mattress with both arms by their sides. The mattress can be elevated for transverse approaches extending far into the flank. The arm on the elevated side can then be moved outward. The skin should be disinfected and draped as far laterally as possible. Abducting the patient’s legs so the surgeon can stand between them has never proved necessary or even advantageous in our experience. The video tower is naturally opposite the cameraman and surgeon. The scrub nurse can stand either beside the video tower or beside the surgeon.

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Access Minilaparotomy generally provides the safest access to the abdominal cavity. The abdominal quadrant in which the least adhesions are suspected should always be chosen. This is the right upper abdomen after leftsided colon resection (▶Fig. 4.35) and the left upper quadrant after right-sided colon resection (▶Fig. 4.36). After upper abdominal operations through a transverse incision, few adhesions are to be expected in the right or left lower abdomen. Trocar placement is shown in ▶Fig. 4.37. After aortic replacement through both a transverse and midline approach, there are always fewer adhesions in the right half of the abdomen, so this should be used for access. It is very helpful to mark the hernia and the planned mesh position before creating the pneumoperitoneum, bearing in mind that the entire original scar must remain visible. This allows the appropriate mesh size to be established at the start of the operation.

Trocar Placement See ▶Fig. 4.35 to ▶Fig. 4.37. An angled optic, e.g., 30°, naturally provides an ideal viewing angle for the abdominal wall. For incisional hernias after midline incisions three trocars are placed along the anterior axillary line: subcostally, at the level of the umbilicus and in the lower abdomen. An additional trocar is inserted on the contralateral anterior axillary line at umbilical level. For incisional hernias after transverse incisions, the trocars are placed in a half-moon arrangement. Meshes up to 20 × 30 cm in size can usually be placed through a 10-mm trocar. A 12- or 13-mm trocar is recommended for larger meshes. For a right-handed surgeon, dissection of the lower abdomen in the space of Retzius is easier from the right. Conversely, dissection from the left side is recommended in the upper abdomen.

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Fig. 4.35  The right upper abdomen can be used for access after left-sided colon resection.

Fig. 4.36  The left upper quadrant can be used for access after right-sided colon resection.

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4.3  Laparoscopic Repair of Incisional Hernias

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Fig. 4.37  The right or left lower abdomen can usually be chosen for access after upper abdominal operations through a transverse incision.

Adhesiolysis Adhesiolysis is the riskiest step in laparoscopic incisional hernia repair. Under pneumoperitoneum conditions, leakage of bowel content must not occur immediately following enterotomy; so, such an injury can easily be overlooked.

Caution



Superficial or transmural injuries of the bowel wall must be avoided. This is best achieved by exclusively sharp adhesiolysis. Energy sources such as monopolar or bipolar scissors or ultrasonic scalpels must be avoided. The same applies for instrumental traction on the bowel. Dissection can be facilitated by external pressure on the abdominal wall with the nondominant hand. The entire anterior abdominal wall must be exposed. The round ligament of the liver and the falciform ligament must always be divided to ensure an adequate overlap. Dissection can continue as far as the left triangular ligament without endangering the hepatic veins. After lower abdominal incisions, the prevesical space must be opened to ensure stable mesh fixation in the extraperitoneal space. Purely intraperitoneal mesh placement will always result in suprapubic recurrence.

Additional medial inguinal or femoral hernias can be covered with the mesh used for incisional hernia repair. Formal transabdominal preperitoneal mesh repair (TAPP) should be performed for additional lateral hernias. If there are very dense adhesions between the intestine and anterior abdominal wall, parts of the posterior rectus sheath can be left on the intestine. In the case of recurrent hernias after intraperitoneal mesh repair, separation of bowel loops from the mesh may not be possible in individual cases, depending on the material used. The mesh can then be mobilized from the abdominal wall and left on the bowel. Segments of bowel adherent in the hernial sac often become visible only on manual pressure from without. In these cases, instrumental traction should always be avoided.

Mesh Placement and Fixation Because of the contact between foreign material and the intestines, simple polypropylene or polyester mesh must not be used. In these cases, massive adhesions and fistula formation would be likely.52 Alternatives approved for intraperitoneal use include ePTFE and coated polypropylene or polyester mesh. Polyvinylidene fluoride (PVDF) is currently the most modern material. The ePTFE-based structures have the greatest tendency to shrinkage24 and must always be removed if infection

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Incisional Hernias occurs. Coated or pretreated polypropylene and polyester structures are inelastic and this limits their handling characteristics considerably. In addition, they sometimes induce substantial adhesions experimentally. Moreover, superimposing two or more meshes has not been studied to date. Polyvinylidene difluoride (PVDF) structures are elastic and transparent, they can be overlapped without difficulty, and are highly resistant to infection due to low microbial adherence. There is hardly any tendency to shrinkage.46,49 A clinical study in 344 patients showed excellent tolerability in this respect also.7 The entire original incision must be covered with an overlap of at least 5 cm in all directions. As mentioned above, the correct mesh size can be established prior to insufflation of the pneumoperitoneum. Four corner sutures are used. Additional cranial and caudal retaining sutures in the midline after midline incisions have been shown to be helpful. When overlapping toward the costal margin (▶Fig. 4.38) or behind the symphysis (▶Fig. 4.39), the midline sutures should be placed 5 to 6 cm from the edge of the mesh to enable

overlapping toward the diaphragm or behind the symphysis. In these cases, the placement of the corner sutures must be altered as required by the anatomy. Because of the greater transverse curvature of the abdominal wall, eight marking sutures are recommended, as shown in ▶Fig. 4.40. The suture material is not critical; absorbable or nonabsorbable sutures can be used, as the surgeon prefers. After introducing the mesh, which should be folded and not rolled, the midline sutures are passed transfascially first, followed by the corner sutures. The mesh is thus optimally positioned. Final fixation is achieved with tacks that again can be absorbable or nonabsorbable. We place tacks every 4 to 5 cm but the sutures are always tied. The literature recommends the use of nonabsorbable material for sutures and tacks15 in conjunction with ePTFE-based structures but there are no definitive experimental or clinical results to substantiate this recommendation. The bladder does not have to be fixed to the anterior abdominal wall with suture or tacks as it resumes its position readily after release of the pneumoperitoneum.

Fig. 4.38  Positioning of the fixation sutures after upper abdominal laparotomy.

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4.3  Laparoscopic Repair of Incisional Hernias Fig. 4.39  Positioning of the fixation sutures after lower abdominal laparotomy.

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Fig. 4.40  Positioning of the fixation sutures after subcostal transverse laparotomy.

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Postoperative Care

Summary

Drains are not required. Unrestricted diet is resumed depending on bowel function. However, stubborn postoperative ileus can occur. Administration of a mild osmotic laxative is recommended, starting on the evening of the operation. Postoperative pain in the initial days is a major problem and is much greater than expected after a laparoscopic procedure. Intensive and consistent analgesia is therefore required, which may even include use of an epidural catheter.

The laparoscopic approach represents an important enhancement of incisional hernia repair options. Accurate knowledge of the anatomical and pathophysiological basis of the hernia and of conventional treatment methods, including component separation is essential as laparoscopic management is not possible in every case. Moreover, laparoscopic incisional hernia repair makes particular demands on the surgeon’s laparoscopic experience, and low case numbers may make it impossible to train surgeons adequately; it may even be necessary to forego use of the technique when the case numbers are too low. In these cases, knowledge of the method and its advantages and disadvantages is particularly important to provide the patient nevertheless with the chance of optimal treatment.

Unanswered Questions Two questions, in particular, remain unanswered today. Firstly, it is not clear whether the mesh should be fixed with tacks and sutures or with only one of these two methods. The idea that corner sutures lead to more pain has not been confirmed in recent studies. Recurrences also do not appear to be influenced by the mode of fixation. Another point of contention is whether the results of laparoscopic repair can be improved by closure of the fascial defect. Various studies have shown that the hernia can be closed laparoscopically and that the recurrence rate is low and sometimes extremely low.70 However, primary and secondary ventral hernias were analyzed jointly, which is no longer permissible today.50,95 A recent study that retrospectively compared the standard procedure with repair with fascial suture showed better results with regard to recurrence rate and patient satisfaction after the gap in the fascia was closed.20 This group, however, did not distinguish between primary and secondary ventral hernias. In addition, the results of the standard procedure are unusually poor as regards both aspects. Thus, the literature is still unable to answer this question. There are theoretical considerations, however, that render fascial closure doubtful. Compared with retromuscular mesh placement, intraperitoneal mesh placement is very much weaker. Usually, these meshes can be separated bluntly from the anterior abdominal wall. In addition, there is considerable tension on the fascial suture, which can hardly be absorbed by an intraperitoneal mesh compared with retromuscular placement. There is also a danger that smaller meshes are used so that a hernia will recur with the further fascial dehiscence that can be expected in the short term. Until the permanence of anatomical reconstruction by laparoscopic fascial suture is confirmed, surgeons should refrain from this procedure. Anatomical reconstruction certainly makes sense for very large defects, such as following a subcutaneous burst abdomen. In our hands, however, this can best be achieved with component separation and subfascial mesh repair. To date, no studies have investigated the size of fascial defect above which such reconstruction is useful because of the improvement in function.

4.3.2  Endoscopic Totally Extraperitoneal Transhernial Sublay Ventral Hernia Repair using the Single-Port Technique Wolfgang Reinpold The Rives and Stoppa sublay mesh herniorrhaphy80 is currently the most frequently used procedure in ventral hernia surgery, apart from laparoscopic intraperitoneal mesh repair (lap. IPOM). The advantages of the RivesStoppa operation are as follows: •• Extraperitoneal mesh position without the need for extensive mesh fixation with tacks, staples, or transmural sutures. •• Hernia closure over the mesh is often possible. •• Standard plastic mesh and self-adhesive mesh can be used. •• Abdominal cavity remains intact in an ideal case. The disadvantages are higher infection rates described in the literature and greater access trauma. To date, there have been only three studies in the literature of endoscopic totally extraperitoneal sublay mesh implantation for ventral hernias.48,60,100 The use of single ports has not yet been reported. In the endoscopic totally extraperitoneal sublay ventral hernia repair using the single-port technique developed by our working group, transhernial extraperitoneal mesh implantation is performed minimally invasively. The procedure combines the advantages of the Rives-Stoppa operation and the laparoscopic IPOM technique We have so far used the transhernial single-port ventral TEP procedure in 24 patients with small and mediumsized ventral and incisional hernias: the average defect size was 17 cm², the average mesh size 292 cm², and minimum mesh sublay 5 cm. In 12 cases, the abdominal cavity

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4.3  Laparoscopic Repair of Incisional Hernias was not opened. No complications occurred apart from two retromuscular hematomas, which were treated conservatively. With a follow-up of 8 months (2–15 months), no recurrences and no chronic pain have occurred to date. The high cost is a disadvantage, approximately 300 Euros for the single port. We have not yet treated lateral incisional hernias with this technique.

Access

Indications

Precise knowledge of the anatomy of the anterior abdominal wall is essential. Protect the nerves supplying the rectus muscle; these are readily visible endoscopically. Check the peritoneum carefully for tears that must be repaired. If impaired gastrointestinal transit due to adhesions and/or bands is suspected clinically or on ultrasound, laparoscopy and laparoscopic adhesiolysis should be performed, with “mini-open” adhesiolysis if appropriate. If gas-tight placement of the single port is not possible, gasless endoscopy should be performed with long narrow retractors. When reusable metal single ports are used, monopolar electrocauterization should be employed with particular caution. Very careful hemostasis is required. The skin incision should be somewhat larger, especially during the first operations and in very obese patients; so, the hernial sac and orifice can be identified with certainty and to enable gas-tight introduction of the single port. One to two additional 5-mm trocars may be introduced if necessary for insertion of very large meshes.

Small- and medium-sized ventral and incisional hernias (EHS classification W1 and W2).

Relative Contraindications Lateral incisional hernia. Incisional hernia after transverse laparotomy (no experience to date).

Contraindications Absolute general inoperability or absence of consent.

Alternative Procedures •• Endoscopic totally extraperitoneal transhernial sublay mesh repair of the abdominal wall with gasless endoscopy. •• Endoscopic totally extraperitoneal transhernial sublay mesh repair of the abdominal wall with standard endoscopy using the three-trocar technique. •• Rives-Stoppa open sublay mesh hernia repair. •• Laparoscopic IPOM repair.

Operation Preparation •• Preoperative diagnostics: standard preparation, ultrasound of the abdomen and abdominal wall. •• Antibiotic prophylaxis, e.g., cefazolin 2 g i.v. 30 minutes preoperatively. •• Medical thrombosis prophylaxis always given, preferably with low-molecular-weight heparin.

Special Risks, Informed Consent

Two skin incisions over the hernia up to 4 cm long. The exact skin incision can be determined preoperatively by ultrasound.

Relevant Anatomy, Dangers, and Tricks

Management of Special Complications Extensive hematoma: endoscopic hematoma evacuation. Infection: endoscopic debridement, irrigation, and drainage initially; open procedure if necessary; mesh removal if necessary.

Postoperative Care

•• Bowel and bladder injury (< 1%). •• Nerve injury (< 1%). •• Bleeding (< 5%). •• Hernia recurrence (< 5%). •• Infection (< 1%). •• Chronic pain (0–10%).

Brief hospitalization for treatment is usually possible, with clinical and ultrasound monitoring and monitoring of inflammatory parameters. Patients with cardiopulmonary comorbidity may require respiratory therapy. We recommend an elastic abdominal bandage for 3 to 6 weeks depending on the hernia size. The evidence level for this measure is grade D.

Anesthesia

Operation Techniques

General anesthesia.

Dissection of the Hernial Sac and Orifice

Position

A 2- to 4-cm skin incision is made over the hernia. The sac is dissected and excised as necessary. The peritoneum is closed if it was opened.

Supine.

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Insertion of the Single Port A small preperitoneal space with a radius of 1 to 2 cm is prepared by “mini-open” dissection. The single port is introduced into the hernial orifice. If necessary, this is tightened to allow gas-tight insertion of the single port with three 5-mm ports (▶Fig. 4.41).

Endoscopic Dissection of the Preperitoneal Space We use a long 5-mm, 30° optic. The procedure is performed with conventional straight 5-mm instruments. Preperitoneal dissection is initially in cranial and caudal direction posterior to the linea alba (▶Fig. 4.42). A vertical incision is made in the posterior layer of the rectus sheath bilaterally 1 to 1.5 cm lateral to the medial border of the rectus muscle (▶Fig. 4.43). Dissection then continues bilaterally anterior to the posterior layer of the rectus sheath, if necessary as far as the lateral border of the rectus compartment (▶Fig. 4.44). The entire rectus compartment can thus be dissected endoscopically. The posterior layer of the rectus sheath

remains open. The mesh is in preperitoneal position medially in the region of the linea alba and in front of the posterior layer of the rectus sheath laterally on both sides. The largest mesh we have implanted using this technique was 35 × 25 cm. Dissection is performed through 360° around the hernia defect. The laparoscopy tower is initially at the patient’s feet and is moved to the patient’s left and right side as needed. An alternative is to use several monitors.

Mesh Insertion After repeated skin disinfection and removal of the single port, the mesh is inserted transhernially using the double-roll technique, as far as possible without skin contact. It is first opened and spread out under digital control. The single port is reinserted and the mesh is placed in its final position endoscopically (▶Fig. 4.45). The edge of the mesh can be fixed endoscopically with sutures or staples but this can be omitted if the mesh overlaps the hernia defect by at least 5 cm and the hernia is then closed with anatomical reconstruction of the linea alba. Alternatively, self-adhesive mesh can be used. Fig. 4.41  Hernial orifice dissection and “mini-open” preparation of the preperitoneal space.

Fig. 4.42  Single port insertion and a 360° dissection of the preperitoneal space, initially in cranial and caudal direction posterior to the linea alba.

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4.3  Laparoscopic Repair of Incisional Hernias Fig. 4.43  Endoscopic vertical incision of the posterior layer of the rectus sheath bilaterally through the single port.

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Fig. 4.44  The 360° dissection of the preperitoneal space laterally in front of the posterior layer of the rectus sheath bilaterally.

Fig. 4.45  Endoscopic mesh positioning.

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4.3.3  Laparoscopic Repair of Parastomal Hernias Dieter Berger Parastomal hernia is a very frequent complication after construction of a terminal colostomy or ileostomy. It was recently shown that the majority of patients with parastomal hernias have clinical symptoms that have a considerable impact on their daily life.63 It is generally accepted that nonabsorbable mesh is necessary to repair a parastomal hernia, which is regarded as a special form of incisional hernia. Nevertheless, the results of clinical studies are not exactly promising as there are significant wound complication rates as well as recurrence rates between 10 and 50%. However, the validity of most studies is diminished by the limited number of patients.37 Laparoscopic repair is increasingly promoted in the literature. There are three procedures: •• The keyhole technique. •• The Sugarbaker technique. •• The sandwich technique.

Keyhole Technique The principle of this technique is based on a keyholeshaped incision in a mesh, which is then passed around the stoma loop. Recent studies, however, have shown that recurrence rates between 30 and nearly 50% can be expected. Only one series of 72 patients showed a recurrence rate of only 3%. However, this patient population had extreme operation-related morbidity; so, this procedure should generally be avoided as the revision rate is 13% with mesh complications in 7%.104 In summary, the keyhole technique is today regarded in the literature as unpromising.37

Sugarbaker Technique This technique was first described in 1985 as a conventional procedure.96 It is based on intraperitoneal mesh placement, placing the stoma loop between the mesh and the abdominal wall and lateralizing it by at least 5 cm. If necessary, the midline can be covered by a suitably larger mesh. This technique is ideal for a laparoscopic approach and ultimately corresponds to a simple incisional hernia repair. The results in the literature are conflicting, with recurrence rates between 0 and 33%. A recent meta-analysis of nonrandomized studies favors this technique, however, as it is compared exclusively with the keyhole technique.37 A study conducted by us in 41 patients,6 who were treated laparoscopically by the Sugarbaker technique, yielded a recurrence rate of nearly 20%. All these patients had a lateral hernia, from which the recurrence ultimately arose. The Sugarbaker technique therefore is reserved for

Tip



It must be pointed out that in the case of an additional simultanuous incisional hernia, the entire original access must always be covered with a wide overlap. parastomal hernias where the fascial defect is located medially. This is often difficult to assess laparoscopically.

Sandwich Technique After the Sugarbaker technique proved unsuccessful in our experience for laterally located hernias, a combination of keyhole and Sugarbaker technique was introduced, known as the sandwich technique. The background to this is the need to stabilize the lateral abdominal wall by the keyhole cut in the first mesh. Medial stabilization and broad lateral overlapping6,7 are achieved by a second mesh as in the Sugarbaker method.

Operation Techniques As described for incisional hernia, the operation can be divided into individual steps.

Patient, Surgeon, and Video Tower Positioning Patients are placed supine on a vacuum mattress with both arms by their sides if possible. If necessary, especially in the case of very obese patients, the arm on the side of the stoma can be abducted. Antibiotic prophylaxis is given routinely. A transurethral bladder catheter should be placed to facilitate later dissection of the prevesical space. The video tower is on the side of the stoma, and the surgeon and cameraman stand on the opposite side. The scrub nurse can stand beside or opposite the surgeon. After skin disinfection and sterile draping, the stoma is covered with a round sponge that is fixed with an adhesive film. The mesh with keyhole incision is then marked and the second Sugarbaker mesh is also marked on the abdominal wall. In this way, the mesh size can be established at the start of the operation.

Access and Trocar Placement A minilaparotomy is performed in the anterior axillary line, usually subcostally, on the side opposite the stoma, and a trocar and the 30° optic are placed under vision. More trocars are introduced in the anterior axillary line at umbilical level and in the lower abdomen. A further subcostal trocar on the stoma side is usually helpful subsequently. In patients who have had a colectomy with access not extending to the xiphoid, the primary minilaparotomy can also be subxiphoid. Naturally, if there is an intact quadrant in the upper abdomen, the Veress needle puncture is also possible. However, it is possibly always safer to perform minilaparotomy.

