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Acs0527 Open Repair Of Abdominal Wall Hernia 2007
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Acs0527 Open Repair Of Abdominal Wall Hernia 2007 Acs0527 Open Repair Of Abdominal Wall Hernia 2007 Document Transcript

  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 1 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA Robert J. Fitzgibbons, Jr., M.D., F.A.C.S., Alan T. Richards, M.D., F.A.C.S., and Thomas H. Quinn, Ph.D. Abdominal wall hernias are so common that their management and in those who have previously undergone inguinal hernia constitutes the largest part of the average general surgeon’s prac- repair. tice. In the past, personal recollections and single-center series The prevalence of abdominal wall hernias is difficult to deter- written by experts with a vested interest in publishing good results mine, as the wide range of published figures in the literature illus- were the principal data sources that surgeons relied on in choosing trates.The major reasons for this difficulty are (1) the lack of stan- the optimum treatment strategy for a patient. In recent years, for- dardization in how inguinal and ventral hernias are defined, (2) the tunately, population-based studies have provided much better data inconsistency of the data sources used (which include self-report- on the true failure rates associated with the various herniorrha- ing by patients, audits of routine physical examinations, and insur- phies. In addition, trials designed to examine the natural history of ance company databases, among others), and (3) the subjectivity hernias have shed some light on nonoperative treatment options. of physical examination, even when performed by trained sur- In this chapter, we describe many different operations for geons. Most authorities, however, subscribe to the two-peak theo- abdominal wall hernias. A well-known surgical dictum states that ry for inguinal hernias, which states that that a new diagnosis of an when numerous different operations exist to treat the same dis- inguinal hernia is most likely in patients younger than 1 year and ease, the perfect procedure does not exist. This dictum does not in patients older than 55 years. Clearly, though, hernias can be hold true for abdominal wall herniorrhaphy, however. Because the diagnosed across any given age group.4 A 1996 analysis of a geo- disease is so heterogeneous, many different procedures are needed graphically defined population in the United Kingdom estimated to address individual patients’ needs; thus, it can be said that mul- that the lifetime risk of having to undergo an inguinal hernia repair tiple perfect procedures exist. was 27% for men and 3% for women.5 The incidence of the most common type of ventral hernia, inci- sional hernia, depends on how the condition is defined. The best Epidemiology definition of incisional hernia is any abdominal wall gap, with or In the United States, approximately 1,000,000 abdominal without a bulge, that is perceptible on clinical examination or diag- wall herniorrhaphies are performed each year, of which 750,000 nostic imaging within 1 year after the index operation. A definition are for inguinal hernias, 166,000 for umbilical hernias, 97,000 that requires the presence of a visible bulge will lead to underesti- for incisional hernias, 25,000 for femoral hernias, and 76,000 for mation of the true incidence of the condition. The reported inci- miscellaneous hernias.1 About 75% of all abdominal wall hernias dence of incisional hernia after a midline laparotomy ranges from occur in the groin.Worldwide, some 20 million groin hernias are 3% and 20%, and it doubles if the index operation was associated repaired each year.2 Inguinal hernias are more common on the with infection. Incisional hernias are most common after midline right side than on the left. They occur seven times more fre- and transverse incisions, but they are also well documented after quently in males than in females; only 8% of groin hernia repairs paramedian, subcostal, McBurney (gridiron), and Pfannenstiel are performed in women. Femoral hernias account for fewer incisions.6 An analysis of 11 publications dealing with ventral her- than 10% of all groin hernias; however, 40% present as emer- nia incidence after various types of incisions concluded that the gencies (i.e., with incarceration or strangulation), and mortality risk was 10.5% for midline incisions, 7.5% for transverse incisions, is higher for emergency repair than for elective repair. In male and 2.5% for paramedian incisions.7 Upper midline incisions are patients, indirect inguinal hernias are the most common type, associated with the highest incidence of ventral