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4.3  Laparoscopic Repair of Incisional Hernias Adhesiolysis As with all secondary ventral hernias, adhesiolysis represents the most difficult and hazardous step of the operation. Energy sources should not be used during adhesiolysis. as their use drastically increases the rate of secondary enterotomy. As shown in ▶Fig. 4.46, the opening of a parastomal hernia is often not very large; so, mobilization of adherent loops of bowel in the hernial sac can be very difficult. Manual pressure from the exterior can facilitate dissection and reduction of prolapsed loops of bowel. Mobilization of the stoma loop without endangering the bowel is possible only in isolated cases. Overall, dissection of the stoma loop and mesocolic or mesenteric segment is the most difficult operation step. Direct traction on bowel loops must always be avoided. After complete adhesiolysis of the anterior abdominal wall and identification of the stoma loop, the round ligament of the liver (▶Fig. 4.47) must usually and the falciform ligament sometimes be dissected. The fat pad between the medial folds, including the latter, is also divided just below

the umbilicus and dissected from the anterior abdominal wall to open the space of Retzius widely (▶Fig. 4.48). These steps are essential to adequately stabilize the midline, which is usually dehiscent also.

Mesh Placement and Fixation Depending on the size of the parastomal fascial defect, a keyhole incision is made in the mesh; this mesh usually measures 15 × 15 cm. The central opening is roughly 1 cm. The mesh is passed around the stoma loop so that both leaves of the mesh lie medially (▶Fig. 4.49). These are joined with two nonabsorbable transfascial sutures and spiral tacks (▶Fig. 4.50). It is essential to close it with nonabsorbable material. As mentioned before, this mesh is indispensable for stabilizing the lateral abdominal wall. In exceptional cases, it is further fixed in two rows, an outer one at the edge of the mesh and an inner one around the stoma. The distance between the tacks can be 3 or 4 cm so that the inner row consists finally of four fixing points.

Fig. 4.46  View into a parastomal hernia.

Fig. 4.47  Divided round ligament of the liver.

Fig. 4.48  Caudal view into the opened space of Retzius.

Fig. 4.49  Placement of the keyhole mesh.

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Fig. 4.50  Fixation of the keyhole mesh.

Another mesh is placed in the Sugarbaker technique to cover the midline and lateralize the stoma loop by at least 5 cm between the two meshes (▶Fig. 4.51). Secure fixation of this mesh requires adequate dissection of the round ligament of the liver and the space of Retzius. As in laparoscopic incisional hernia repair, corner sutures and sutures in the midline are placed in the nonincised mesh. The corner sutures pass through the fascia and can be tied. Final fixation can be obtained with absorbable tacks. Crucial requirements for success are, firstly, adequate stabilization of the lateral abdominal wall by the keyhole mesh and secondly, adequate lateralization of the stoma loop between the keyhole mesh and the Sugarbaker mesh by at least 5 cm. The availability of mesh structures that allow adequate integration even when superimposed is the crucial precondition for the sandwich technique. This therefore rules out ePTFE-based sheets. To our knowledge, coated meshes have not been investigated in this regard. Thus, the PVDF-based mesh, which is available in the market under the brand name Dyna-Mesh IPOM, is the only structure that can be used in the sandwich technique. The only internationally published results regarding this procedure are our own results, which showed a single recurrence in 47 patients. However, stenosis at fascial level occurred twice, which was due to the subcutaneous prolapse. Treatment consists of local revision of the stoma loop down to fascial level so that the subcutaneous prolapse can be eliminated by shortening the loop. Infections in the hernial sac region should always be treated with vacuum therapy.6,7

Postoperative Care As with laparoscopic incisional hernia repair, drains are useful or necessary only in exceptional cases. The most

Fig. 4.51  Placement of the Sugarbaker mesh with parietalization of the stoma loop.

striking problem is the sometimes severe early postoperative pain, which requires consistent analgesia, possibly including the use of an epidural catheter. Any paralytic ileus can be countered by immediate postoperative use of osmotically acting laxatives. Routine administration of such laxatives, with additional parenteral stimulation of bowel activity as necessary, has considerably hastened the postoperative recovery of our patients after both laparoscopic incisional hernia and parastomal repair. Seromas in the hernial sac require further treatment only rarely, as they usually resolve spontaneously within a few months. Infections that can occur after sac aspiration respond very readily to vacuum therapy.

Limits of the Laparoscopic Technique When the abdominal cavity is inaccessible, a laparoscopic procedure is naturally impossible. In individual cases, the stoma must be relocated because of the difficulty of management due to unfavorable positioning. In these cases, an open procedure with subfascial mesh augmentation of the midline and previous stoma exit site can be useful. At the same time, a prophylactic mesh should be used at the new stoma site. The midline and previous stoma site can be managed laparoscopically using the IPOM method. The prophylactic mesh can be placed intraperitoneally using a specifically designed three-dimensional structure (Dyna-Mesh IPST). Overall, preference should be given to prevention of parastomal hernia by placing the mesh in intraperitoneal or else subfascial position at the index operation as this measure can substantially reduce the frequency of parastomal hernia. The size of the hernia is not in itself a contraindication to the laparoscopic technique as the fascial opening can be very small relative to the size of the sac, which itself can be very extensive, so it can be repaired laparoscopically without difficulty.

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Summary Laparoscopic repair of parastomal hernias is possible in most cases. The sandwich technique is preferable; although it is very complex, it is highly promising in regard to the low recurrence rate. The complication rate is low in experienced hands. Nevertheless, this procedure is reserved for surgeons with laparoscopic experience and especially those with great expertise in laparoscopic repair of incisional hernias. As with incisional hernia, the laparoscopic technique does not relieve the surgeon of the need for accurate knowledge of the pathophysiology and general treatment options of parastomal hernia.

4.3.4  Open Repair of Parastomal Hernias Ulrich Andreas Dietz Parastomal hernia is neither a ventral nor an incisional hernia. It is a phenomenon that occurs at the margin of an artificial opening in the abdominal wall. The ideal stoma opening enables a section of bowel to emerge (usually with collapsed lumen) in a region with typically high pressure, at the same time preventing bowel prolapse and herniation of neighboring loops of bowel through the same opening. In recent years, there has been increasing evidence that prophylactic mesh implantation, when the stoma is created diminishes the rate of parastomal hernias.8,39,45 Every parastomal hernia is morphologically unique, as the location of a stoma is determined not only by the muscular anatomy; the surrounding skin and the proximity to the umbilicus, skin creases, belt line, and bone structures must also be considered and pose potential risks for a suboptimal stoma. Parastomal hernias are thus highly variable.27,65 Consistent implementation of the strategy developed for the treatment of incisional hernias with mesh implantation is also useful for parastomal hernias and markedly superior to stoma relocation (10 vs. 40% recurrences, respectively).42

Indications Indications are peristomal dermatitis, abdominal pain and parastomal symptoms, problems with stoma care, increase in the size of the parastomal hernia, impaired intestinal transit in the hernial sac, intestinal strangulation, or perforation in the sac. ▶ Relative indications. Advanced malignant disease with peritoneal carcinomatosis, large-volume ascites. ▶ Contraindications. A parastomal hernia with few symptoms that is well tolerated by the patient is not an operation indication per se as both the recurrence and

complication rates are high. Otherwise, there are none apart from general inoperability or lack of consent. ▶ Alternative procedures. Relocation of the stoma exit site (consider the high recurrence rate).

Operation Preparation ▶ Preoperative diagnostics. Colonoscopy and CT of the abdomen. ▶ Bowel preparation. Enema through the stoma the evening before the operation. Orthograde bowel preparation is not indicated.

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Special Risks, Informed Consent Concomitant peristomal contamination, a scarred operation field, and thinned fascia present a technical challenge. The aim is to achieve a balance between a narrow stoma opening and optimally ensuring intestinal transit. There is a lifelong risk of deterioration due to the permanent tendency of the bowel to slide and prolapse through the fascial opening even after the operation. •• Bowel injury (~ 5%). •• Wound infection (3%).4 •• Chronic pain due to transfascial sutures (5–10%). •• Fistula and arrosion by the mesh (3%). •• Recurrence (2–26%).4,81 •• Mortality (as with incisional hernias).

Anesthesia General anesthesia.

Positioning Supine position.

Operation Technique 1: Retromuscular Mesh Position See also Kasperk et al 2000.47 •• Time out. •• Perioperative antibiotic: 1.5 g cefuroxime and 0.5 g metronidazole, 30 minutes before skin incision. •• The stomal opening is covered with a sponge and transparent adhesive film.

Access A midline incision distant from the stoma that includes the original laparotomy scar is recommended. The proximal end of the incision can be extended transversely to facilitate subcutaneous dissection of the sac and prolapsed bowel (▶Fig. 4.52). Intra-abdominal adhesions are first divided through the laparotomy to expose the fascial opening.

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Subcutaneous Dissection Following subcutaneous dissection, the bowel is cautiously dissected free at this level, ensuring that neither the blood supply nor the bowel wall is damaged when the bowel is mobilized from the fascial opening. The entire margin of the fascial opening of the stoma is dissected (▶Fig. 4.53).

Reduction of the Sac and Opening of the Rectus Sheath If possible, the sac is returned to the abdomen without opening it (▶Fig. 4.54). The medial border of the posterior rectus fascia is incised vertically parallel to the linea alba to enable access to the posterior rectus sheath. As much as possible of the posterior layer of the rectus sheath should be preserved to provide a good suture site for reconstruction.

Dissection of the Posterior Rectus Sheath The rectus muscle is dissected laterally from the posterior rectus sheath, recalling that this is absent below the arcuate line (▶Fig. 4.55). The epigastric vessels should be preserved. The entire tube of bowel can now be mobilized completely and the extensive fascial layer exposed for mesh onlay. Depending on stoma position, the dissection may have to be continued into the lateral muscles to ensure the required minimum overlap of 5 cm.81 When mesh implantation is planned, further bowel resection should be omitted. Reduction of the bowel can usually be achieved by a combination of careful sharp and blunt dissection at the fascial margin.

Sutured Tightening of the Fascial Opening and Mesh Placement

Fig. 4.52  Parastomal hernia I: incision that excises the midline scar. The skin incision can be extended transversely if necessary.

When the diameter of the fascial opening is over 6 cm, it is useful to tighten the hernial opening medially with 0 PDS suture so the bowel can just pass through (guideline: 2 finger breadths). A 12 × 12 cm elastic, lightweight and large-pored polypropylene mesh with rounded corners is then prepared with a 2-cm circle excised in the center (▶Fig. 4.56). The mesh is placed around the bowel like a collar and rotated so that the slit lies medially.

Fig. 4.53  Parastomal hernia II: subcutaneous dissection of the bowel and hernial orifice.

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Mesh Fixation and Retromuscular Vacuum Drain The slit in the mesh is closed with nonabsorbable 3/0 sutures. The closed mesh is fixed to the posterior rectus sheath or peritoneum with absorbable interrupted sutures, the operation site is irrigated thoroughly, and a vacuum drain is inserted (▶Fig. 4.57). If a midline incisional hernia is present, this is also managed with the mesh (section ▶4.2.1).81

Continuous Suture of the Linea Alba When mesh reinforcement is complete, the stoma exit site is tightened with PDS sutures and the corresponding rectus sheath is closed with a continuous PDS suture, including the contralateral linea alba. The anterior rectus sheath is also narrowed at the stoma exit site with 0 PDS sutures (▶Fig. 4.58). The subcutaneous tissue is irrigated and a subcutaneous vacuum drain is inserted. The operation ends with skin suture, digital palpation of the stoma and attachment of a stoma bag.

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Fig. 4.54  Parastomal hernia III: reduction of the sac. Scissors: opening of the rectus sheath and exposure of the peritoneum and posterior layer of the rectus sheath.

Fig. 4.55  Parastomal hernia IV: dissection of the retromuscular space, carefully preserving the epigastric vessels, to create a sufficient mesh layer.

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Incisional Hernias Fig. 4.56  Parastomal hernia V: the diameter of the hernial opening is narrowed to 2 to 3 cm by 2 to 4 medial interrupted sutures (0). A 12 × 12 cm mesh is then prepared with rounded corners and excision of a 2-cm circle from the center. It is opened by a lateral incision and placed around the bowel.

Fig. 4.57  Parastomal hernia VI: mesh fixation to the rectus sheath and suture with interrupted sutures. Retromuscular vacuum drain.

Fig. 4.58  Parastomal hernia VII: continuous suture of the linea alba and muscle.

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Mesh Position in Anteriorposterior Projection The principle of this repair is that the mesh surrounds the stoma opening by 5 to 6 cm in all directions (▶Fig. 4.59). The fascial sutures and mesh fixation sutures are intended to prevent mesh dislocation within the first two weeks; after this, stability is ensured by firm connective tissue integration in the scar.

Relevant Anatomy, Dangers, and Tricks •• If extension of the retromuscular layer lateral to the rectus sheath into the lateral compartment of the abdominal wall is necessary for mesh implantation, this can be achieved by a vertical incision at the lateral border of the rectus sheath. •• Since the neurovascular structures run mainly between the internal oblique and transversus muscles, the lateral mesh position should be one layer above this, between the internal oblique and external oblique.81 •• Simultaneous stoma correction should be omitted when mesh is inserted. If absolutely necessary, however, this can be done after completion of the

procedure (after step 7 above). This minimizes the risk of mesh contamination.

Management of Special Complications •• Injury of the epigastric artery: transfixation ligature. •• Transmural bowel injury: bowel suture and copious irrigation. •• Postoperative hematoma: surgical evacuation. •• Mesh infection: antibiotic therapy, interventional drain insertion, or mesh explantation.28 •• Bowel arrosion by the mesh: partial mesh explantation and bowel repair, if necessary with relocation of the stoma.

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The Sugarbaker Intraperitoneal Mesh Operation Technique See also Sugarbaker 1985.96 The Sugarbaker technique comprises intra-abdominal relocation of the bowel, extending it along the lateral abdominal wall. This reduces any prolapse that may be present. Narrowing of the fascial opening is optional. The intraperitoneal mesh forms a tunnel that holds the bowel extended against the abdominal wall and overlaps the fascial opening with an adequate circumferential safety margin.92,96 ▶ Contraindication. Double-barrel stomas. ▶ Special instruments. Stitching and grasping forceps for transfascial suture (from laparoscopy). ▶ Perioperative antibiotics. Perioperative antibiotics include 1.5 g cefuroxime and 0.5 g metronidazole, 30 minutes before skin incision. ▶ The stoma opening is covered with a sponge and transparent adhesive film.

Mesh Type Specially manufactured mesh for this indications are made of polyester with protective collagen film, where a strip double coated with collagen allows contact with the bowel. Mesh for general intraperitoneal use includes PVDF or ePTFE.

Caution

Fig. 4.59  Parastomal hernia VIII: mesh position in anteriorposterior projection.

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Only meshes approved for this indication and for intraperitoneal use may be used. This should be clarified beforehand with the manufacturer. At present, there are still no convincing data regarding the use of biological mesh for parastomal hernias83 (see section ▶1.5).

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Access Midline laparotomy is performed, with adhesiolysis around the sac and the last 20 cm of the bowel conduit. The hernial sac is resected subcutaneously. Evaluation of the stoma opening: the stoma opening should ensure unimpeded passage of the bowel and must be assessed individually. Medial narrowing of the fascial opening is recommended when the diameter is greater than 6 cm; this is achieved with transfascial interrupted or figure-of-eight suture using 0 PDS. The line of the planned tunnel and the transfascial fixation points are marked on the skin with a sterile pen. This defines the desired mesh position precisely. The mesh is either circular (15 or 20 cm in diameter) or cut to this shape. Ensure that the mesh is placed with the correct side.

Preparation of the Mesh Tunnel Six PDS 2/0 sutures are placed in the mesh in the region of the planned tunnel, leaving both suture ends about 20-cm long (▶Fig. 4.60). It should be noted that the medial sutures (c and c') are positioned in the plane of the mesh equator (broken line) and thus correspond to the actual diameter of the fascial opening.

If renal function is normal, the mesh is wetted with 80 mg refobacin (bactericidal) immediately before implantation. The six double sutures in the mesh are passed outward through all layers of the abdominal wall with the stitching and grasping forceps (arrow) and held temporarily with the Péan clamps.

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Tip

Bring out each suture end separately, as the knot will not hold otherwise. The sutures are passed through the fascia in the order a – b – c. When bringing out the “a” sutures, ensure that the tunnel for bowel exit is tension-free. Any necessary corrections can be made by passing the sutures through the fascia again before tying them.

Transfascial Mesh Fixation The mesh is drawn to the abdominal wall by the six double transfixation sutures, ensuring that mesh encloses the bowel conduit like a tunnel (▶Fig. 4.61). The transfascial sutures can now be tied. The mesh is then fixed from within the abdomen with Vicryl 2/0 sutures. These must pick up the internal abdominal fascia (endoabdominal fascia) also. Fig. 4.60  Mesh tunnel preparation (a–a', b–b', and c–c': transfascial sutures placed in the mesh beforehand. d, projection of the fascial opening; broken line, mesh equator.

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4.3  Laparoscopic Repair of Incisional Hernias Fig. 4.61  Transfascial mesh fixation with supplementary Vicryl 2/0 sutures.

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The abdomen is irrigated with saline. The abdominal wall is closed in the midline with a continuous PDS looped suture and the skin is closed over a subcutaneous vacuum drain. A sterile dressing is applied. The transparent film and sponge are removed, the lumen and tunnel are palpated digitally, and a stoma bag is attached.

Mesh Position in Anteriorposterior Projection Mesh projection after the Sugarbaker repair (▶Fig. 4.62): direction of the tunnel for bowel accommodation (arrow). The planned points for the transfixation sutures are indicated. Depending on the findings, mesh augmentation across the midline to the contralateral side may be necessary. If there is a midline incisional hernia, this is repaired with an additional mesh at the same session.

Relevant Anatomy, Dangers, and Tricks •• When planning the transfascial sutures, always note the course of the inferior epigastric artery and the structures of the inguinal canal. •• The transfascial sutures should be tied sensitively, as correction of a tear at the knot at this stage of the operation is more complex. •• Before cutting the subcutaneous suture knots, they can be detached from the subcutaneous tissue by traction on the skin and subcutaneous tissue to prevent skin retraction.

Management of Special Complications •• Injury of the inferior epigastric artery: transfixation with the stitching and grasping forceps using 2/0 suture.

Fig. 4.62  Mesh projection after the Sugarbaker repair (arrow refers to the tunnel for bowel accommodation).

•• Transmural bowel injury: bowel suture and thorough irrigation of the operation site. •• Chronic pain in the area of the transfascial sutures: symptomatic or with local infiltration (scandicaine and topical salicylic acid + triamcinolone); this is usually self-limiting as the suture material is absorbable.

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Incisional Hernias •• Mesh infection: antibiotic therapy, interventional drain insertion, or mesh explantation.28 •• Bowel arrosion by the mesh: partial mesh explantation and bowel repair, if necessary with relocation of the stoma.

Postoperative Care ▶ Medical care. The vacuum drains are removed when the drain volume is less than 10 mL/d. Stoma therapist support until normal stoma function returns. The patient should be provided with an information leaflet on gradual resumption of physical efforts. ▶ Diet. This depends on the extent of adhesiolysis and postoperative resumption of bowel activity. Liquid diet is usually well tolerated on the first postoperative day. ▶ Bowels. If resumption of stoma function is sluggish, an enema should be given through the stoma from postoperative day 3. ▶ Mobilization. Possible immediately on arrival in the ward with nursing support. ▶ Physical therapy. None required.

for the escape of intra-abdominal organs into the hernia. Based on the law of Laplace, the hernia increases in size very slowly initially but then increases rapidly over a certain size. Simultaneously with the increase in hernia size, there is relaxation of the diaphragm and retraction of the abdominal muscles (▶ Fig. 4.63a). The reduced diaphragm tone is responsible for the deterioration in respiratory function seen with very large hernias. Forceful reduction with direct fascial closure in these cases often leads to respiratory insufficiency due to lung compression and subsequent pneumonia. As the intra-abdominal pressure is greatly increased postoperatively, suture dehiscence and postoperative cardiovascular failure due to venous obstruction may also occur. The principle of preoperative progressive pneumoperitoneum consists of slow stretching of the abdominal wall and diaphragm by intermittent air insufflation. Gradual toning of the diaphragm leads to optimization of respiratory function and enables the hernia contents to be reduced with low-tension fascial repair (▶ Fig. 4.63b). Unmasking of other weak sites in the abdominal wall and reduction of mesenteric edema in the hernia are further benefits of progressive pneumoperitoneum.

▶ Incapacity for work. Two to three weeks.

Indications

4.3.5  Preoperative Progressive Pneumoperitoneum Stefan Willis

Very large inguinal and incisional hernias with loss of domain are the only indications for preoperative progressive pneumoperitoneum. The size of the fascial defect, on the other hand, plays a secondary role. This procedure can be considered in patients in whom complete reduction of the hernia contents appears doubtful.

Physiological Basis

Contraindications

When a hernia forms, a positive pressure gradient from the abdomen to the hernial sac develops, which is responsible

Incarcerated hernias or decompensated cardiopulmonary failure are absolute contraindications. Fig. 4.63  Principle of abdominal wall expansion by progressive pneumoperitoneum for incisional hernia. a  Diaphragmatic flattening and abdominal muscle retraction with enlarging incisional hernia. b  Stretching of the diaphragm and abdominal muscles by pneumoperitoneum.

a

b

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4.3  Laparoscopic Repair of Incisional Hernias The presence of compensated respiratory or cardiac failure is not a contraindication as the patient’s individual tolerance threshold can be determined by the pneumoperitoneum in a controlled fashion and patients can slowly become accustomed to the postoperative state. In our opinion, extensive intra-abdominal adhesions are a relative contraindication, although it is postulated that the pneumoperitoneum causes lysis of adhesions.

Technique In Moreno’s original description in 1947, intermittent puncture of the abdominal wall was recommended, and this is still performed today by a few authors. To reduce the risk of injury of intra-abdominal organs, we recommend use of a commercially available suprapubic bladder catheter (Cystofix) as a permanent air inlet. The fasting patient first has sterile puncture of the abdomen under local anesthesia in the operating room using an 18-French Veress needle. If adhesions are present, e.g., after midline laparotomy, puncture is performed at a different site, ideally where the catheter will later be inserted. An ultrasound scan of the abdominal wall helps finding a site free of adhesions and blood vessels. The pneumoperitoneum is then obtained by insufflating air using a laparoscopy unit. In this way, the intra-abdominal pressure and insufflated volume can be measured exactly. The insufflation should be stopped when a pressure of 15 mm Hg is reached, when the patient has a circulatory reaction, or if pain occurs. The initial volume is usually 1,000 to 4,000 mL. The catheter is then inserted under local anesthesia in an adhesion-free site in the upper abdomen, usually in the left anterior axillary line 5 cm below the costal margin  (▶Fig. 4.64). In this way, the risk of injuring an intra-abdominal organ is minimal. Gas escaping under pressure shows

that the catheter is in correct position, and if there is any uncertainty, an X-ray can be taken after injection of water-soluble contrast. To prevent air embolism, it is essential to ensure that there is no blood in the catheter. Depending on the patient’s tolerance, room air is insufflated through a bacterial filter once or twice daily. Carbon dioxide (CO2) should not be used because of potential hypercapnia. In addition, air is absorbed more slowly than pure CO2 or oxygen (O2). The insufflated volume varies between 500 and 3,000 mL. The following parameters are monitored during and after insufflation: •• Blood pressure. •• Pulse rate. •• Capillary O2 saturation.

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The insufflation is stopped if a circulatory reaction or discomfort occurs. To avoid exceeding a critical intra-abdominal pressure, it is monitored through a CVP system (▶Fig. 4.65). The intra-abdominal pressure should not exceed 20 cm H2O when the patient is supine, as otherwise renal perfusion is impaired, with a consequent drop in creatinine clearance or a decrease in blood flow in the vena cava with an increased risk of thrombosis. The rise of the intraabdominal pressure leads initially to a stretching of the hernial sac and overlying skin. After a certain critical tension is reached, however, only the abdominal wall and diaphragm stretch, without a further increase of the size of the hernia. If symptoms persist or cardiopulmonary complications arise, controlled air release through the catheter is possible at any time. The right-sided shoulder pains that usually occur first are due to tension on the suspensory ligaments of the liver and normally improve when the patient is in supine position.

Fig. 4.64  Creating the pneumoperitoneum through a Cystofix catheter. a  Puncture site. b  Catheter placement.

a

b

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Fig. 4.65  Pressure-controlled creation of the pneumoperitoneum.

Tip

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Nausea and vomiting occur occasionally because of stomach compression. It is therefore advisable for the patient to remain fasting during and directly after the air insufflation and to have central venous access. Moreover, medical thrombosis prophylaxis and laxatives are essential. For this reason, pneumoperitoneum is not an ambulant procedure.

The pneumoperitoneum is maintained for between 7 and 60 days, depending on the author. Normally, about 10 insufflations over 2 to 3 weeks with a total volume of

5,000–15,000 mL is sufficient. Simultaneous measurements of intra-abdominal pressure and abdominal girth on our patients showed that there was no further significant increase in girth after just one week. For this reason, we tended increasingly to carry out daily air insufflations for 7 to 10 days. The usual hernia operation techniques are used. Reduction of the hernia contents is generally unproblematic and is followed by the Lichtenstein repair of inguinal hernias and sublay mesh augmentation of incisional hernias. Nitrous oxide anesthesia after pneumoperitoneum is strictly contraindicated as rapid diffusion of the nitrous oxide into the abdomen takes place, with a consequent rise in intra-abdominal pressure and respiratory failure.

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Complications There are no definite figures regarding the general incidence of complications. In our hospital, abdominal wall infection resulting in cessation of the pneumoperitoneum occurred in nine patients. Minor hematomas and subcutaneous emphysema occurred repeatedly and did not require any specific treatment. Despite the pneumoperitoneum, one of our patients with known asthma developed fulminant pneumonia postoperatively. To date, there have been no reports of air embolism and only one case of peritonitis as a result of bowel injury has been described. Isolated cases of generalized emphysema with mediastinal and pericardial involvement, abdominal wall hematoma requiring revision, or mesenteric injury have also been described. In a series of 487 patients, Moreno reported 11 wound infections, nine pneumonias, four cases of thrombosis with consequent pulmonary embolism, and three myocardial infarctions. Six of his patients died (one of peritonitis, two of pulmonary embolism, three of myocardial infarction), corresponding to a mortality rate of 1.4%.61 In a recent publication, SFigagh et al report 10 tension-free repairs in 17 patients; the colon had to be resected in three patients to create space, and hernia repair was unsuccessful in four patients despite pneumoperitoneum. One patient died postoperatively of ventilatory failure, and seven patients had significant complications (morbidity 41%, mortality 6%).86 In a preliminary publication, the same author even reported mortality of 11%.85

Results Reports in the literature of successful hernia repair following progressive pneumoperitoneum are usually only case descriptions. Because these patients are rare even in large centers, controlled studies of the long-term results are lacking. Moreover, randomization of these patients is not possible because of the different hernia locations, size, and additional comorbidities. Despite these systematic difficulties, Hamer in 197236 compared the results after 2 years in 10 patients who had preoperative pneumoperitoneum with those of 20 patients who had primary repair of very large incisional hernias. While three recurrences occurred after direct closure, these were absent after progressive pneumoperitoneum. At the Aachen University Hospital, eight patients had surgery after preoperative pneumoperitoneum, three with giant scrotal hernias (the Shouldice repair) and five incisional hernias (two edge-to-edge, three sublay mesh), without any recurrence to date.106 Without stating the follow-up period, Koontz in 1958 reported recurrence in eight patients. Raynor et al reported three recurrences in seven patients within 36 months, which were repaired by direct suture without problem.79 Caldironi describes two recurrences in 40 patients in an average follow-up period of 25 months.13 Moreno himself reported 14 recurrences in a total of 487

patients but without information regarding the hernia type and follow-up period.61

Conclusion Progressive pneumoperitoneum should be considered only for patients in whom reduction of the hernia contents using conventional methods does not appear possible. Because of the considerable risk of complications, it should be performed only if strictly indicated.

4.3.6  Giant Incisional Hernia

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Joachim Conze and Volker Schumpelick “Every large hernia was once a small hernia.” There is no clear definition of the descriptive term “giant,” as applied by the surgeon. These hernias can have quite varied forms and characteristics. Incisional hernias with a transverse fascial defect over 10 to 15 cm may be called giant, but the term also refers to potential visceral eventration, which is described as “loss of domain.” It is the volume of exenterated abdominal contents that makes the operation challenging, as this “domain” must be regained. The size of the hernia is not always critical, but rather the extent of the fascial defect.

Diagnosis The diagnosis is usually obvious. Intestinal peristalsis is often visible below the thin and frequently compromised skin scar. Clinical examination allows palpation of the fascial margins. The size of the defect and, in particular, the morphology of the remainder of the abdominal wall can be determined accurately by ultrasonography. Depending on the width of the fascial defect and the bulging of the hernia, preoperative CT/MRI may be indicated, especially in the case of very obese patients. Preoperative pulmonary function tests are useful in the case of a very large defect and/or respiratory impairment.

Indications ▶ Absolute indications. Maceration of the overlying skin with exposure of bowel loops and imminent or actual intestinal fistula, disturbed gastrointestinal transit, incarceration, or intestinal strangulation. ▶Relative indications. Persistent symptoms, sustained incapacity for work, social deprivation, increase in size. To achieve adequate fascial strength, at least six months should have passed since the last operation. ▶ Contraindications. Peritoneal carcinomatosis, general inoperability, respiratory impairment in particular, and absence of consent.

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Preoperative Preparation and Informed Consent Infection-free skin is desirable for elective procedures. Pressure ulcers should first be treated conservatively. An enema is given the evening before the operation. Orthograde bowel preparation is not indicated. The patient must be informed carefully about the possible need to extend the operation and about the risks and complications:22 •• Extension: ○○ Component separation. ○○ Partial bowel resection. •• Risks and complications: ○○ Wound seroma. ○○ Wound infection. ○○ Necrosis of the wound edges. ○○ Foreign body sensation. ○○ Bowel injury. ○○ Chronic pain. ○○ Recurrence.

Anesthesia General anesthesia and epidural catheter, if possible.

Position Depending on the location, the position is slightly hyperextended during dissection and neutral position during the repair.

Operation Tactics The objectives of operative repair of giant incisional hernias are: •• Sufficient and long-term repair of the fascial defect, taking into account the physiological tension of the

abdominal wall and avoiding an abdominal compartment syndrome. •• Final covering of the repair with vital soft tissue. Management of giant hernias has hitherto been mainly by open surgery. Since the previous operations were usually complex, dense adhesions can be anticipated and excision of the compromised skin is often necessary. Numerous operation procedures are available to the surgeon as with repair of classic incisional hernias. The following are the main types of repairs.

Mesh Augmentation or Mesh Bridging The choice of repair method is determined by the degree of lateralization of the abdominal wall muscles and how well the fascial edges can be brought closer or approximated without postoperative burst abdomen or an abdominal compartment syndrome. Augmentation of the abdominal wall can often be achieved by anterior or posterior abdominal wall component separation techniques (e.g., the Ramirez technique. Besides adequate mesh overlapping, the greatest possible fascial cover of the mesh graft is desirable as the best way to prevent infection. Because the epifascial soft tissues are often thin, adequate mobilization and resection should be ensured. Collaboration with a plastic surgeon may be useful.

Extra- or Intraperitoneal Mesh Position Regardless of whether augmentation or bridging is planned, a precondition for extraperitoneal mesh placement is dissection or preservation of enough of the posterior wall of the rectus sheath and of the peritoneum/hernial sac to act as a natural protective barrier between the mesh and the abdominal content. This is crucial when choosing the mesh position either extraperitoneal as sublay on the posterior layer of the rectus sheath (retromuscular; ▶Fig. 4.66a) or intraperitoneal open placement (IPOM; ▶Fig. 4.66b).

Fig. 4.66  a and b. a  Retromuscular extraperitoneal mesh augmentation. b  Intraperitoneal mesh augmentation (open IPOM).

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Perioperative Management •• Time out. •• Perioperative antibiotics, e.g., 1.5 g cefuroxime and 0.5 g metronidazole if appropriate, 30 minutes before skin incision. •• Marking of the old scar, if appropriate.

5. The mesh is fixed with transfascial interrupted sutures at intervals of 3 to 4 cm ensuring that there is adequate mesh overlap of at least 5 cm. 6. The medial fascial border is sutured continuously to the mesh. 7. Drain, subcutaneous suture, reattachment of the umbilicus if necessary, skin closure.

Repair Techniques

The following are the individual operation steps.

With giant hernias, it is often not possible to see preoperatively or at the start of the operation which operation technique is suitable or feasible. If it is possible to achieve fascial approximation by the use of component separation, the repair can be continued as an open extraperitoneal retromuscular or intraperitoneal mesh augmentation (see section ▶4.2.3). Techniques for repair of abdominal wall defects where fascial approximation (augmentation) is not possible, i.e., where the defect must be bridged, are described next.

Excision of the Complete Skin Scar, Dissection of the Hernial Sac, and Exposure of the Fascial Defect

Bridging Technique

Opening of the Hernial Sac, Local Adhesiolysis, and Exploration of the Abdominal Cavity

Extraperitoneal, Retromuscular Mesh Bridging with/without Component Separation Dissection 1. The complete skin scar is excised and the fascial defect is exposed, preserving the hernial sac. 2. Local adhesions are divided and the abdomen is explored. 3. The anterior fascia is dissected.

Repair 1. The rectus sheath is incised. 2. The retromuscular mesh site is dissected. The posterior layer of the rectus sheath is incised both sides of the linea alba, exposing the fatty triangle. 3. The abdominal cavity/posterior wall (peritoneum/ sac) is closed with a continuous suture. 4. The mesh site is measured and the graft is placed.

Fig. 4.67  Dissection with preservation of the subcutaneous perforating vessels.

The entire length of the existing and usually broad skin scar is excised. The sac is dissected gradually from the subcutaneous tissue as far as the edge of the fascial defect. This is exposed circumferentially and the sac is opened. This enables better vision, prevents other fascial defects from being missed, and avoids iatrogenic bowel injury during dissection of the mesh site. The entire fascial scar is then incised under vision.

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The sac is incised and the abdomen is opened, preserving the sac. This can be resected later, after secure closure of the suture line. This ensures that enough of the patient’s own tissue is present for later closure of the posterior wall. This is followed by local division of adhesions to the anterior abdominal wall. Interenteric adhesions should be divided only if there are corresponding clinical symptoms. Finally, the abdominal content is covered with a moist towel.

Dissection of the Anterior Fascia The extent of epifascial dissection depends on whether extension of the operation by anterior component separation is planned. If this is omitted, dissection for approximately 5 to 6 cm is useful; so, the transfascial sutures can be placed under good vision. Perforating vessels must be preserved (▶Fig. 4.67 and ▶Fig. 4.68).

Fig. 4.68  Dissection with preservation of the subcutaneous perforating vessels in the Ramirez component separation.

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Incisional Hernias Alternatively, the fixation sutures can also be brought out through the skin and buried subcutaneously.

Incision and Dissection of the Posterior Rectus Sheath The rectus sheath is incised and entered from the medial side. The hernial sac remains posterior and should be preserved if possible. This enables a natural barrier to be placed between the abdominal content and the mesh.

Dissection of the Retromuscular Mesh Site Dissection on the posterior layer of the rectus sheath continues on both sides as far as the lateral border. The vessels running there must be preserved. To achieve adequate overlapping at the midline, the posterior layer of the rectus sheath is incised both sides of the linea alba with exposure of the fatty triangle. When the fascial defect extends as far as the xiphoid, the mesh site can be extended by preparation of the retroxiphoid space. A sufficiently large mesh site can be dissected after detaching the posterior layer of the rectus sheath from the xiphoid. When the defect extends to the symphysis, dissection extends behind the symphysis into the space of Retzius (see section ▶4.2.1; open retromuscular mesh augmentation).

Continuous Closure of the Abdominal Cavity/Suture of the Posterior Wall (Peritoneum) (▶Fig. 4.69) Continuous suture of the peritoneum/sac creates a natural barrier to the abdominal viscera, ensuring that the mesh is in extraperitoneal position. An absorbable suture can be used (e.g., 2/0 PDS). Protruding peritoneum/sac can then be resected.

Measurement of the Mesh Site and Mesh Placement The extraperitoneal mesh site is measured, carefully ensuring that the fascial margin will overlap the mesh by at least 5 cm in all directions. The aim is to obtain a broad contact area between mesh and tissue. Simple, flat mesh grafts can be used due to the extraperitoneal mesh position.

Mesh Fixation with Transfascial Interrupted Sutures With bridging techniques, there is no thrust bearing for the mesh due to the lack of fascial closure, so careful mesh fixation is necessary until adequate fibrocollagenous ingrowth of the mesh has taken place. This is achieved by transfascial interrupted sutures, which are placed at intervals of 3 to 4 cm. The sutures are placed in U shape through the abdominal wall muscle and fascia and tied later on the fascia (▶Fig. 4.70). Depending on the extent of epifascial

Fig. 4.69  Continuous suture of the posterior rectus sheath, possibly using parts of the hernial sac.

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4.3  Laparoscopic Repair of Incisional Hernias dissection, the sutures can be tied either directly on the fascia or transcutaneously through small skin incisions. By ensuring a sufficiently wide mesh-tissue contact area, rapid ingrowth is achieved so a slowly absorbable suture material (e.g., PDS 2/0) suffices.

mesh surface. Careful soft tissue cover is obtained by approximating subcutaneous sutures (e.g., Vicryl 3/0). The skin is closed with interrupted sutures or staples, as this enables partial wound opening if healing is disturbed.

Circumferential Suture of the Fascial Margin to the Mesh

Intraperitoneal Bridging with/without Component Separation

To prevent further retraction and lateralization of the fascial margin, this is fixed to the mesh by a continuous suture (e.g., Prolene 2/0). The needle must pass strictly tangentially to avoid possible bowel injury. This “quilting stitch” enlarges the contact area between mesh and fascia while diminishing the exposed area of mesh (▶Fig. 4.71).

Drainage, Subcutaneous Sutures, Reattachment of the Umbilicus If Necessary, Skin Closure Because of the extensive dissection, subcutaneous vacuum drains should be placed in the epifascial region. If an umbilicus is still present, it can be reattached in an appropriate position, if necessary, on the exposed

See section ▶4.2.3.

Dissection 1. Excision of the complete skin scar and exposure of the fascial defect, preserving the hernial sac. 2. Local adhesiolysis and exploration of the abdominal cavity. 3. Epifascial dissection of the anterior fascia. 4. Dissection of the intra-abdominal mesh site: ○○

○○

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Division of the round ligament of the liver/ falciform ligament if necessary. Retropubic extension into the space of Retzius if necessary.

Fig. 4.70  Extraperitoneal mesh fixation with transfascial interrupted sutures.

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Incisional Hernias Fig. 4.71  Narrowing of the exposed area of mesh by continuous suture of the medial fascial margin to the mesh.

Repair

Measurement of the Mesh Site and Mesh Placement

1. The mesh site is measured and the graft is placed. 2. The mesh is fixed with transfascial interrupted sutures at intervals of 3 to 4 cm ensuring an adequate mesh overlap of at least 5 cm. 3. The medial fascial border is sutured continuously to the mesh. 4. Drain, subcutaneous suture, reattachment of the umbilicus if necessary, skin closure.

After meticulous hemostasis, the fascia defect and the mesh site are measured. The intraperitoneal mesh site is cut to size, carefully ensuring adequate mesh overlapping at the fascial margin of at least 5 cm in all directions. The aim is to obtain a broad contact area between the mesh and tissue. When the mesh is intraperitoneal, a coated mesh or mesh that is antiadhesive on one side should be used to prevent adhesions between the intestines and foreign material.

Steps 1–3: excision of the complete skin scar, entering the abdominal cavity, local adhesiolysis, epifascial dissection, and creation of an adequate intraperitoneal mesh site: see before.

Creation of an Adequate Mesh Site, with Detachment of the Round Ligament/Falciform Ligament Cranially or Retropubic Dissection into the Space of Retzius Caudally as Necessary When the mesh is in intraperitoneal position, it is placed directly on the parietal peritoneum avoiding creases. Detachment of the round ligament of the liver and falciform ligament cranially may be necessary. If the caudal part of the fascial defect extends to the symphysis, the mesh would lie directly on the posterior wall of the bladder. In this case, as in retromuscular mesh repair, the retrosymphyseal space of Retzius must be dissected to obtain a sufficiently wide mesh site.