hernia formation, occurring approximately twice as frequently as direct inguinal transverse or oblique incisions with the lowest. Muscle-splitting hernias; femoral hernias account for a much smaller percentage. incisions probably have a lower incidence of incisional hernias, but In female patients, indirect inguinal hernias are also the most such incisions restrict access to the abdominal cavity. Most inci- common type, but femoral hernias are seen more frequently sional hernias are detected within 1 year of surgery; the most com- than direct hernias, which are rare in this population. Emergency mon cause is believed to be separation of aponeurotic edges in the operations are more frequently required for female patients. In a early postoperative period. The male-to-female incidence ratio is study from the Swedish Hernia Registry that analyzed 90,648 1:1, even though early evisceration is more common in males. inguinal hernia operations (88,753 in men, 6,895 in women) At present, little information is available on the risk of major between 1992 and 2003, emergency operations were more fre- complications arising from untreated abdominal wall hernias. quently needed in women (16.9%) than in men (5.0%), leading The main reason for this scarcity of data is that surgeons are to bowel resection in 16.6% and 5.6% of cases, respectively.3 taught, first, that all hernias, even asymptomatic ones, should be Femoral recurrences were particularly common in women repaired at diagnosis to prevent potential strangulation or bowel whose diagnosis at the time of the primary repair was direct or obstruction, and second, that herniorrhaphy becomes more diffi- indirect hernia (41.6%, compared with 4.6% for men), a finding cult the longer repair is delayed. As a result, it is difficult to find strongly suggesting that a hernia was missed at the original pro- a whole population in which at least some of the members do not cedure. Femoral hernias are also more common in older patients routinely have their hernias repaired regardless of symptoms. In
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 2 Table 1—Nyhus Classification System for Table 3—Classification System for Incisional Hernias Groin Hernias Parameter Categories Type Description Vertical Midline, above or below umbilicus 1 Indirect hernia with normal internal abdominal ring. This type is typically seen in infants, children, and small adults. Midline, including umbilicus Paramedian Indirect hernia in which internal ring is enlarged without impinge- Transverse 2 ment on the floor of the inguinal canal. Hernia does not extend Location Above or below umbilicus to the scrotum. Crosses midline 3A Direct hernia. Size is not taken into account. Oblique Above or below umbilicus Indirect hernia that has enlarged enough to encroach upon the Combined posterior inguinal wall. Indirect sliding or scrotal hernias are usu- 3B ally placed in this category because they are commonly associ- < 5 cm ated with extension to direct space. This type also includes pantaloon hernias. Size* 5–10 cm > 10 cm 3C Femoral hernia. Primary Recurrent hernia. Modifiers A, B, C, and D are sometimes added Recurrence Multiply recurrent 4 to type 4, corresponding to indirect, direct, femoral, and mixed, Stratification for type of previous repair respectively. Yes Obstruction these circumstances, accurate estimates of the natural history of No obstruction Reducibility the disease are impossible. No The natural history of an untreated, minimally symptomatic Obstruction inguinal hernia was addressed in a randomized, controlled trial No obstruction from 2006, in which 364 men were assigned to “watchful waiting” Asymptomatic (WW), and 356 men underwent routine operation.8 Only two Symptoms Symptomatic patients in the WW group required emergency operations for *Difficult to measure consistently. strangulation over the follow-up period of 2 to 4.5 years. This result translated into a rate of 1.8 per 1,000 patient-years (0.18%), or about one fifth of 1% for each year that the hernia remains recovered uneventfully. The question that remained to be unrepaired.The two patients who required emergency operations answered was, which group fared better overall, the WW group or the group whose hernias were repaired immediately in accordance with conventional teaching? The answer to this question was at Table 2 Zollinger Classification System for variance with conventional assumptions. At the conclusion of the Ventral Abdominal Wall Hernias study, functional status, as measured by quality-of-life instruments and pain scales, was identical in the two groups. About one third Type Examples of the patients in the WW group crossed over to undergo opera- tive treatment, principally because