Mesh Fixation with Transfascial Interrupted Sutures The mesh is fixed with transfascial interrupted sutures at intervals of 3 to 4 cm, ensuring adequate mesh overlapping of at least 5 cm (▶Fig. 4.94). Steps 7 and 8 are then performed: •• The medial fascial margin is fixed to the mesh by a continuous suture. •• Drainage, subcutaneous sutures, reattachment of the umbilicus, if necessary, skin closure.

Relevant Anatomy, Dangers, and Tricks of the Open Bridging Techniques •• Iatrogenic enterotomy due to the usually thin soft tissue cover over the fascial defect must be avoided. Division of adhesions between bowel loops is indicated only if there is a history of disturbed gastrointestinal transit.

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4.3  Laparoscopic Repair of Incisional Hernias •• The transfascial sutures are placed blindly through the abdominal wall; so, there is always a danger of vascular injury with bleeding into the soft tissues. Careful control of bleeding must be ensured. The medial fascial quilting stitch also has a potential for iatrogenic enterotomy and should be passed strictly tangentially. •• The risk of infection is higher due to the direct contact between the exposed mesh surface and the often thin subcutaneous tissue. For this reason, adequate soft tissue cover should be attempted. Depending on the extent of epifascial dissection, there is then an increased risk of wound margin necrosis also. Blood vessels should always be preserved during dissection. •• The greatest postoperative risk in incisional hernia surgery arises from the possible effects on the respiratory system. If the abdominal wall tension is “overcorrected,” the surgeon creates an abdominal compartment syndrome (ACS) with corresponding effects on respiration and renal perfusion.

Management of Special Complications •• Injury of the inferior epigastric artery: transfixation ligature. •• Transmural bowel injury: bowel suture and copious irrigation. •• Postoperative hematoma: surgical evacuation if necessary. •• Mesh infection: antibiotic therapy, interventional drain insertion or VAC therapy, mesh explantation, if necessary. •• Bowel arrosion by the mesh: complete or partial mesh explantation and bowel repair. •• Wound margin necrosis with/without wound dehiscence should be resected until vital tissue is reached, with VAC conditioning and later secondary suture as necessary. •• Respiratory insufficiency with abdominal compartment syndrome: bladder pressure measurement, operative revision and temporary laparostomy if necessary.

Postoperative Care ▶ Medical care. The vacuum drains are removed when the drain volume is less than 20 mL/d. The patient should

be provided with an information leaflet on gradual resumption of physical effort. ▶ Diet. This depends on the extent of adhesiolysis and postoperative resumption of bowel activity. Liquid diet is usually well tolerated on the first postoperative day. ▶ Bowels. If resumption is sluggish, a laxative should be given, e.g., an enema from postoperative day 3. ▶ Mobilization. Mobilization is possible immediately on arrival in the ward with nursing support. ▶ Physical therapy. Respiratory therapy in particular, depending on the extent of the repair and pre-existing comorbidity.

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▶ Incapacity for work. Two to three weeks.

4.3.7  Posterior Component Separation According to Rosen Wolfgang Reinpold Operative management of giant ventral hernias is problematic. Hybrid procedures with different forms of muscle separation are becoming increasingly important. Anterior open component separation according to Oscar Ramirez40,77 is today a standard method of managing very large ventral and incisional hernias. A disadvantage is the high rate of delayed wound healing and infection, which is attributable to the extensive detachment of skin and subcutaneous tissue with division of perforating blood vessels. Besides endoscopic component separation, described in section ▶4.3.9, the Rosen posterior component separation68 is another option for myofascial mobilization to close very large eventrations. Posterior component separation, also called transversus abdominis release (TAR), allows retromuscular or preperitoneal placement of giant standard synthetic meshes into the entire abdominal wall. We have performed posterior component separation (see section ▶4.3.8) in 53 very large ventral and incisional hernias. Myofascial mobilization of the abdominal wall by 3 to 6 cm (▶Fig. 4.72) on every side Fig. 4.72  Mobilization of the abdominal wall by 3 to 6 cm on every side.

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Incisional Hernias is similar to the release obtained with endoscopic component separation. It is only about half as effective, however, as in open Ramirez component separation, in which mobilization of 5 to 15 cm can be achieved on both sides. According to the recent literature40,68,84 and our experience, wound infections and delayed wound healing occur significantly less often than after open component separation.

Special Risks, Informed Consent •• Bowel/bladder injury (< 1%). •• Nerve injury with rectus muscle paresis (< 1%). •• Bleeding (< 5%). •• Hernia recurrence (5–25%). •• Bulging of the lateral abdominal wall (< 5%). •• Infection (0–30%). •• Chronic pain (0–15%).

Anesthesia

Indications ▶ Indications. •• Large and very large ventral and lateral abdominal wall and incisional hernias (EHS classification W3, hernia defect transverse diameter > 10 cm). •• ventral and lateral abdominal wall and incisional hernias with a transverse diameter under 10 cm (EHS classification W2; hernia defect transverse diameter < 10 cm and > 4 cm), where the defect cannot be closed without tension. ▶ Relative contraindication. Scarring-induced destruction of the rectus compartment. ▶ Contraindications. Absolute general inoperability or absence of consent. ▶ Alternative procedures. Open component separation  (higher rate of delayed wound healing): •• Endoscopic component separation. •• Open and laparoscopic procedures with bridging of the hernia defect (disadvantage: no dynamic reconstruction of the abdominal wall).

General anesthesia; an epidural catheter can usually be omitted.

Position Supine.

Access The access depends on the hernia location and course of the scar. A midline vertical incision is most suitable.

Operation Steps In posterior component separation, retromuscular dissection in the rectus compartment is performed first, as in the Rives operation, mobilizing the rectus muscle completely from the posterior layer of the rectus sheath as far as the lateral border of the rectus compartment (▶Fig. 4.73). Posterior component separation begins with a vertical incision of the posterior layer of the rectus sheath, which

Diagnosis and Operation Preparation •• Ultrasonography, with CT or MRI for very large hernias (“loss of domain”). •• Basic cardiopulmonary diagnostics in patients with risk. •• Consider preoperative progressive pneumoperitoneum for loss of domain. •• A transurethral bladder catheter should always be placed in the case of lower abdominal hernias. •• Antibiotic prophylaxis, e.g., cefazolin 2 g i.v. 30 minutes preoperatively.

Note

[M! ]

Medical thrombosis prophylaxis should always be given, preferably with low-molecular-weight heparin.

Fig. 4.73  Posterior layer of the rectus sheath detached.

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4.3  Laparoscopic Repair of Incisional Hernias is made about 2 cm medial to the lateral border of the rectus compartment to spare the segmental nerves to the rectus muscle (▶Fig. 4.74). This incision separates the cranial third of the transversus abdominis from the rectus compartment (▶Fig. 4.75, ▶Fig. 4.76), as the muscle fibers of transversus abdominis along the semilunar line radiate only cranially in the posterior layer of the rectus sheath (▶Fig. 4.77). Blood vessels and nerves are preserved carefully during further preperitoneal dissection in the lateral compartment. Dissection can be extended as far as the spinal column as needed. Complete transversus abdominis release takes place in the middle and lower thirds of the abdominal wall lateral to the semilunar line (▶Fig. 4.78).

Caution



Great caution is required when detaching the muscle to avoid injuring the nerves that run between the internal oblique muscle and the transversus abdominis muscle. The posterior layers of the rectus sheath can usually be approximated in the midline entirely without tension.

•• There is a risk of injuring the segmental nerves during medial detachment of the transversus abdominis in the middle and lower thirds of the abdominal wall. •• The peritoneum may be injured if the incision in the posterior layer of the rectus sheath is too low.

When dissection of the mesh site is very extensive and a very large mesh with wide overlapping is inserted, fixation of the edge of the mesh is required only if the hernia defect cannot be closed (hernia bridging).  

Very careful hemostasis is required.

Management of Special Complications •• Extensive hematoma: open hematoma evacuation. •• Infection:

Relevant Anatomy, Dangers, and Tricks

External oblique Transversus abdominis

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[M! ]

Note

○○

•• Precise knowledge of abdominal wall anatomy is required, especially the course of the segmental nerves.



Tip

○○

With early infection, mesh preservation should be attempted with open debridement, irrigation, drainage, and vacuum dressings. With late and persistent infection, the mesh must be explanted, possibly replacing it with biological mesh.

Rectus abdominis

Posterior layer of the rectus sheath

Internal oblique

Fig. 4.74  Vertical incision of the posterior layer of the rectus sheath.

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Fig. 4.75  Vertical incision of the posterior layer of the rectus sheath usually produces only partial separation of the transversus abdominis from its medial attachment.

Postoperative Care •• Close clinical and ultrasound monitoring. •• Monitoring of inflammatory parameters. •• Respiratory therapy in the case of cardiopulmonary comorbidity and obesity.

Tip



We recommend wearing an elastic abdominal bandage for 6 weeks. This confers added stability on the abdominal wall and facilitates respiratory therapy.

Summary Fig. 4.76  The entire length of the posterior layer of the rectus sheath is divided approximately 2 cm medial to the lateral border of the rectus compartment, preserving blood vessels and nerves. The cranial third of the rectus abdominis is detached medially with this maneuver. This greatly medializes the posterior layer of the rectus sheath.

Posterior component separation allows extension of the Rives-Stoppa procedure to the lateral compartment with extraperitoneal mesh placement and nerve preservation for giant ventral hernias. The myofascial mobilization of 3 to 6 cm achieved on each side is similar to endoscopic anterior component

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4.3  Laparoscopic Repair of Incisional Hernias

External oblique

Rectus abdominis

Transversus abdominis

Posterior layer of the rectus sheath

Internal oblique

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Semilunar line

Fig. 4.77  Variable course of the semilunar line. The fibers of transversus abdominis usually radiate cranially into the posterior layer of the rectus sheath.

Posterior layer of the rectus sheath

abdominal wall defect. The Ramirez component separation is a meshfree alternative to numerous mesh procedures. Ramirez et al76 developed this operation procedure in 1990, which uses dissection and separation of parts of the lateral abdominal wall to allow tension-free midline closure of abdominal wall defects up to 20 cm (▶Fig. 4.79). The original technique does not use any foreign material.

Transversus abdominis

Indications

Fig. 4.78  The posterior layer of the rectus sheath is split vertically, with the transversus abdominis exposed but not yet detached from its medial insertion.

separation but less than that obtained with open anterior component separation (Ramirez), see section ▶4.3.8. Large subcutaneous skin flaps are avoided. Delayed wound healing occurs significantly less often after posterior component separation than after anterior component separation.

4.3.8  Anterior Component Separation According to Ramirez Michael Stumpf

Basis Various reconstruction methods can be used today for large incisional hernias when there is an extensive

In our opinion, the pure Ramirez technique, i.e., not combined with insertion of any alloplastic material, is indicated, especially in patients with abdominal wall defects following laparostomy (e.g., young patients after polytrauma), in whom delayed wound healing and abnormal scarring (“herniosis”) need not be antici­ pated. Infection, where use of alloplastic tissue should be avoided, is another indication, but this is becoming less important with the modern mesh materials available today.

Operation Techniques The following description is limited to pure component separation without additional use of alloplastic material. A midline laparotomy is first performed, excising the entire old scar. A complete laparotomy and ventral adhesiolysis are carried out to avoid accidental bowel injury during subsequent lateral dissection. The lateral border of the rectus sheath (semilunar line) is the easiest to find by palpation of the entire abdominal wall, including from

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Fig. 4.79  Systematic illustration of component separation.

Fig. 4.80  After complete laparotomy and ventral adhesiolysis, the epifascial plane is dissected widely beyond the semilunar line. The lateral border of the rectus sheath is palpated.

the abdominal side. The viscera are then covered with a moist abdominal towel. After resecting any of the sacs present in the subcutaneous tissue, epifascial dissection is carried out and must continue 2 to 3 cm beyond the lateral border of the rectus sheath. The edge of the rectus sheath can best be detected by palpation between the thumb and index finger (▶Fig. 4.80). It is important to dissect directly on the fascia to avoid dissection of the subcutaneous fat with consequent areas of necrosis. The entire dissection can readily be done with electrocautery. After the lateral border of the rectus sheath (semilunar line) has been clearly defined, the external oblique

Fig. 4.81  Incision of the external oblique aponeurosis approximately 1 cm lateral to the semilunar line (lateral border of the rectus sheath). Dissection laterally on the internal oblique muscle.

aponeurosis is split over its entire length roughly 1 cm lateral to the semilunar line (▶Fig. 4.81). If possible, the split should end at the costal margin. The plane between the external and internal oblique muscles is then dissected bluntly in lateral direction. This can be done without danger as the segmental nerves and vessels run between the internal oblique muscle and the transversus abdominis muscle. This lower plane must be protected. Dissection is usually carried out on both sides (▶Fig. 4.82). If this does not facilitate the approximation of the two medial fascial borders, tension-free closure can usually be obtained by relaxing incisions in the anterior fascia over the rectus muscles. With

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4.3  Laparoscopic Repair of Incisional Hernias recurrence rates of large and giant ventral hernias are much higher when plastic implants are not used. The combination of endoscopic component separation with open retromuscular mesh augmentation is particularly suitable. Open retromuscular dissection is the first step in the operation. If the hernia defect cannot be closed without tension after this, bilateral endoscopic component separation is then performed in addition.

Indications

Fig. 4.82  Complete dissection with displacement of the medial fascial borders.

the correct indication, alloplastic reinforcement is not required, even in the lateral dissected areas. A loose, approximating 1 PDS looped suture is used to close the fascia. Following hemostasis, the skin is closed with an intracutaneous continuous absorbable suture omitting a drain.

4.3.9  Endoscopic Component Separation Wolfgang Reinpold Endoscopic component separation is also called laparoscopic component separation in the international literature. Since the procedure is limited to the lateral compartment of the abdominal wall, however, and the abdomen is not opened, the term “endoscopic component separation” is more accurate. Since the procedure was first described in 2002 by Losanoff et al,57 150 cases have so far been published.2,11,33,38,57,82 The principle of the procedure is a large relaxing incision of the lateral abdominal wall with separation and retraction of the external oblique against the internal oblique. Unlike in open component separation, the vessels supplying the skin of the anterior abdomen are spared in endoscopic component separation. Delayed wound healing and infections are therefore less often. Endoscopic component separation can be combined with open and laparoscopic techniques to manage ventral and incisional hernias. This is then called a hybrid procedure. Endoscopic component separation can be performed with or without mesh augmentation. The

▶ Indications. Large and very large ventral and incisional hernias (EHS classification W3, hernia defect transverse diameter more than 10 cm). Ventral and incisional hernias with a transverse diameter under 10 cm (EHS classification W2; hernia defect transverse diameter < 10 cm and > 4 cm), where the defect cannot be closed without tension. Single-stage management of large ventral and incisional hernias with mesh infection and removal.

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▶Relative contraindication. Ventral and incisional hernia after transverse laparotomy. ▶Contraindications. Lateral abdominal wall hernia: absolute general inoperability or absence of consent. ▶Alternative procedures. Open component separation (higher rate of delayed wound healing). Open and laparoscopic procedures with bridging of the defect (disadvantage: no dynamic reconstruction of the abdominal wall).

Diagnosis and Operation Preparation Ultrasonography, with CT or MRI of very large hernias (“loss of domain”), thorough cardiopulmonary diagnostics in patients at risk. Consider preoperative progressive pneumoperitoneum for loss of domain. A transurethral bladder catheter should always be placed in the case of lower abdominal hernias. Antibiotic prophylaxis, e.g., cefazolin 2 g i.v. 30 minutes preoperatively. Medical thrombosis prophylaxis should always be given, preferably with low-molecular-weight heparin.

Special Risks, Informed Consent •• Bowel/bladder injury (< 1%). •• Nerve injury (< 1%). •• Bleeding (< 5%). •• Hernia recurrence (5–25%). •• Bulging of the lateral abdominal wall (< 5%). •• Infection (0–33%). •• Chronic pain (0–15%).

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Anesthesia

Operation Steps

General anesthesia; an epidural catheter should be considered.

Trocar Placement and Separation of the External Oblique from the Internal Oblique

Position

The video tower should be beside the patient on the opposite side of the dissection and it is changed to the contralateral side during the operation. A 1.5-cm skin incision is made at the costal margin lateral to the rectus compartment, the external oblique fascia is exposed, and incised between retaining sutures. The internal oblique is identified. The space between the external oblique and internal oblique is entered with a 10-mm switching stick through which a 10-mm trocar is introduced. The nerve- and vessel-free space between the external and internal oblique muscles is widened cautiously (▶Fig. 4.83). An endoscopic dilatation balloon is introduced and the space is expanded under camera vision (10-mm

Supine.

Access ▶ The first 10-mm trocar. A 1.5-cm transverse skin incision is made at the costal margin just lateral to the rectus compartment, roughly 3 cm medial to the anterior axillary line. The skin incision can be determined accurately by preoperative ultrasound. ▶ The second 10-mm trocar. Under camera vision, a second 10-mm port is introduced about 5 cm lateral to the first, halfway between the costal margin and the iliac crest (▶Fig. 4.83).

Fig. 4.83  Entering the space between the external oblique and internal oblique.

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4.3  Laparoscopic Repair of Incisional Hernias 30° optic; ▶Fig. 4.84). Carbon dioxide (CO2) is delivered at a pressure of 12 mm Hg and up to 14 mm Hg. Under camera vision, a second 10-mm port is introduced about 5 cm lateral to the first, halfway between the costal margin and iliac crest. The external oblique is further sepa­ rated from the internal oblique under camera vision as far as possible posteriorly and cranially. For cranial dissection, the optic is changed to the lateral port. The inguinal region must be carefully protected during caudal dissection.

Division of the External Oblique Fascia Under camera vision, the fascia of the external oblique is divided vertically just lateral to the rectus muscle from the costal margin to just above the inguinal liga­ ment (▶Fig. 4.85). We prefer to use electrocautery

but this can also be done with scissors or an ultrasonic scalpel. The inguinal region must be carefully protected during this maneuver. The subcutaneous fascia should also be divided vertically. After vertical splitting of the external oblique fascia, the abdominal wall can be medialized by 2 to 6 cm (▶Fig. 4.86). With open component separation, mobilization of the rectus compartment by 10 to 12 cm on each side is possible but at the expense of a considerably increased rate of delayed wound healing and infection. Endoscopic component separation is always performed bilaterally. Drains can be omitted if bleeding has ceased. Augmentation of the lateral compartment with alloplastic material can be considered following endoscopic component separation. To date, we have always refrained from this.

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Fig. 4.84  Widening of the blood vesseland nerve-free space between the external oblique and internal oblique muscle with a dilatation balloon.

Fig. 4.85  Division of the fascia of the external oblique muscle with electrocautery.

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Incisional Hernias Fig. 4.86  The rectus compartment can be mobilized by 2 to 6 cm on each side by endoscopic component separation.

Relevant Anatomy, Dangers, Tricks •• Precise knowledge of the anatomy of the lateral abdominal wall muscles is required. Only the external oblique aponeurosis may be split. Confusing the layers with mistaken division of the internal oblique and external oblique must absolutely be avoided. •• The wall between the rectus compartment and the lateral abdominal wall must not be damaged. •• In very slim patients, the external oblique fascia should be divided very carefully with scissors to avoid burns to the skin. •• Very careful hemostasis is required although the layer between the two oblique muscles is poorly vascularized. •• The first skin incision should be somewhat longer in the first operations and in very obese patients so the plane between the external and internal obliques can be identified securely. •• When the situation is unclear, insertion of a third trocar a little above the groin can be considered.

Management of Special Complications •• Extensive hematoma: endoscopic hematoma evacuation. •• Infection: initially, endoscopic debridement, irrigation, and drainage; open procedure, if appropriate; augmentation with biological mesh, if appropriate. •• Hernia development in the lateral compartment: insertion of alloplastic material between the internal and external obliques; open onlay mesh repair; laparoscopic or open IPOM repair.

Postoperative Care •• Close clinical and ultrasound monitoring. Monitoring of inflammatory parameters. Respiratory therapy in the case of cardiopulmonary comorbidity. •• We recommend wearing an elastic abdominal bandage for 6 weeks. This gives the patient additional support and facilitates respiratory therapy and coughing.