of symptom progression. Omphalocele However, there appeared to be no penalty for delaying surgery. Congenital Gastroschisis Umbilical (infant) Before this study, most surgeons assumed that a hernia would become harder to repair the longer it remained (because of Midline enlargement and buildup of scar tissue) and that patients whose Diastasis recti operations were delayed would experience more complications. Epigastric The investigators found, however, that postoperative complication Umbilical (adult, acquired, paraumbilical) rates were the same in patients who underwent immediate surgery Acquired Median Supravesical (anterior, posterior, lateral) as in those who were assigned to watchful waiting but had to cross Paramedian over to surgical treatment. Spigelian Interparietal Classification of Inguinal and Ventral Hernias Midline Numerous classification schemes for groin hernias have been Paramedian Incisional devised, usually bearing the name of the responsible investigator Transverse Special operative sites or investigators (e.g., Casten, Lichtenstein, Gilbert, Robbins and Rutkow, Bendavid, Nyhus, Schumpelick, and Zollinger).The vari- Penetrating, autopenetrating* ety of classifications in current use indicates that the perfect sys- Blunt tem has yet to be developed.9 The main problem in developing a Focal, minimal injury Traumatic single classification scheme suitable for wide application is that it Moderate injury Extensive force or shear is impossible to eliminate subjective measurements so as to ensure Destructive consistency from observer to observer.The advent of laparoscop- ic herniorrhaphy has further complicated the issue in that some of *Penetration from host tissue such as bone. the measurements needed cannot be obtained via a laparoscopic
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 3 approach. At present, the Nyhus system enjoys the greatest degree and enter the skin through the subcutaneous tissue. of acceptance [see Table 1]. The first layers encountered beneath the skin are Camper’s and A classification system for abdominal wall hernias outside the Scarpa’s fasciae in the subcutaneous tissue. The only significance groin has been proposed by Zollinger [see Table 2].10 Ventral inci- of these layers is that when sufficiently developed, they can be reap- sional hernias are common enough to warrant their own discrete proximated to provide another layer between a repaired abdominal classification system.The scheme most often used for categorizing wall and the outside. The major blood vessels of this superficial incisional hernias [see Table 3] was the result of a 1998 consensus fatty layer are the superficial inferior and superior epigastric ves- conference held in conjunction with the European Hernia sels, the intercostal vessels, and the superficial circumflex iliac ves- Society’s annual congress.11 This system is important in that it sels (which are branches of the femoral vessels). affords investigators a reliable means of comparing results between The external oblique muscle is the most superficial of the great one procedure and another or between one center and another. flat muscles of the abdominal wall [see Figure 1].This muscle aris- es from the posterior aspects of the lower eight ribs and interdigi- tates with both the serratus anterior and the latissimus dorsi at its Abdominal Wall Anatomy origin.The posterior portion of the external oblique muscle is ori- The skin of the lower anterior abdominal wall is innervated ented vertically and inserts on the crest of the ilium. The anterior by anterior and lateral cutaneous branches of the ventral rami portion of the muscle courses inferiorly and obliquely toward the of the seventh through 12th intercostal nerves and by the ven- midline and the pubis. The muscle fibers give way to form its tral rami of the first and second lumbar nerves. These nerves aponeurosis, which occurs well above the inguinal region. The course between the lateral flat muscles of the abdominal wall obliquely arranged anterior inferior fibers of the aponeurosis of the Linea Alba Anterior Rectus Sheath Semilunar Rectus Line Abdominis Internal Oblique Muscle Transversus Abdominis External Oblique Muscle Posterior Rectus Inguinal Sheath Ligament Arcuate Line External Oblique Muscle Aponeurosis of Internal Internal Oblique Oblique Muscle (Fused with Muscle Anterior Rectus Sheath) Transversus Abdominis Muscle and External Ring Aponeurosis Medial Crus Spermatic Cord Inferior Reflected Epigastric External Vessels Oblique Aponeurosis Superficial Transversalis Inguinal Fascia Ring Spermatic Cord Figure 1 Shown are the great flat muscles of the abdominal wall. The insert depicts the relationship of the great muscles to the groin.