Fig. 4.87  Laparostomy with skin covering the Vicryl mesh.

4.3.10  Laparostomy Hernias Joachim Conze

Definition

[ ]

• “Planned” incisional hernias, when fascial closure was not possible during the index operation. • Result of temporary abdominal wall closure when the fascial defect was initially bridged, e.g., with an inlay absorbable mesh, and subsequently either the mobilized skin and subcutaneous tissue was closed over this (▶Fig. 4.87) or secondary cover was obtained, e.g., with a mesh graft (▶Fig. 4.88). ▶Fig. 4.89 provides a schematic illustration of laparostomy hernia.

Treatment Laparostomy hernias can vary greatly and may reach an enormous size. Accordingly, the treatment options are similar to the techniques described in section ▶4.3.6 for

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4.3  Laparoscopic Repair of Incisional Hernias giant incisional hernias. The choice of repair technique depends especially on: •• The width of the defect. •• Eventration of viscera. •• The remaining soft tissue cover. •• The patient’s individual risk profile for disorders of collagen metabolism. Repair of laparostomy hernias belongs to the domain of open surgery. The decision regarding the possible surgical procedure can often only be made at operation.

The following treatment algorithm can assist decision making: ▶ A. In laparostomy patients without a risk profile, primary abdominal wall closure with a continuous suture can be attempted, depending on the width of the defect (▶Fig. 4.90). A nonabsorbable suture (0 or 2/0) should be used to approximate the fascial margins with low tension using a small-bite, small-stitch technique. This is possible, especially with narrow laparotomies where the abdominal wall is otherwise intact. ▶ B. If it proves at operation that approximation of the fascial margins is possible only with great tension, anterior or posterior component separation should be considered. If there is no risk profile, midline closure can then take place without mesh reinforcement (▶Fig. 4.91).

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▶ C. On the other hand, if the patient has risk factors and/or anatomic restrictions due to unstable fascial margins, additional augmentation of the midline by a retromuscular mesh is indicated. The mesh is placed in extraperitoneal position with the fascia closed over it (▶Fig. 4.92). Covering the abdominal viscera with the preserved hernial sac/peritoneum achieves a natu­ ral barrier so the mesh is in extraperitoneal position. A large-pore, surface-reduced, barrier-free mesh is used in this procedure. Fig. 4.88  Laparostomy with mesh graft cover over the Vicryl mesh.

▶ D. In the case of broad laparostomy hernias, where dissection of an extraperitoneal space is possible but Fig. 4.89  Laparostomy hernia.

Fig. 4.90  Defect closure with continuous suture.

Fig. 4.91  Defect closure with continuous nonabsorbable suture after anterior component separation.

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Incisional Hernias Fig. 4.92  Defect closure with continuous suture after anterior component separation with retromuscular mesh augmentation.

Fig. 4.93  Defect closure with extraperitoneal retromuscular mesh bridging with/without anterior component separation.

Fig. 4.94  Defect closure with intraperitoneal mesh bridging with/ without anterior component separation.

low-tension fascial closure with or without component separation cannot be achieved, extraperitoneal bridging of the defect should be attempted. An overlap of at least 5 cm in all directions is important to ensure a sufficiently broad contact area between the mesh site and mesh. To avoid mesh dislocation, it should be fixed transfascially (▶Fig. 4.93). Depending on the extent of epifascial dissection, the sutures may be passed epifascially or transcutaneously. In addition, the medial fascial border should be fixed to the mesh. On the one hand, this prevents further retraction of the fascial margins and on the other hand, the mesh contact area is enlarged and the exposed mesh area is reduced. In the case of giant laparostomy hernias with marked lateralization of the remainder of the abdominal wall muscles, dissection of the peritoneum/hernial sac to provide natural cover of the viscera can be difficult if not impossible. There is too little natural tissue to ensure that the bridging mesh is in extraperitoneal position. Intraperitoneal onlay mesh (open IPOM) is used in this situation (▶Fig. 4.94). Mesh with an appropriate antiadhesive barrier layer should be used in this procedure. To ensure durable repair with extensive fibrocollagenous integration of the mesh, overlapping of the fascial border of at least 5 cm is desirable. If the fascia is not closed over the mesh or if the fascia cannot be closed in front of the mesh, the mesh must be fixed transfascially with interrupted sutures 3 to 4 cm apart. With this repair method, the medial fascial border should be quilted onto the mesh.

Summary The management of laparostomy hernias is a complex surgical challenge, which is often made even more difficult by intraperitoneal adhesions. Iatrogenic bowel

injuries must absolutely be avoided. Adequate soft tissue cover over the repair is also important, especially when bridging techniques are used. Surgeons who take up this challenge should be familiar with the anatomy of the abdominal wall and with the different techniques.

4.4  Abdominal Wall Tumors Filip Muysoms and Joachim Conze

4.4.1 Epidemiology Primary tumors of the abdominal wall are rare. They constitute a varied group of benign and malignant conditions. Desmoid tumors (or fibromatosis) are the most frequent primary tumors of the abdominal wall, followed by soft tissue sarcomas.71,93 Desmoid tumors have more locally invasive growth without a tendency to metastasis. Ten percent of patients with familial adenomatous poly­ posis develop desmoid tumors.67 Secondary tumors of the abdominal wall are increasing in incidence. This is mainly due to the longer survival of patients with metastatic malignancies as a result of newer multidisciplinary oncological treatment. The use of exploratory staging laparoscopy for gynecological or gastrointestinal tumors has led to an increase in the number of patients with port-site metastasis.

4.4.2  Clinical Symptoms Primary tumors of the abdominal wall can reach a considerable size before they lead to clinical symptoms. At the time of diagnosis, the tumors often present as a painless swelling. Subsequently, skin ulceration and infiltration of abdominal organs can occur due to invasive growth into the skin and peritoneum.

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4.4  Abdominal Wall Tumors The differential diagnosis of sudden and rapidly growing swellings includes spontaneous or traumatic hematomas, especially in patients on anticoagulation. Pain, erythema, and fever can be signs of an abscess of the abdominal wall. Pain and swelling of the abdominal wall occurring in women at the same time as menstruation may indicate endometriosis. Sister Joseph’s nodule is a specific tumor of the abdominal wall. This umbilical mass is not an umbili­ cal hernia but a manifestation of intraperitoneal carcinomatosis (▶Fig. 4.95).29

4.4.3 Diagnosis Diagnostic Imaging •• Ultrasonography: After clinical examination, ultrasound is the first investigation of abdominal wall swellings. It allows an estimate of tumor size, its echogenicity and hence homogeneity, and demarcation from intra-abdominal organs. In addition, it can detect other intraparenchymal masses in the liver, spleen, and kidneys as well as enlarged lymph nodes. •• Computed tomography (CT): CT provides more precise imaging of the size, vascularity, and heterogeneity of the mass and allows assessment of infiltration of the skin and intra-abdominal organs. ▶Fig. 4.96 shows a primary abdominal wall tumor in the rectus muscle. There are no morphological CT criteria that enable differentiation between desmoid tumors and soft tissue sarcomas. •• Magnetic resonance tomography (MRI): MRI is particularly helpful in assessing the degree of invasion of soft tissue tumors in the extremities. An assessment of abdominal wall masses is often limited by respiratory movement artefacts. •• Positron emission tomography (PET): PET has the advantage of whole-body scanning to detect any other lesions. Increased glucose metabolism in the tumor increases the likelihood that the tumor is malignant (▶Fig. 4.97).

Fig. 4.95  Small tumor at the umbilicus, a manifestation of intraperitoneal carcinomatosis (Sister Joseph’s nodule).

In summary, diagnostic imaging cannot provide a clear diagnosis of tumors within the abdominal wall. Tumor biopsy is therefore essential for correct diagnosis.

Differential Diagnosis •• Primary tumors of the abdominal wall: ○○ Desmoid tumor or fibromatosis. ○○ Soft tissue sarcoma. ○○ Extra-gastrointestinal stromal tumor (EGIST). ○○ Hibernoma (vestiges of fetal brown fat). •• Secondary or metastatic tumors of the abdominal wall: ○○ Skin metastases. ○○ Musculofascial metastases. ○○ Peritoneal metastases. ○○ Infiltration of the abdominal wall by intra-abdominal tumors. ○○ Port-site metastases: –– after laparoscopic exploration, e.g., because of ovarian carcinoma. –– after laparoscopic removal of gallbladder carcinoma. •• Benign lesions (lesions mimicking tumor): ○○ Endometriosis, e.g., in a cesarean or hysterectomy scar. ○○ Hematoma: traumatic; spontaneous (with anticoagulants). ○○ Infection: abscess. ○○ Gossypiboma (foreign body-related inflammatory pseudotumor). ○○ Solitary neurofibroma. ○○ Schwannoma. ○○ etc.

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Pathological Diagnosis Since neither the clinical picture nor diagnostic imaging is pathognomonic for correct identification of abdominal wall pathology, biopsy is essential so that appropriate treatment can be planned.

Fig. 4.96  Computed tomography of a tumor in the rectus muscle (desmoid tumor; see ▶Fig. 4.98).

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Fig. 4.97  Positron emission tomography (PET scan) showing a highly positive abdominal wall mass (abdominal wall metastasis of an adenocarcinoma of the colon resected 3 years ago).

•• Fine needle aspiration (FNA) cytology is insufficient for correctly differentiating between a desmoid tumor and a sarcoma. •• Punch biopsy usually facilitates a diagnosis and tumor grading, but the sample often does not provide enough tissue for all the necessary histological stains that allow correct diagnosis. •• Excisional biopsy of the mass should be done only with small lesions (< 3 cm). Excision of larger tumors often makes radical resection more difficult if a malignant sarcoma is diagnosed. •• Incisional biopsy is indicated especially for larger masses. The biopsy incision should be in an area of skin

that can be included if subsequent tumor resection is necessary. Further details of the pathological diagnosis and immunohistochemistry of desmoid tumors and sarcomas are not given here.

4.4.4 Treatment Conservative A watchful waiting approach is acceptable with a symptomatic desmoid tumor.88 This is also appropriate when the histological result shows tumor cells in the resection

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4.5  Prevention of Incisional Hernias margin following excision (R1 resection). This situation does not necessarily require further resection but can be observed.

Surgical The indication and planning of tumor resection depend on the histological result of the biopsy. In case of desmoid tumors, resection limited to the tumor margin is sufficient. Wide and mutilating resection is not necessary (▶Fig. 4.98). Extensive resection of soft tissue sarcomas is indicated, including the surrounding tissue, with intraoperative frozen section of the resection margins. Surgery offers the only possibility of local tumor control and is the most important measure. Following resection, which may be mutilating, reconstruction of the abdominal wall is often necessary. The extent of tumor resection depends on the tumor location and involvement of skin, peritoneum, or intra-abdominal organs. ▶Table 4.2 shows the classification of defects after oncological resection of abdominal wall tumors.99

Reconstruction of the abdominal wall for type I or II defects is tailored individually to the location and extent of tumor resection. Use of synthetic or biologi­ cal mesh materials is frequently indicated. Type III defects may require cover by means of a myocutaneous flap. Which form of flap is used depends on the defect location. With defects in the middle and lower parts of the abdominal wall, reconstruction is usually with an anterior thigh flap, while a latissimus dorsi flap is preferred for defects in the upper part of the abdominal wall.

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Adjuvant Therapy Multidisciplinary tumor board discussion is essential preand postoperatively to determine the need for adjuvant radiotherapy or chemotherapy for malignant abdominal wall tumors.

4.4.5 Prognosis Desmoid tumors or fibromatosis of the abdominal wall have a low recurrence rate after macroscopically complete resection (R0 and R1). The prognosis of fibromatosis of the abdominal wall is better than that of fibromatosis of the extremities. Primary sarcomas of the abdominal wall have a significant risk of local recurrence. The risk increases when the tumor diameter exceeds 10 cm and when the tumor is poorly differentiated.

4.5  Prevention of Incisional Hernias René H. Fortelny

Fig. 4.98  Resected specimen of a desmoid tumor (see ▶Fig. 4.96). En-bloc resection including the posterior rectus fascia because of tumor infiltration. Complete macroscopic and microscopic resection (R0 resection).

Table 4.2  Classification of defects after oncological resection of abdominal wall tumors (after [73]) Type

Features

I

Defects with skin loss exclusively

II

Myofascial defects with intact skin cover

III

Myofascial defects without intact skin cover

The risk of incisional hernia after midline laparotomy is described as 5 to 20% in the literature.101 The main risk factors for developing incisional hernias caused by impaired collagen production are: •• Obesity. •• Corticosteroid therapy. •• Malnutrition. •• Smoking. •• Connective tissue diseases.51,89 There are numerous references in the literature regarding an association between aortic aneurysms and other abdominal wall defects such as inguinal hernias.73,75 Retrospective and prospective studies show an average risk of 31.6% for developing an incisional hernia after abdominal aortic aneurysm surgery. A recently published randomized controlled study concerning this risk group reports significantly lower incisional hernia incidence after retromuscular mesh augmentation in a follow-up period of over 2 years.10

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Incisional Hernias Obese patients with a body mass index  (BMI) of ≥ 27 are another high-risk group, with an incisional hernia incidence of 22% after 12 months.43,97 While only 50% of the incisional hernias become clinically apparent within 1 year, the long-term incidence is over 30%. The type and technique of closure are the first steps in avoiding an incisional hernia after midline laparo­ tomy. Since the experimental and clinical publications by Israelsson,17,43,44 there has been scientific evidence that a special abdominal wall closure technique with defined suture-incision length ratio and suture material leads to a significant reduction in wound infections and to a decrease of incisional hernia incidence. The second preventive step, especially with regard to risk-defined groups of patients, is an additional reinforcement of the primary midline laparotomy closure to reduce the risk of incisional hernia. Numerous studies show clear benefits for the use of plastic mesh and also show that these are safe as part of primary wound closure after midline laparotomy.23,30,35 These studies showed that the risk of incisional hernias was significantly reduced. The infection risk, especially with contaminated wounds when a stoma was created, was not increased.98

4.5.1  Abdominal Wall Closure Techniques Dissection of the Linea Alba Before making the midline incision, the linea alba should be cleared sufficiently of subcutaneous fat so that the

midline is opened exactly where the fibers cross. It is also necessary to dissect the umbilicus, which often has a minimal fascial opening of a few millimeters; this must be regarded as a potential weak point where an incisional hernia can arise (▶Fig. 4.99). This is, thus, an important first step to avoid accidentally opening the rectus sheaths.

Closure Basis In midline laparotomy closure, trauma to the fascial margins due to the needle-suture combination and suture traction is the most important factors that interfere with healing. Therefore, the traction of the continuous suture that approximates the fascial margins must be correct. High suture-induced stress on the tissue is directly associated with the development of “button holes,” which can result in the feared early postoperative complication of burst abdomen or later in an incisional hernia. Reducing trauma to the abdominal wall is therefore the key element both in optimizing surgical technique and suture material. Following the biomechanical principles of abdominal wall tension, the distribution of suture traction to small tissue bridges using appropriate needle and suture sizes to minimize tissue trauma is the most important approach. Accordingly, the use of large-caliber needles and suture systems, as in the widely used looped suture, is counterproductive. Fig. 4.99  Initial dissection of the linea alba: pre-incisional precise (fat-free) exposure of the linea alba with detachment of the umbilicus.

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4.5  Prevention of Incisional Hernias Fig. 4.100  Suturing the incision with the large-bites technique.

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Table 4.3  Large-bites technique

Table 4.4  Small-bites technique

Parameter

Characteristics

Parameter

Characteristics

Suture material

Monofilament, slowly absorbable

Suture material

Monofilament, slowly absorbable

Size

0 or 1

Size

0 or 2/0

Suture technique

Continuous through all layers

Suture technique

Suture-incision length ratio

≥ 4:1

Continuous, taking only the aponeurosis ≥ 5:1

Distance from corner

> 1 cm

Suture-incision length ratio

Stitch interval

1 cm

Distance from corner

> 1 cm

Distance from wound edge

1 cm

Stitch interval

4–5 mm 5–8 mm

Stitch length

≤ 5 cm

Distance from wound edge

Other

Approximating traction on suture line (< 1.5 kp)

Stitch length

≤ 2.5 cm

Other

Approximating traction on suture line (< 1.5 kp)

Large-Bites Technique The evidence-based data on primary abdominal closure have been confirmed at the highest evidence level based on numerous studies and meta-analyses.1,26 The recommendation (level A) is to use a continuous monofilament, slowly absorbable suture in a suture-wound length ratio of at least 4:1 for primary laparotomy closure. This large-bites technique (▶Fig. 4.100 and ▶Table 4.3) was for a long time regarded as the gold standard for midline abdominal closure. Based on experimental data17 and clinical studies from Sweden,58 however, a new small-bites or short-stitch technique was developed, which causes less tissue trauma.

Caution: button holes Suture bridges should be visible

Small-Bites Technique This technique (▶Table 4.4) is based on reducing the distance from the wound margin and between stitches (▶Fig. 4.101) with an associated increase in suture-wound length ratio to ≥ 5:1 and on use of a slowly absorbable suture (0 or 2/0) in combination with a fine needle (e.g., HR-26 needle, 16 mm length). This suturing technique takes only the aponeurosis (no muscle), further reducing tissue trauma. This method leads to a significant decrease of both the infection rate

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Incisional Hernias Fig. 4.101  Suturing the incision with the smallbites technique.

and the incisional hernia incidence compared with the large-bites method.

Suture Material Discussion of the ideal suture material for abdominal wall closure continues. The comparison in the ISSAAC study1 between suture materials with different properties—PDS or MonoPlus versus MonoMax, a monofilament, ultra-slowly absorbable suture with high elasticity and flexibility—showed that the new elastic suture material had minor, nonsignificant advantages with regard to incisional hernia incidence. The markedly delayed absorption combined with high elasticity corresponding to abdominal wall compliance enables low-tension closure with a synergistic effect on longterm scar formation. This could produce additional improvements if used with the small-bites technique with a single thread compared with the looped suture employed in the ISSAAC study.

4.5.2  Indications for Prophylactic Mesh Reinforcement The primary indication for prophylactic mesh implantation essentially involves two high-risk groups: •• Patients with BMI of ≥ 27. •• Patients undergoing an abdominal aortic graft.

•• Other indications are patients with a history of previous hernia surgery, either in the inguinal or umbilical region. Onlay or retromuscular sublay mesh are suitable methods for reinforcing the midline wound closure, performed with the large- or preferably small-bites technique. Prophylactic onlay and sublay mesh reinforcements are currently being performed in the Primary Mesh Closure of Abdominal Midline Wound (PRIMA) trial, a multicenter, double-blind, randomized study. The primary endpoint of the study is the incidence of incisional hernia compared with traditional continuous suture with a slowly absorbable suture material. The secondary endpoints are the postoperative complication rate, pain, quality of life, and cost-effectiveness.74 Another randomized multicenter study comparing continuous suture closure alone versus additional onlay mesh reinforcement is currently under way in Austria.78 A recent review of this subject confirms that there is a significant reduction in incisional hernias when prophylactic mesh reinforcement is employed in the high-risk patient group without a significant increase in seroma and infection rates.66 A final recommendation on the preferred method of prophylactic mesh reinforcement is not yet possible, as the results of the abovementioned studies are still awaited. The choice of procedure must therefore be seen in the context of the surgeon’s experience in this area, especially when using the technically more complex sublay technique.

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4.5  Prevention of Incisional Hernias Fig. 4.102  Onlay mesh reinforcement with mesh overlap of 3 cm in all directions.

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4.5.3  Prophylactic Mesh Reinforcement Operation Procedure The patient’s informed consent to the chosen procedure must be obtained in the usual way. The risks of mesh infection and of seroma must be listed as potential complications.

Initial Dissection of the Linea Alba Before incising the linea alba, this must be exposed precisely, if possible cleared of subcutaneous fat, depending on the planned mesh reinforcement: •• If the retromuscular method is chosen, dissection must be ≥ 1 cm bilaterally and cranial and caudal (in all directions) to the planned midline incision line. •• More than or equal to 3 cm for onlay mesh (▶Fig. 4.99). Complete detachment of the umbilicus from the aponeurosis is also required to obtain exact closure. Precise midline division of the crossing aponeurotic fibers of the linea alba is possible only with this initial preparation.

Operation Procedure: Onlay Mesh After dissecting the linea alba and aponeurosis (≥ 3 cm in all directions) and performing the operation, the incision is closed with the small-bites technique (▶Fig. 4.101) ensuring the appropriate stitch intervals and suture tension (▶Table 4.3 and ▶Table. 4.4) with a continuous monofilament, slowly absorbable material. The closed incision is finally reinforced with a largepored (≥ 1 mm diameter), lightweight mesh (polypropylene,

polyester, or polyvinylidene fluoride) with an overlap of ≥ 3 cm on all sides. The mesh should be fixed with absorbable interrupted sutures (2/0 or 3/0) or alternatively with glue (absorbable, e.g., fibrin glue, ▶Fig. 4.102). An epifascial vacuum drain can optionally be placed for seroma prophylaxis.

Operation Procedure: Sublay Mesh Before the planned incision, the linea alba is initially dissected for a distance of more than or equal to 1 cm on all sides. Dissection of the abdominal wall must selectively expose the posterior layer of the rectus sheath, including the fatty triangle in the subxiphoid or retropubic region. The posterior layer of the rectus sheath and the peritoneum are closed with a continuous absorbable suture (▶Fig.  4.103). A large-pored  (≥ 1 mm pore size), lightweight synthetic mesh (polypropylene, polyester, or polyvinylidene fluoride) at least 6 cm wide with an overlap of greater than or equal to 3 cm on all sides is fixed with 3/0 absorbable interrupted sutures or with glue (▶Fig. 4.104). A vacuum drain can optionally be placed in the retromuscular compartment for hematoma and seroma prophylaxis The large-bites technique (▶Fig. 4.100) or preferably the small-bites technique (▶Fig. 4.101) can be used for final closure of the incision.

4.5.4  Postoperative Management Ultrasound-controlled seroma aspiration is indicated only if it causes clinical symptoms.

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Incisional Hernias Fig. 4.103  Sutured closure of the posterior rectus sheath/peritoneum with the small-bites technique.

Fig. 4.104  Sublay mesh reinforcement with mesh overlap of 3 cm on all sides, fixed wit fibrin glue.

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4.5 Prevention of Incisional Hernias

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4.5 Prevention of Incisional Hernias [87] Sajid MS, Bokhari SA, Mallick AS, Cheek E, Baig MK. Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg. 2009; 197(1):64–72 [88] Salas S, Dufresne A, Bui B, et al. Prognostic factors influencing progression-free survival determined from a series of sporadic desmoid tumors: a wait-and-see policy according to tumor presentation. J Clin Oncol. 2011; 29(26):3553–3558 [89] Sauerland S, Korenkov M, Kleinen T, Arndt M, Paul A. Obesity is a risk factor for recurrence after incisional hernia repair. Hernia. 2004; 8(1):42–46 [90] Schumpelick V, Binnebösel M, Conze L. Clinical results after open mesh repair. In: Schumpelick V, Kingsnorth A, eds. Hernia repair sequelae. Berlin: Springer; 2010: 228–232 [91] Seiler CM, Bruckner T, Diener MK, et al. Interrupted or continuous slowly absorbable sutures for closure of primary elective midline abdominal incisions: a multicenter randomized trial (INSECT: ISRCTN24023541). Ann Surg. 2009; 249(4):576–582 [92] Stelzner S, Hellmich G, Ludwig K. Repair of paracolostomy hernias with a prosthetic mesh in the intraperitoneal onlay position: modified Sugarbaker technique. Dis Colon Rectum. 2004; 47(2):185–191 [93] Stojadinovic A, Hoos A, Karpoff HM, et al. Soft tissue tumors of the abdominal wall: analysis of disease patterns and treatment. Arch Surg. 2001; 136(1):70–79 [94] Strzelczyk J, Czupryniak L, Loba J, Wasiak J. The use of polypropylene mesh in midline incision closure following gastric by-pass surgery reduces the risk of postoperative hernia. Langenbecks Arch Surg. 2002; 387(7–8):294–297 [95] Subramanian A, Clapp ML, Hicks SC, Awad SS, Liang MK. Laparoscopic ventral hernia repair: primary versus secondary hernias. J Surg Res. 2013; 181(1):e1–e5 [96] Sugarbaker PH. Peritoneal approach to prosthetic mesh repair of paraostomy hernias. Ann Surg. 1985; 201(3):344–346 [97] Sugerman HJ, Kellum JM, Jr, Reines HD, DeMaria EJ, Newsome HH, Lowry JW. Greater risk of incisional hernia with morbidly obese than steroid-dependent patients and low recurrence with prefascial polypropylene mesh. Am J Surg. 1996; 171(1):80–84

[98] Tam KW, Wei PL, Kuo LJ, Wu CH. Systematic review of the use of a mesh to prevent parastomal hernia. World J Surg. 2010; 34(11):2723–2729 [99] Tang R, Gu Y, Gong DQ, Qian YL. Immediate repair of major abdominal wall defect after extensive tumor excision in patients with abdominal wall neoplasm: a retrospective review of 27 cases [corrected]. Ann Surg Oncol. 2009; 16(10):2895–2907 [100] Tarnoff M, Rosen M, Brody F. Planned totally extraperitoneal laparoscopic Spigelian hernia repair. Surg Endosc. 2002; 16(2):359 [101] van ’t Riet M, Steyerberg EW, Nellensteyn J, Bonjer HJ, Jeekel J. Meta-analysis of techniques for closure of midline abdominal incisions. Br J Surg. 2002; 89(11):1350–1356 [102] van’t Riet M, Burger JW, Bonthuis F, Jeekel J, Bonjer HJ. Prevention of adhesion formation to polypropylene mesh by collagen coating: a randomized controlled study in a rat model of ventral hernia repair. Surg Endosc. 2004; 18(4):681–685 [103] Venclauskas L, Maleckas A, Kiudelis M. One-year follow-up after incisional hernia treatment: results of a prospective randomized study. Hernia. 2010; 14(6):575–582 [104] Wara P, Andersen LM. Long-term follow-up of laparoscopic repair of parastomal hernia using a bilayer mesh with a slit. Surg Endosc. 2011; 25(2):526–530 [105] Welti H, Eudel F. Un procédé de cure radicale des éventrations post-opératoires par auto-étalement des muscles grand droits, aprés incision du feuillet anterieur de leurs gaines. Mem Acad Chir 1941; 28:791–798 [106] Willis S, Conze J, Müller S, Klosterhalfen B, Schumpelick V. Progressives Pneumoperitoneum in der Behandlung von Leisten- und Narbenhernien. Tierexperimentelle Ergebnisse und klinische Anwendung. Langenbecks Arch Chir. 1996; 381(3):132–137 [107] Winkler MS, Gerharz E, Dietz UA. Narbenhernienchirurgie. Ubersicht und aktuelle Trends. Urologe A. 2008; 47(6):740–747 [108] Yezhelyev MV, Deigni O, Losken A. Management of full-thickness abdominal wall defects following tumor resection. Ann Plast Surg. 2012; 69(2):186–191

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1

Chapter 5 Complications

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5 5.1 Infection

306

5.2 Incarceration

310

5.3

Postoperative Pain

311

5.4

Triple Neurectomy

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Complications

5  Complications 1.5% can be expected under optimal conditions. Infection rates around 10% or more occur with surgery of umbilical or incisional hernias, which are regarded as potentially contaminated. Infection rates over 50% can be anticipated when the hernia surgery is performed acutely for incarceration with gangrene or an infected burst abdomen (▶Fig. 5.1). The cause of a wound infection in hernia surgery is often multifactorial, involving patient factors, surgical technique, and anesthesia. It was shown in a meta-analysis that the hernia patient’s age and nutritional status, smoking history, overweight, and immune status have a significant influence on the rate of wound infections. Important aspects as regards the operation in general are the nature and duration of the operation, the care taken with skin antisepsis, including the question of when and how the skin is depilated, duration of preoperative hospitalization depending on the hernia type and choice of procedure, antibiotic

5.1 Infection Bernhard J. Lammers

5.1.1 Introduction Infections are rare events in hernia surgery but are found with all types of operative treatments. In inguinal hernia surgery, infection rates up to 1.55% were observed in the first quality assurance study by the German North Rhine medical council for the years 1991–2000 (▶Table 5.1).35 By contrast, surgery of incisional hernia is known to have wound infection rates of up to 18%.13,38 With emergency hernia surgery, there is a substantial increase with infection rates of up to 50%. Even in hernia surgery, clean, clean contaminated, and septic procedures are distinguished. In clean procedures such as inguinal hernias, epigastric hernias, or spigelian hernias, wound infection rates of less than

Table 5.1  Complications of inguinal hernia surgery in the North Rhine medical council study 1991–2000 Year

99

98

97

96

95

94

93

92

91

Total

Number of patients (n)

19,266

18,619

19,732

20,940

19,646

19,907

19,740

18,738

17,605

173,923

Operations (n)

22,015

21,162

22,212

23,245

21,639

21,888

21,354

20,203

19,000

192,718

Postoperative complications (%)

5.9

5.6

5.5

5.1

6.4

7.6

7.9

8.1

9.7

Reoperation (%)

1.10

1.16

1.13

1.12

1.17

1.48

1.42

–

–

Seroma, hematoma (%)

3.85

3.27

3.11

2.8

3.54

4.46

4.39

4.27

5.08

Wound infection (%)

0.89

0.84

0.90

0.79

1.19

1.31

1.51

1.48

1.55

Swelling of the scrotum (%)

0.55

0.58

0.56

0.44

0.58

0.75

0.77

0.74

0.81

Testicular swelling (%)

0.26

0.28

0.32

0.24

0.34

0.53

0.49

0.42

0.52

–

Fig. 5.1  Burst abdomen after conventional intraperitoneal onlay mesh (IPOM).

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5.1 Infection prophylaxis, and insertion of wound drains.25 Moreover, in every procedure, meticulous operation technique plays a crucial part in preventing a wound infection. With regards to anesthesia, the oxygen partial pressure, body temperature, fluid balance, and early postoperative pain control have considerable significance.

5.1.2 Definition Postoperative wound infections were defined in 1999 by the Centers for Disease Control and Prevention (CDC).42 A distinction is made between superficial wound infections, known as A1 or superficial surgical site infections SISSI and A2 or deep ISSI (DISSI). •• A1 infections are limited to the skin and subcutaneous tissue within the first 30 days after an operation. •• A2 infections are deep, subfascial infections within 30 days after operations without implants or within 1 year postoperatively when foreign material has been implanted. •• A3 infections do not play any part in hernia surgery. These refer to postoperative infections of organs and body cavities. This generally accepted definition of postoperative wound infections can be criticized, as it inadequately describes the phenomenon of late infections after mesh implantation. For instance, bacterial colonization was observed several years after implantation on meshes that were not infected macroscopically, and some mesh infections with abscess formation only become apparent clinically 4 to 5 years after operation.

5.1.3  Infections in Inguinal Hernia Surgery In patients without risk factors for postoperative wound infection, such as obesity, active smoking, age over 70 years, diabetes mellitus, or an otherwise compromised immune system, no significant differences are observed between open suture and mesh repairs in the case of an uncomplicated primary inguinal hernia

operation. The infection rate is very low at 0 to 2%. Compared with the open procedures, the infection rate is even lower after endoscopic and laparoscopic repairs (▶Table 5.2). Against this background, the European Hernia Society (EHS) does not recommend antibiotic prophylaxis with inguinal hernia surgery in its guidelines.53 Patient-related risk factors or complicated repair of incarcerated hernia or recurrent hernia with the use of wound drains can be exceptions. In these patients, the wound infection rate is often more than 5% and can be reduced by a single-shot perioperative antibiotic.

5.1.4  Infections in Incisional Hernia Surgery

5

The rates of wound infections after incisional hernia repair reported in the literature vary greatly, from 0 to 18%. This is explained by the heterogeneity of the fascial defects and the variety of forms of repair. In general, postoperative wound infections occur much more often with open procedures as compared with laparoscopic repair.8,10,12 Possible causes of this phenomenon are the greater wound area and the greater risk of transferring skin microbes into deeper layers of the wound. Among the open procedures, the lowest infection rates can be expected with a simple sutured repair. However, since sutured repair is indicated only for small fascial defects less than 1 to 2 cm in size, there are naturally no comparative studies of sutured and mesh repairs. The mesh position in the abdominal wall also appears to play a part in the development of an infection. Wound and mesh infections occur more often with onlay repairs, where the mesh is placed between the fascia and the subcutaneous tissue, than after sublay operations where the mesh is in retromuscular position on the posterior layer of the rectus sheath. It is assumed that this is due to the greater frequency of seromas and poorer local perfusion after onlay repair.

Table 5.2  Overview of laparoscopic IPOM Author

Year

Number (n)

Wound infection (%)

Mesh infection (%)

Mesh removal (%)

Ferrari23

2007

99

1

1

1

Heniford

2000

407

1.23

0.98

0.98

McGreevy43

2003

65

–

4.6

4.6

Olmi

2007

85

–

1

1

LeBlanc39

2000

100

2

1

1

Berger

2002

150

1.3

1

1

Lammers

2012

247

1.2

0.4

0.4

45

7

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Complications

5.1.5  Prevention of Wound Infections Uncomplicated inguinal hernia surgery is not a recognized indication for antibiotic prophylaxis. On the other hand, prophylaxis should be considered in patients with typical risk factors (see above), incarceration, and complicated procedures when a drain is placed53 (▶Fig. 5.2). Liberal use of antibiotic prophylaxis is recommended for surgery of incisional and umbilical hernias with open mesh insertion. If these operations are performed laparoscopically, however, antibiotic use does not have a significant effect, as the infection rate is very low anyway. Second- and third-generation cephalosporins are the prophylactic antibiotics of choice in hernia surgery, as they encompass the usual skin microorganisms. Erythromycin can be given as an alternative.22 It is important to give it at the correct time, 30 minutes before the skin incision, to ensure an adequate tissue level.57 Anesthesia-influenced factors such as body temperature, oxygen partial pressure, fluid balance, and early postoperative analgesia are important, especially when incisional hernia repair is prolonged and involves large wound areas. The aim of all measures must be maintenance of good tissue perfusion with high partial pressure of oxygen. Correct intraoperative and early postoperative fluid balance at all times is ideal, without hypovolemic peripheral vasoconstriction on the one hand or local edema due to “overhydration” on the other hand.28 It is known from colorectal surgery that intraoperative elevation of oxygen delivery to 80% and/or immediate postoperative noninvasive ventilation with concentrated oxygen can reduce the wound infection rate to half.27 There are no corresponding studies on hernia surgery.

From the surgical aspect, a meticulous operation technique with as little tissue trauma as possible provides the foundation for infection-free wound healing. In addition, in open incisional hernia surgery, removal of poorly perfused scar tissue from the subcutaneous space and fascial margins is recommended. The subcutaneous parts of the peritoneal hernial sac should not be left behind as extensive seromas may occur, which later become infected. The mesh must be handled with particular care. It should be removed from its sterile packaging only immediately prior to implantation and after a change of gloves and, if appropriate, repeat disinfection of the operation field, avoiding skin contact. Wound drains are potential portals of infection. If they are regarded as essential, they should preferably not be placed in direct contact with the mesh. Postoperative seromas at the mesh site are frequent within the first 4 to 6 weeks after the operation; they require treatment only if symptomatic.

5.1.6  Treatment of Wound and Mesh Infections in Hernia Surgery An infection that occurs in the context of hernia surgery is defined as an emergency. It should be treated promptly, as sepsis may supervene in rare cases, especially after incisional hernia surgery, which can lead to fatal complications. Subcutaneous infections are treated with the usual measures of debridement and open wound treatment or vacuum therapy, always checking whether there is a contact with the mesh (▶Fig. 5.3). If the implant is involved, the type of material and the timing of the infection essentially determine whether the mesh can be left or should be explanted. An attempt to keep it is Fig. 5.2  Incarcerated umbilical hernia with gangrene and skin necrosis.

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5.1 Infection always justified with early postoperative infections of large-pore monofilament implants. By contrast, colonization of microporous films (e.g., expanded polytetrafluoroethylene [ePTFE]) can rarely be eliminated and these must usually be removed. Antibiotic therapy alone is usually insufficient. Biofilm-forming microorganisms on alloplastic materials, in particular, are largely resistant to systemic antibiotic therapy. Meshes with metal coatings such as gold or titanium appear to counteract colonization with biofilm producers. If the time of onset and the implanted material allow an attempt at preservation, vacuum therapy for 2 to 3 weeks, possibly accompanied by systemic antibiotic therapy, is often successful.19 With late infections, which can manifest clinically after months and years, mesh explantation is usually unavoidable. Often there is a thick abscess capsule that cannot be treated and must be removed with the mesh. The same applies for fistulas to hollow organs such as the bowel and bladder. In these cases, the clinical picture is of a septic abdominal wall with an extensive phlegmon (▶Fig. 5.4).

The diagnosis can be difficult as the association with a mesh inserted years ago is sometimes not apparent. The first step in treatment consists of mesh removal and treatment of the fistula, preferably by suturing the hernia defect or covering it with a rapidly absorbable mesh (e.g., Vicryl mesh). The incisional hernia can then be scheduled for repeat alloplastic repair 12 months later. Alternatively, “biological” mesh can be used; primary implantation is possible even in contaminated wound areas. If the clinical picture is of sepsis, the Tarragona strategy applies to the treatment of a wound infection following hernia repair (▶Table 5.3). Table 5.3  Tarragona strategy for antibiotic treatment of sepsis (within 1 h)

5

Patient’s individual risk factors

“Look at your patient”

Local epidemiology

“Look at your hospital”

Broad initial antibiotic administration

“Hit hard and early”

Which bacteria may be present?

“Get to the point”

Reevaluation within 48–72 h

“Focus?”

Fig. 5.3  Abscess following the Lichtenstein herniotomy.

Fig. 5.4  Recurrent skin fistulas after mesh implantation (polyester) to repair an incisional hernia.

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Complications

5.2 Incarceration Bernd Stechemesser Incarceration (cancer in Latin = enclosure, prison) signifies the entrapment of tissue in the hernia. Every hernia can become incarcerated in principle, regardless of its size and location. An incarcerated hernia is always an emergency, as it may strangulate, when the blood supply to its contents is cut off. “The sun must not rise or set on an incarcerated hernia.” An irreducible hernia should be distinguished from an incarcerated one. Unlike an incarcerated hernia, an irreducible hernia can be asymptomatic and present for a long time. An irreducible hernia is an urgent but not an emergency situation.

5.2.1 Etiology By definition, the orifice of a hernia is a narrow opening in the abdominal wall. Tissue that slides through the hernial opening can swell as a result of impaired venous drainage and can then no longer slide back into the abdomen. The swelling can also interfere with the blood supply and the incarcerated tissue can become ischemic or strangulated. This vicious circle ultimately leads to tissue necrosis. Incarceration of small intestine with its short ischemia time is therefore a particular risk with incarcerated hernia and requires rapid treatment. The Littré-Richter hernia is a special form of incarcerated hernia in which only part of the bowel wall is incarcerated; so, clinical presentation is often late in the form of bowel wall necrosis with peritonitis. The causes for the sliding of tissue into the hernia sac can be sudden rise in intra-abdominal pressure (coughing, sneezing) and also increased peristalsis or meteorism. There is an obvious association between the size of the hernial orifice and the risk of incarceration. The hernia can contain a variety of tissues: •• Preperitoneal fat. •• Greater omentum. •• Small or large intestine. •• Abdominal organs.

immediate operation are overt intestinal obstruction and an acute abdomen with signs of peritonitis. If these clinical signs are absent, the diagnosis can sometimes be difficult. Femoral hernias in women, with an incarceration rate of up to 30% at diagnosis, are often not easy to identify clinically. Internal hernias, too, are detected clinically more from the secondary symptoms such as obstruction and acute abdomen (▶Fig. 5.5).

5.2.3 Diagnosis The diagnosis of an incarcerated hernia is typically clinical. However, there are forms of hernia (femoral hernia, internal hernia, the Littré hernia, spigelian hernia), where additional diagnostic aids may be required. When the situation is unclear, ultrasonography or an abdominal CT may be helpful in making the diagnosis. Since the vitality of bowel in an incarcerated hernia cannot be determined clinically, operation should be resorted to readily.

5.2.4 Treatment Immediate surgery is indicated in all cases where the incarcerated hernia is associated with an acute abdomen or obstruction. A closed attempt at reduction of an incarcerated hernia can be made when these secondary signs are absent and when it has been irreducible for only a short time. As far as possible, reduction should be attempted by an experienced doctor with appropriate analgesia. Spasmolytic agents may be used in addition. The patient should be as relaxed as possible. The doctor uses both hands to prevent the hernia from slipping away and to achieve even pressure on it as far as possible. A cautious reduction attempt can then be made under steady pressure. If this is unsuccessful, operation is indicated. If hernia reduction is successful, the patient should

5.2.2  Clinical Features An incarcerated hernia usually presents clinically as an acute condition, classically with the symptom triad of: •• Pain. •• Swelling. •• Irreducibility. If there is also inflammatory erythema over the hernia, immediate surgery is indicated. Nausea and vomiting can indicate intestinal obstruction and should be further investigated. Other clinical signs indicating the need for

Fig. 5.5  Incarcerated inguinal hernia (laparoscopic view, with the kind permission of Dr René H. Fortelny, Wilhelminenspital, department of general, visceral and tumor surgery, Vienna, Austria).

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5.3  Postoperative Pain be admitted to hospital and observed, and the hernia should be repaired surgically immediately. Reduction of the complete hernia is called en bloc reduction. Reduction of the hernia by tearing the hernial ring is called pseudotaxis. If either of these events takes place, the actual problem of bowel entrapment has not been eliminated, and the symptoms persist so that the intestinal ischemia progresses. When surgical reduction of the hernia is indicated, this should be done promptly. When choosing the procedure, the hernia contents must always be assessed. When an incarcerated inguinal hernia is treated under general anesthesia, for example, spontaneous reduction may occur, and in this case, the entire small intestine must be examined for vitality. It is not sufficient simply to repair the hernia. As regards open versus laparoscopic hernia repair, there is no generalized recommendation. If the treating institution has the appropriate expertise in laparoscopy, the procedure can be performed laparoscopically or endoscopically.14,24,58 Moreover, there are no clear recommendations on whether to repair the hernia with a mesh. However, there do not appear to be any contraindications to the use of polypropylene mesh.6,9,17,21,44

5.2.5  Incarceration Rates and Risk It is not possible to make a general statement about the risk of hernia incarceration. Many factors play a role in incarceration, including hernia location, hernial orifice size, nutritional status, and the patient’s age and sex. An incarceration rate of 0.3 to 3% per year is reported for inguinal hernia. Indirect inguinal hernias become incarcerated about 10 times more often than direct hernias.26,52 After adhesions, hernias appear to be the most frequent cause of small bowel obstruction.29 An eventual incarceration rate of up to 30% is reported for umbilical hernias.51 There is little information in the literature for ventral or incisional hernia but the rate of incarceration is markedly increased at a body mass index (BMI) of over 40 kg/m.2,37 The Herniamed database

currently describes 764 incarcerations with 19,518 recorded incisional hernias (3.9%).

5.3  Postoperative Pain Georg Arlt Postoperative pain after a hernia operation is classified as acute wound pain and chronic postoperative pain persisting beyond 3 months.

5.3.1  Acute Postoperative Pain Acute postoperative pain differs according to: •• The type of repaired hernia. •• The access route. •• The operation technique.

5

In inguinal and femoral hernia surgeries, acute postoperative pain is greatly determined by the access route. Pain along the course of the incisions predominates after open transinguinal and preperitoneal procedures, whereas pain is reported in the area of the dissected mesh site following endoscopic and laparoscopic operations. These symptoms are mild and are often perceived more as a type of extensive “hypersensitivity” than as wound pain. Overall, symptoms after endoscopic inguinal and femoral operations are less in the first 3 to 5 days than after open operations. The differences disappear after this time period. Major differences in pain perception within the first 3 to 6 hours after the operation are also found with different methods of anesthesia. More patients are pain-free up to 8 hours postoperatively after open repair under local anesthesia with long-acting anesthetics such as ropivacaine.46 Significantly less pain is reported within the first 3 to 4 hours postoperatively after operations performed under spinal anesthesia compared with procedures under general anesthesia with laryngeal mask or endotracheal intubation.31 Treatment of acute postoperative pain begins during the operation (▶Table 5.4). In open surgery of inguinal and femoral hernias, field block of the ilioinguinal and

Table 5.4  Recommendations for perioperative pain management after inguinal hernia repair in adults Phase

Measures

Pre- and intraoperative

Local anesthesia with long-acting drugs (e.g., ropivacaine) Field blocks of the ilioinguinal/iliohypogastric nerves Wound edge infiltration

Early postoperative (6–24 h)

Fixed schedule: NSAID/COX-2 inhibitor possibly with paracetamol (acetaminophen) Alternative for neuropathic pain: tramadol/oxycodone If necessary, further wound infiltration/field blocks

Postoperative (> 24 h)

Fixed schedule: NSAID/COX-2 inhibitor possibly with paracetamol (acetaminophen) From postoperative day 3: same medication as needed Alternative for neuropathic pain: tramadol/oxycodone

Abbreviations: COX-2, cyclooxygenase-2; NSAID, nonsteroidal anti-inflammatory drug.

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Complications iliohypogastric nerves close to the anterior superior iliac spine and wound edge infiltration at the conclusion of the operation provide effective analgesia for up to 8 hours postoperatively. Long-acting drugs, such as bupivacaine or ropivacaine, in a concentration of 0.5 to 1% are used. Lower concentrations are ineffective. Continued infiltration treatment is useful only until the first postoperative day. Symptoms subsequently are usually so mild that patients no longer benefit from further infiltration.31 Oral nonsteroidal anti-inflammatory drugs (NSAID) or cyclooxygenase-2 (COX-2) inhibitors are usually suitable for further analgesia. Paracetamol (acetaminophen) alone is often insufficient and should be combined with an NSAID/COX-2 inhibitor. Medication on a fixed schedule is recommended for the first 2 days after the operation, and it is then taken as needed (▶Table 5.4). Nonsteroidal anti-inflammatory drugs and paracetamol are ineffective for treatment of early postoperative neuropathic pain and symptoms should be managed with, for example, tramadol or oxycodone (▶Table 5.4). Early postoperative pain after endoscopic or laparoscopic procedures and all other hernia repairs of the abdominal wall can be reduced by wound edge infiltration. Extensive incisional hernia repair, especially above the umbilicus, produces considerable pain and corresponding interference with the accessory respiratory muscles. The risk of pulmonary complications is further increased by postoperative atony after the adhesiolysis that is usually necessary. In this situation, patients benefit from an epidural catheter inserted preoperatively. As a result of the very effective analgesia, pulmonary complications are observed less often and the goal of early mobilization is supported. Giving 4 to 8 mg of dexamethasone is another effective measure in the multimodal concept for ensuring immediate postoperative mobilization. A single dose of dexamethasone with the premedication immediately before the start of the operation improves general postoperative wellbeing and significantly lowers the risk of nausea, vomiting, dizziness, and fatigue. Medication with NSAID/ COX-2 inhibitors on a fixed schedule, possibly in combination with paracetamol, can be used for analgesia after the first 2 to 3 postoperative days.

5.3.2  Chronic Postoperative Pain after Inguinal and Femoral Hernia Operation Chronic postoperative pain refers to the pain that persists beyond a period of 3 months postoperatively. Depending on the definition of pain intensity, up to 60% of patients are affected after inguinal hernia repair. A severe and disabling pain syndrome occurs in 2 to 6%

of cases. Affected patients suffer from permanent or frequently recurring pain that requires treatment and interferes with their daily activities. The outcomes in about half of these patients include incapacity for work and depression. From experience to date, endoscopic and laparoscopic procedures are involved more rarely than open sutured or mesh repairs.20 However, chronic pain was described in up to 13.8% of patients after TEP or TAPP repair.18 Patientrelated risk factors for developing a disabling inguinal pain syndrome were often identified as surgery of recurrence through the same access,32 age under 65 years,54 a pessimistic preoperative attitude to the operation,47 severe pain immediately postoperatively,54 and female sex. As regards the operation technique, failure to expose potentially affected nerves, use of small-pored and heavyweight mesh,56 and certain mesh fixation techniques with tacks and staples were shown to be detrimental. There are extensive data on the chronic pain syndrome especially after Lichtenstein repair. It was shown that chronic pain correlates with failure to identify nerves at operation.2 Only 3 minutes are required for specific nerve exposure and this has an average success rate of 75%.36 Direct contact between nerves mobilized from their enveloping fascia and suture and mesh materials leads to irreversible damage to the myelin sheath and axon.16 Accordingly, an operation technique that includes ample neurolysis, preferably with nerve preservation, predisposes more to chronic pain.49 Nerves that cannot be moved from the operation field with their enveloping fascia should be resected.30 The same applies for nerves that are damaged intraoperatively. In case of doubt, resection should be preferred to an attempt at preservation.1 As regards mesh fixation, fibrin glue and self-adhesive grafts for Lichtenstein repair were associated with a lower rate of chronic pain syndrome than classic sutured fixation.11,48 The recommendations for preventing chronic groin pain are: •• Awareness of the patient’s risk factors, such as age, and sex. •• Alternative access route for surgery of recurrence: endoscopic after open operation and vice versa. •• Use of lightweight large-pored mesh. •• Reduction of mesh fixation to a minimum, possibly no mesh fixation in TEP, possibly mesh gluing in the Lichtenstein repair or loosely suturing the mesh cranially. •• Identification of the nerves. •• Avoidance of direct mesh-nerve contact. •• Facultative pragmatic neurectomy. The treatment of chronic groin pain comprises a number of methods. An attempt should always be made first to identify the possible cause of the pain. The character of the pain may provide clues. In theory, neuropathic pain as evidence for

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5.3  Postoperative Pain a nerve injury is distinguished from somatic pain (caused by staples, sutures, or hernia recurrence) and from visceral pain (testicular pain, painful ejaculation). In practice, these distinctions are often not possible from the different pain character alone. It is worthwhile, however, to distinguish neuropathic pain after nerve injury from non-neuropathic or nociceptive pain as the treatment approaches differ.

Immediately after injury, the affected nerve can be distinguished by its typical distribution pattern (▶Fig. 5.6). As a result of the peripheral nerve injury, however, structural changes take place in the nervous system after a short time, which can be summarized as peripheral and central sensitization (▶Table 5.5). This influences both the distribution pattern and the pain character.

T 12 L1 L2

Subcostal nerve (T12)

L3

Ilioinguinal nerve

L4

Iliohypogastric nerve

L5

Genitofemoral nerve Femoral branch

5

Genital branch Lateral cutaneous femoral nerve

Fig. 5.6  Peripheral nerves in the inguinal and femoral region with the corresponding areas of innervation.

Table 5.5  Pathophysiology of chronic pain syndrome after peripheral nerve lesion Sensitization

Causes

Peripheral sensitization with ectopic excitation due to

Damaged C afferents express Na channels on intact fibers Downregulation of the thresholds for heat and cold Sensitization of pain fibers for adrenergic substances

Central sensitization with reduction of descending inhibition by

Apoptosis of spinal inhibitory GABAergic interneurons Downregulation of supraspinal inhibition in the brainstem Cellular changes in the thalamus and sensory cortex

Abbreviation: GABA, gamma-aminobutyric acid.

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Complications The diagnostic algorithm includes a careful pain history and clinical examination with a description of hypo-, hyper- and paresthetic areas and a search for hernia recurrence. An ultrasound scan and possibly MRI should also be performed. This sometimes shows shrunken and creased mesh grafts (“meshoma”), or larger neuromas may be identified. The differential diagnosis includes vertebral symptoms, hip osteoarthritis, and insertion tendinopathies of the adductor and rectus muscles. Targeted local anesthesia close to the anterior superior iliac spine provides evidence for involvement of the ilioinguinal and iliohypogastric nerves (▶Fig. 5.7). As with all pain syndromes, the general recommendation for treating chronic groin pain is to eliminate the pain as early and effectively as possible. The NSAID and COX-2 inhibitors, possibly combined with paracetamol, are suitable analgesics for treating nociceptive pain. If their effect is insufficient, these drugs must be combined with a mild opioid such as tramadol. Neuropathic pain syndromes are treated with calcium channel-modulating anticonvulsants such as gabapentin or sodium channel blockers, e.g., carbamazepine. From clinical experience,

it may be necessary to combine calcium channel modulation or sodium channel block with an effective opioid analgesic, e.g., tramadol or oxycodone. Besides systemic therapy, successful topical treatment based on the vanilloid receptor agonist capsaicin has been described. Topical application of capsaicin leads to a reversible loss of function of nociceptive afferents in the skin and reduces the hyperalgesia that is often present in the peripheral neuropathic pain syndrome. Improvement or elimination of neuropathic pain after open inguinal hernia repair can be expected in about 75% of patients with local corticosteroid injection therapy5 or local radiofrequency ablation.50 Overall, the risk of reoperation because of persistent disabling pain after transinguinal groin hernia surgery is low at about 0.5%.15 Similar reliable data for endoscopic or laparoscopic repair are not available.

5.4  Triple Neurectomy Georg Arlt The term “triple neurectomy” as a treatment of chronic groin pain dates back to a publication by P.K. Amid in 2002.3 The purpose of the method is sensory denervation of the groin region in patients with chronic pain after inguinal hernia repair (▶Fig. 5.8). The dermatomes of the iliohypogastric and ilioinguinal nerves and the genital branch of the genitofemoral nerve overlap and, in addition, the pain areas resulting from peripheral nerve damage are regularly extended due to peripheral and central sensitizations; so, all three nerves are resected. Please refer to section ▶1.1 for details of the anatomy and innervation of the inguinal region. ▶Fig. 5.6 shows the sensory nerves with their corresponding dermatomes. All patients with pain persisting beyond the 3-month limit that seriously interferes with their daily activities (disabling pain syndrome) are potential candidates for surgical intervention. The success of treatment depends critically on patient selection. The following diagnostic algorithm is derived from the recommendations for this selection.

5.4.1 Diagnosis

Fig. 5.7  Diagnostic infiltration of local anesthetic at the anterior superior iliac spine to differentiate chronic groin pain.

Together with details of previous operations and a careful pain history using a visual analog scale (VAS), the areas of pain projection (▶Table 5.6) and evidence of hernia recurrence must be recorded in the clinical examination40 (for differential diagnosis, see section ▶5.3).

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5.4  Triple Neurectomy Fig. 5.8  Sketch of the operation area of transinguinal triple neurectomy. The dotted line shows the actual operation field where the nerve branches should be sought and resected over a long distance.

Iliohypogastric nerve Ilioinguinal nerve Deep inguinal ring

Genitofemoral nerve ve genital branch

Table 5.6  Pain characteristics: neuropathic versus nociceptive pain Neuropathic

Nociceptive

Typical trigger

Sitting, walking, stretching

Physical exertion

Pain duration

Shooting, episodic

Constant

Pain quality

Burning, stabbing

Pressing, boring, dragging

Pain area

Hypoesthesia/paresthesia

Skin sensation intact

Allodynia

No paresthesia

The most accurate information possible about the previous hernia repair should be obtained, as the causes of the pain may differ depending on access and mesh location. After transinguinal repair, involvement of the ilioinguinal and iliohypogastric nerves and of the genital branch are the primary causes. Moreover, after these procedures, irritation of the pubic periosteum is observed when periosteal sutures are placed too low, especially in the medial part of the inguinal region. When the mesh is in preperitoneal position, the genital branch is often involved in its course proximal to the deep inguinal ring. The ilioinguinal and iliohypogastric nerves are at risk when mesh is inserted preperitoneally if the mesh is fixed in the upper outer quadrants with staples and tacks that pass deeply (▶Fig. 5.9). Non-neuropathic pain is caused by scar-mesh tumors (meshomas) after transabdominal preperitoneal mesh repair (TAPP), totally extraperitoneal mesh repair (TEP), or transinguinal preperitoneal patch (TIPP) repair or results from scarring of rigid mesh with muscle or the bladder. After plug repairs, the implant often forms a very rough foreign body, sometimes shrunk to 30% of its original size, in the preperitoneal space, which compresses nerves and soft tissues during movement and causes corresponding symptoms. Following clinical examination, a diagnostic field block with local anesthetic is recommended immediately medial to the anterior superior iliac spine on the affected side. This measure tests the peripheral involvement of the

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Fig. 5.9  Three-dimensional CT scan of multiple clips and tacks after totally extraperitoneal mesh repair repair bilaterally with wide mesh fixation. Chronic pain syndrome is more pronounced on the right. Note several tacks in the pubic periosteum.

iliohypogastric and ilioinguinal nerves. If there is a positive response to this nerve block, neurectomy of these nerves is promising. If it is negative, the possibility of involvement of the genital branch or of a non-neuropathic pain syndrome, caused by a meshoma, irritation of the pubic periosteum,

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Complications or scarring of soft tissues with rigid mesh grafts should be considered in the differential diagnosis. Ultrasound can help to identify meshomas, periosteal edema, large neuromas, and scar granulomas and may find a hernia recurrence that cannot be detected clinically. It sometimes also shows the relation between an extended mesh graft and fascia, muscle, and the bladder. If ultrasound does not yield any clear result, an MRI scan to show the soft tissues in the affected inguinal region is indicated.

5.4.2 Indications Patients with persistent or new-onset disabling groin pain of neuropathic type beyond a 3-month postoperative interval are potential candidates for triple neurectomy. Pain syndromes not due to operation must be excluded. There should be no hernia recurrence or evidence of meshoma or other mesh-associated symptoms such as pubic periostitis. Diagnostic nerve block at the anterior superior iliac spine should have had a positive result. Dual neurectomy with resection of the ilioinguinal and iliohypogastric nerves, without including the genital branch, is an alternative, producing obliteration of the ilioinguinal and iliohypogastric nerves in the space between the internal oblique and transversus abdominis medial to the anterior superior iliac spine with radiofrequency ablation.33 Patients with a painful meshoma, suture- or mesh-­ related involvement of the pubic periosteum, or painful impairment of movement due to rigid mesh in the groin typically do not respond to diagnostic nerve block. For these patients, apart from long-term pharmacological analgesia, mesh explantation, possibly with simultaneous neurectomy, is a possibility.4,34

5.4.3  Operation Techniques The operation can be performed under local anesthesia,3 but others prefer spinal or general anesthesia so that the operation can be extended readily.4,41 The iliohypogastric

and ilioinguinal nerves are exposed through a transinguinal incision after splitting the external oblique aponeurosis on the internal oblique lateral to the deep inguinal ring, outside the previous operation area, and these are dissected proximally and distally as far as possible. The entire dissected length of the nerves is resected. When the operation is performed under spinal or general anesthesia, local anesthetic is injected beneath the nerves prior to resection. The proximal end is then ligated and the nerve stumps are buried in the internal oblique to prevent secondary contact with the inguinal ligament or the external oblique aponeurosis through scarring. Whether the ligature prevents the otherwise definite development of a nerve stump neuroma is still unclear. Without mobilizing the spermatic cord, the genital branch of the genitofemoral nerve is also exposed on the floor of the deep inguinal ring. This nerve is also dissected. With light traction, a ligature can be placed as far proximally as possible so that the nerve stump retracts spontaneously behind the level of the deep inguinal ring after resection and adhesions at the inguinal ring are avoided. All scarring and adhesions to foreign material along the course of the nerves are divided, and the parts of the mesh in question, sutures, and staples are likewise removed (▶Fig. 5.10). Laparoscopic triple neurectomy with division of all three nerves in their course on the iliopsoas muscle has been described as an alternative to the transinguinal procedure.55 To date, there are no reports of experience with this access in a larger group of patients.

5.4.4 Results Results published to date on neurectomy for chronic groin pain largely derive from small clinical series with different selection criteria and disparate follow-up. Average success rates of 60 to 70% are reported. In about one-third of treated patients, a sustained improvement

Fig. 5.10  Operation site showing the scarred ilioinguinal nerve and genital branch following Lichtenstein repair.

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5.4  Triple Neurectomy

Fig. 5.11  Explanted mesh after right-sided transabdominal preperitoneal mesh repair repair with extensive scarring of the genital branch of the genitofemoral nerve at the caudal mesh border. Persistent chronic groin pain after transinguinal triple neurectomy. Asymptomatic after additional mesh explantation.

in pain symptoms does not take place. In a few studies, a worsening was described in a few patients. Better results are regularly found in larger series of more than 50 patients, with 75 to 80% of patients becoming completely asymptomatic or obtaining a sustained improvement in symptoms.3,4,41 Apart from careful patient selection, the operative learning curve for the procedure may play a part.41 In the primary treatment failures, a complex pain syndrome is present in about half of the patients, whose symptoms are due not only to a peripheral nerve lesion but are also associated with a foreign body, e.g., meshoma, periostitis etc. These patients benefit in the long term from mesh explantation (▶Fig. 5.11).4 Recurrence of pain is observed in the long term in a few patients1 who develop symptomatic neuromas at the nerve stumps. If this is suspected, targeted diagnostic nerve blocks should be performed again. If the result is positive, further resection of the affected nerve stump can achieve freedom from symptoms.41

Further Reading [1] Alfieri S, Amid PK, Campanelli G, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia. 2011; 15(3):239–249 [2] Alfieri S, Rotondi F, Di Miceli D, et al; Groin Pain Trial Group. [Chronic pain after inguinal hernia mesh repair: possible role of surgical manipulation of the inguinal nerves. A prospective multicentre study of 973 cases] Chir Ital. 2006; 58(1):23–31

[3] Amid PK. A 1-stage surgical treatment for postherniorrhaphy neuropathic pain: triple neurectomy and proximal end implantation without mobilization of the cord. Arch Surg. 2002; 137(1):100–104 [4] Arlt GD, Huhn U, Kersten CC. Surgery for chronic inguinal pain: neurectomy, mesh explantation, or both? In: Schumpelick V, Fitzgibbons RJ (eds) Hernia repair sequelae. Berlin: Springer; 2010: 294–298 [5] Aroori S, Spence RA. Chronic pain after hernia surgery—an informed consent issue. Ulster Med J. 2007; 76(3):136–140 [6] Atila K, Guler S, Inal A, Sokmen S, Karademir S, Bora S. Prosthetic repair of acutely incarcerated groin hernias: a prospective clinical observational cohort study. Langenbecks Arch Surg. 2010; 395(5):563–568 [7] Berger D, Bientzle M, Müller A. Laparoskopische Narbenhernienreparation. Chirurg. 2002a; 73(9):905–908 [8] Berger D, Bientzle M, Müller A. Postoperative complications after laparoscopic incisional hernia repair. Incidence and treatment. Surg Endosc. 2002b; 16(12):1720–1723 [9] Bessa SS, Abdel-Razek AH. Results of prosthetic mesh repair in the emergency management of the acutely incarcerated and/or strangulated ventral hernias: a seven years study. Hernia. 2012; 26:26 [10] Bingener J, Buck L, Richards M, Michalek J, Schwesinger W, Sirinek K. Long-term outcomes in laparoscopic vs open ventral hernia ­repair. Arch Surg. 2007; 142(6):562–567 [11] Campanelli G, Pascual MH, Hoeferlin A, et al. Randomized, controlled, blinded trial of Tisseel/Tissucol for mesh fixation in patients undergoing Lichtenstein technique for primary inguinal hernia repair: results of the TIMELI trial. Ann Surg. 2012; 255(4):650–657 [12] Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002; 89(5):534–545 [13] Conze J, Kingsnorth AN, Flament JB, et al. Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg. 2005; 92(12):1488–1493 [14] Deeba S, Purkayastha S, Paraskevas P, Athanasiou T, Darzi A, Zacharakis E. Laparoscopic approach to incarcerated and strangulated inguinal hernias. JSLS. 2009; 13(3):327–331 [15] Delikoukos S, Fafoulakis F, Christodoulidis G, Theodoropoulos T, Hatzitheofilou C. Re-operation due to severe late-onset persisting groin pain following anterior inguinal hernia repair with mesh. Hernia. 2008; 12(6):593–595 [16] Demirer S, Kepenekci I, Evirgen O, et al. The effect of polypropylene mesh on ilioinguinal nerve in open mesh repair of groin hernia. J Surg Res. 2006; 131(2):175–181 [17] Derici H, Unalp HR, Nazli O, et al. Prosthetic repair of incarcerated inguinal hernias: is it a reliable method? Langenbecks Arch Surg. 2010; 395(5):575–579 [18] Dickinson KJ, Thomas M, Fawole AS, Lyndon PJ, White CM. Predicting chronic post-operative pain following laparoscopic inguinal hernia repair. Hernia. 2008; 12(6):597–601 [19] Dietz UA, Spor L, Germer CT. Therapie der Netz(-Implantat)Infektion. Chirurg. 2011; 82(3):208–217 [20] Eker HH, Langeveld HR, Klitsie PJ, et al. Randomized clinical trial of total extraperitoneal inguinal hernioplasty vs Lichtenstein repair: a long-term follow-up study. Arch Surg. 2012; 147(3):256–260 [21] Elsebae MM, Nasr M, Said M. Tension-free repair versus Bassini technique for strangulated inguinal hernia: A controlled randomized study. Int J Surg. 2008; 6(4):302–305 [22] Falagas ME, Makris GC. Mesh-related infections after hernia repair. In: Schumpelick V, Fitzgibbons RJ, eds. Hernia repair sequelae. Berlin: Springer; 2010: 98–102 [23] Ferrari GC, Miranda A, Di Lernia S, et al. Laparoscopic repair of incisional hernia: Outcomes of 100 consecutive cases comprising 25 wall defects larger than 15 cm. Surg Endosc. 2008; 22(5):1173–1179 [24] Ferzli G, Shapiro K, Chaudry G, Patel S. Laparoscopic extraperitoneal approach to acutely incarcerated inguinal hernia. Surg Endosc. 2004; 18(2):228–231 [25] Finan KR, Vick CC, Kiefe CI, Neumayer L, Hawn MT. Predictors of wound infection in ventral hernia repair. Am J Surg. 2005; 190(5):676–681

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Complications [26] Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg. 1991; 78(10):1171–1173 [27] Greif R, Akça O, Horn EP, Kurz A, Sessler DI; Outcomes Research Group. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. N Engl J Med. 2000; 342(3):161–167 [28] Hopf HW. Patient factors as a major determinant of wound outcome and infection after surgery. In: Schumpelick V, Fitzgibbons RJ, eds. Hernia repair sequelae. Berlin: Springer; 2010:294–298 [29] Ihedioha U, Alani A, Modak P, Chong P, O’Dwyer PJ. Hernias are the most common cause of strangulation in patients presenting with small bowel obstruction. Hernia. 2006; 10(4):338–340 [30] Johner A, Faulds J, Wiseman SM. Planned ilioinguinal nerve excision for prevention of chronic pain after inguinal hernia repair: a meta-analysis. Surgery. 2011; 150(3):534–541 [31] Joshi GP, Rawal N, Kehlet H, et al; PROSPECT collaboration. Evidence-based management of postoperative pain in adults undergoing open inguinal hernia surgery. Br J Surg. 2012; 99(2):168–185 [32] Kalliomäki ML, Meyerson J, Gunnarsson U, Gordh T, Sandblom G. Long-term pain after inguinal hernia repair in a population-based cohort; risk factors and interference with daily activities. Eur J Pain. 2008; 12(2):214–225 [33] Kastler A, Aubry S, Piccand V, Hadjidekov G, Tiberghien F, Kastler B. Radiofrequency neurolysis versus local nerve infiltration in 42 patients with refractory chronic inguinal neuralgia. Pain Physician. 2012; 15(3):237–244 [34] Keller JE, Stefanidis D, Dolce CJ, Iannitti DA, Kercher KW, Heniford BT. Combined open and laparoscopic approach to chronic pain after inguinal hernia repair. Am Surg. 2008; 74(8):695–700; discussion 700–701 [35] Lammers BJ, Meyer HJ, Huber HG, Gross-Weege W, Röher HD. Developments in inguinal hernia based on newly introduced intervention techniques in the North Rhine district [Article in German] Chirurg. 2001; 72(4):448–452 [36] Lange JF, Wijsmuller AR, van Geldere D, et al. Feasibility study of three-nerve-recognizing Lichtenstein procedure for inguinal hernia. Br J Surg. 2009; 96(10):1210–1214 [37] Lau B, Kim H, Haigh PI, Tejirian T. Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernias. Am Surg. 2012; 78(10):1118–1121 [38] Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg. 1998; 133(4):378–382 [39] LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy in 100 patients. Am J Surg. 2000; 180(3):193–197 [40] Loos MJ, Roumen RM, Scheltinga RM. Classifying postherniorrhaphy pain syndromes following elective inguinal hernia repair. World J Surg. 2007; 31(9):1760–1765, discussion 1766–1767 [41] Loos MJ, Scheltinga RM, Roumen RM. Tailored neurectomy for treatment of postherniorrhaphy inguinal neuralgia. Surgery. 2010; 147(2):275–281 [42] Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR; Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999; 20(4):250–278; quiz 279–280

[43] McGreevy JM, Goodney PP, Birkmeyer CM, Finlayson SR, Laycock WS, Birkmeyer JD. A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs. Surg Endosc. 2003; 17(11):1778–1780 [44] Nieuwenhuizen J, van Ramshorst GH, ten Brinke JG, et al. The use of mesh in acute hernia: frequency and outcome in 99 cases. Hernia. 2011; 15(3):297–300 [45] Olmi S, Scaini A, Cesana GC, Erba L, Croce E. Laparoscopic versus open incisional hernia repair: an open randomized controlled study. Surg Endosc. 2007; 21(4):555–559 [46] Peiper C, Ehrenstein P, Schubert D, Junge K, Krones C, Schumpelick V. Ropivacain zur Leistenhernienoperation in Lokalanästhesie. Eine prospektiv randomisierte, doppelt blind kontrollierte Studie. Chirurg. 2005; 76(5):487–492 [47] Powell R, Johnston M, Smith WC, et al. Psychological risk factors for chronic post-surgical pain after inguinal hernia repair surgery: a prospective cohort study. Eur J Pain. 2012; 16(4):600–610 [48] Quyn AJ, Weatherhead KM, Daniel T. Chronic pain after open inguinal hernia surgery: suture fixation versus self-adhesive mesh repair. Langenbecks Arch Surg. 2012; 397(8):1215–1218 [49] Reinpold WM, Nehls J, Eggert A. Nerve management and chronic pain after open inguinal hernia repair: a prospective two phase study. Ann Surg. 2011; 254(1):163–168 [50] Rozen D, Ahn J. Pulsed radiofrequency for the treatment of ilioinguinal neuralgia after inguinal herniorrhaphy. Mt Sinai J Med. 2006; 73(4):716–718 [51] Schumpelick V. Nabelhernie. In: Schumpelick V, ed. Hernien, 1st ed. Stuttgart: Thieme; 1996 [52] Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009; 13(4):343–403 [53] Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2009; 13(4):343–403 [54] Singh AN, Bansal VK, Misra MC, et al. Testicular functions, chronic groin pain, and quality of life after laparoscopic and open mesh repair of inguinal hernia: a prospective randomized controlled trial. Surg Endosc. 2012; 26(5):1304–1317 [55] Song JW, Wolf JS, Jr, McGillicuddy JE, Bhangoo S, Yang LJ. Laparoscopic triple neurectomy for intractable groin pain: technical report of 3 cases. Neurosurgery. 2011; 68(2, Suppl Operative):339–346, discussion 346 [56] Uzzaman MM, Ratnasingham K, Ashraf N. Meta-analysis of randomized controlled trials comparing lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair. Hernia. 2012; 16(5): 505–518 [57] Weber WP, Marti WR, Zwahlen M, et al. The timing of surgical antimicrobial prophylaxis. Ann Surg. 2008; 247(6):918–926 [58] Yang GP, Chan CT, Lai EC, Chan OC, Tang CN, Li MK. Laparoscopic versus open repair for strangulated groin hernias: 188 cases over 4 years. Asian J Endosc Surg. 2012; 5(3):131–137[59] Zacest AC, Magill ST, Anderson VC, Burchiel KJ. Long-term outcome following ilioinguinal neurectomy for chronic pain. J Neurosurg. 2010; 112(4):784–789

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6 6.1 Training in Hernia Surgery: Hernia Compact—Young Surgery as a 3-Day Further Education Course

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Miscellaneous

6  Miscellaneous 6.1  Training in Hernia Surgery: Hernia Compact—Young Surgery as a 3-Day Further Education Course Ralph Lorenz, Bernd Stechemesser, and Wolfgang Reinpold Training surgical residents in hernia surgery is a particular challenge today. Many doctors in training are dissatisfied with current hernia surgery training.12 This is especially due to: •• The variety of available methods nowadays.4 •• The enormous variety of materials (meshes and fixation systems).4 •• The increased complexity of the procedures. •• The lack of training procedures. •• The growing shift of “uncomplicated” hernia operations from the universities and higher teaching hospitals to the ambulant sector.4 •• The absence of standards and guidelines for the individual operation techniques. •• Altered hospital structures with increasing emphasis on economy. •• A lack of structures in further education.12 •• A lack of evidence regarding training and further education models. •• Poor training of mentors and those in charge of further education.12 Added to this are the following special features: •• The “best operation technique” employed in practice is often not technically justified. It is usually guided by where and under which external conditions the operation takes place.4 •• Rotation of surgical trainees to a special ambulant surgery institution appears useful in view of the increasing shift of uncomplicated hernia procedures to the ambulant sector.6 •• The learning curve for endoscopic hernia procedures (especially totally extraperitoneal [TEP]) is generally regarded as longer than for open hernia repair.9 •• Significantly longer operation duration is described in the course of the learning curve,10,18 while serious complications may also occur at the same time.10 Surgical training can be radically improved by an additional special anatomy course. The nerve identification success rate during inguinal hernia operations was increased significantly.2 Simulated operations on cadavers

increase surgical skills.3 Furthermore, use of simulation models and other virtual technologies can improve and speed up the training of resident doctors in the area of hernia surgery.16,18

6.2  Hernia Register: Outcome Research in Hernia Surgery Ferdinand Köckerling, Dietmar Jacob, and Christine Schug-Paß Hernia is the most frequent diagnosis worldwide requiring surgery. Of the just under 7 billion people on earth, roughly 1 million will develop an inguinal hernia in their lifetime. According to estimates of the international hernia societies, 20 million inguinal hernias are operated on annually worldwide. In Germany, 275,000 inguinal hernias and just under 100,000 abdominal wall hernias are currently treated annually.11 Despite the high number of hernia surgery procedures, the results are anything but satisfactory. In Germany, the rates of both recurrence and chronic groin pain after inguinal hernia operations are over 10%.15 More than 100 different operative methods have been described for managing inguinal hernias. Year on year, new hernia meshes and fixation techniques for these meshes come into the market without scrutiny of their effectiveness in clinical studies. Guidelines on the treatment of inguinal hernia in adults were first issued in 2009 by the European Hernia Society (EHS).14 Also, the development of binding classifications of inguinal and abdominal wall hernias took place only in the past few years.7,8 The International Endohernia Society guidelines on endoscopic inguinal hernia repair procedures were published in 2011.1 The results of many clinical studies have only limited application to routine management.17 Systematic review articles, which are accepted as the highest level in evidence-based medicine and have a major influence on health policy decisions, only perpetuate this problem, as they summarize the available evidence from individual studies. Routine management, however, takes place in a complex context. What is important for patients is the ultimate outcome of the actual treatment.17 The task of applied healthcare research is to assist implementation of the knowledge generated by evidencebased science in routine clinical practice, evaluate it, and ultimately research the outcome. Based on this framework, hernia surgery is thus an ideal area for healthcare research, as it is performed on both an ambulant and inpatient basis in hospitals and

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6.2  Hernia Register: Outcome Research in Hernia Surgery medical practices. Thus, specific healthcare structures are examined at the same time. The aim of Herniamed, a non-profit project, is ultimately to improve quality across the entire spectrum of hernia surgery. For instance, it was shown in Denmark that there was a significant reduction in recurrence rates following introduction of a hernia registry.5 The demand of the society to deliver outcome quality after surgery is accordingly becoming ever louder.13

6.2.1  Patient Data and Methodology Project The non-profit Herniamed society was founded in 2009 to implement the hernia surgery outcome research project. This is a network of German-speaking surgeons particularly interested in hernia surgery, which will be international in future due to cooperation with the EHS. The key aspect of the Herniamed project is an internetbased registry in which all interested hospitals and surgeons can easily and quickly input the hernia operations they have performed according to a well-founded scientific standard. The treatment results are followed up for 10 years so that late problems can be identified. Based on these results, the best treatment options for patients can be elaborated from the latest information by constant analysis and publications. The database includes all forms of abdominal wall hernias, such as inguinal, umbilical, incisional, and epigastric hernias. In addition, data regarding internal hernias and the rarer parastomal and hiatal hernias are included. The German Hernia Society (DHG) has now established participation in a quality assurance study as a requirement for hernia center certification.

Informed Consent Prior to the operation, each patient is asked to sign an informed consent form that includes data protection consent after his doctor has given him detailed information. The aims of the general data capture are mentioned and he is informed that the anonymous treatment and follow-up data will be sent to the central database of the non-profit society Herniamed. The data are stored only when the patient gives his consent; the data can be deleted at any time at the patient’s wish.

Recording of Clinical Data General Part All data from patients included in the Herniamed registry are recorded prospectively in special study forms by

the treating doctors. Each form is configured specifically according to hernia type in the current EHS classification.

Patient Data Patients are asked about risk factors that can influence hernia pathogenesis and the development of postoperative complications, such as chronic obstructive pulmonary disease (COPD), bronchial asthma, diabetes mellitus, aortic aneurysm, immunosuppression, corticosteroid therapy, smoking, clotting disorders, use of antiplatelet drugs (or whether these were discontinued in good time before the operation) and use of coumarin derivatives. Patients’ current health status is recorded according to the American Society of Anesthesiologists (ASA) grading. Patients are graded preoperatively by the treating anesthetist into grade I-IV based on systemic diseases (ASA 1: normal healthy patient, ASA 2: patient with mild systemic disease, ASA 3: patient with severe systemic disease, ASA 4: patient with severe systemic disease that is constantly life-threatening). All previous operations in the abdomen and groin region are classified as laparoscopic/endoscopic or open and noted down. Preoperative pain is reported by the patients using a numerical analog scale (NAS). This is a self-assessment scale from 0 to 10, where 0 corresponds to no pain and 10 to the most severe pain. The pain event must occur within 4 weeks preoperatively.

6

Operation Data Inpatient or ambulant care is recorded and whether the operation is urgent (emergency within 24 hours) or elective. The form of anesthesia is classified as local, spinal, or general anesthesia. The operative documentation includes the surgeon, any incarceration, bowel resection, operation time, antibiotic therapy (single shot, a few days, no therapy), and whether this is a primary operation or the number of previous recurrences and their management. All currently licensed meshes are listed by manufacturers and can be checked, ensuring clear identification. The effective width and length of the meshes used and mesh fixation (suture, tacks, glue) are documented. Use of a drain is recorded. Tacks and glue used are also listed and recorded precisely by the manufacturer and on the product.

Complications Bleeding or injuries of blood vessels, stomach, spleen, bowel, and liver are noted as intraoperative complications. Postoperative complications are divided into surgical and general complications. The predefined surgical complications comprise secondary bleeding, bowel injury, suture

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Miscellaneous dehiscence, impaired wound healing, seroma, infection, symptoms of obstruction, and whether reoperation was performed. The predefined general complications comprise fever (> 38.0°C, > 1 day), hypertensive crisis, gastritis/ulcers, renal failure, pleural effusion, diarrhea, heart failure, pulmonary embolism, myocardial infarction, COPD/asthma, urinary tract infection, coronary heart disease (CHD), thrombosis, pneumonia, and perioperative mortality.

Pain Postoperative pain is documented like preoperative pain using the NAS. In this category, the worst pain event within 7 days postoperatively is recorded. Analgesic use and duration (in days) are recorded and any existing nerve lesions and dysesthesia are noted.

European Hernia Society Classification All hernia types included in the hernia quality assurance are coded by the surgeon according to the current EHS classification (where applicable). Epigastric hernias are classified as small (