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 4 external oblique muscle fold back upon themselves to form the face of the muscle, leaving only transversalis fascia to cover the pos- inguinal ligament, which attaches laterally to the anterior superior terior surface of the rectus abdominis. iliac spine. In most persons, the medial insertion of the inguinal lig- The innervation of the anterior wall muscles is multifaceted. ament is dual: one portion of the ligament inserts on the pubic The seventh through 12th intercostal nerves and the first and sec- tubercle and the pubic bone, whereas the other portion is fan- ond lumbar nerves provide most of the innervation of the lateral shaped and spans the distance between the inguinal ligament prop- muscles, as well as of the rectus abdominis and the overlying skin. er and the pectineal line of the pubis. This fan-shaped portion of The nerves pass anteriorly in a plane between the internal oblique the inguinal ligament is called the lacunar ligament. It blends lat- muscle and the transversus abdominis, eventually piercing the lat- erally with Cooper’s ligament (or, to be anatomically correct, the eral aspect of the rectus sheath to innervate the muscle therein.The pectineal ligament). The more medial fibers of the aponeurosis of external oblique muscle receives branches of the intercostal nerves, the external oblique muscle divide into a medial crus and a lateral which penetrate the internal oblique muscle to reach it. The ante- crus to form the external or superficial inguinal ring, through rior ends of the nerves form part of the cutaneous innervation of which the spermatic cord (in females, the round ligament) and the abdominal wall. The first lumbar nerve divides into the ilioin- branches of the ilioinguinal and genitofemoral nerves pass.The rest guinal nerve and the iliohypogastric nerve [see Figure 2]. These of the medial fibers insert into the linea alba after contributing to important nerves lie in the space between the internal oblique the anterior portion of the rectus sheath. muscle and the external oblique aponeurosis. They may divide Beneath the external oblique muscle is the internal oblique within the psoas major or between the internal oblique muscle and muscle.The fibers of the internal oblique muscle fan out following the transversus abdominis. The ilioinguinal nerve may communi- the shape of the iliac crest, so that the superior fibers course cate with the iliohypogastric nerve before innervating the internal obliquely upward toward the distal ends of the lower three or four oblique muscle. The ilioinguinal nerve then passes through the ribs while the lower fibers orient themselves inferomedially toward external inguinal ring to run parallel to the spermatic cord, while the pubis to run parallel to the external oblique aponeurotic fibers. the iliohypogastric nerve pierces the external oblique muscle to These fibers arch over the round ligament or the spermatic cord, innervate the skin above the pubis. The cremaster muscle fibers, forming the superficial part of the internal (deep) inguinal ring. which are derived from the internal oblique muscle, are innervat- Beneath the internal oblique muscle is the transversus abdo- ed by the genitofemoral nerve.There can be considerable variabil- minis.This muscle arises from the inguinal ligament, the inner side ity and overlap. of the iliac crest, the endoabdominal fascia, and the lower six costal The blood supply of the lateral muscles of the anterior wall cartilages and ribs, where it interdigitates with the lateral diaphrag- comes primarily from the lower three or four intercostal arteries, matic fibers. The medial aponeurotic fibers of the transversus the deep circumflex iliac artery, and the lumbar arteries. The rec- abdominis contribute to the rectus sheath and insert on the pecten tus abdominis has a complicated blood supply that derives from ossis pubis and the crest of the pubis, forming the falx inguinalis. the superior epigastric artery (a terminal branch of the internal Infrequently, these fibers are joined by a portion of the internal thoracic [internal mammary] artery), the inferior epigastric artery oblique aponeurosis; only when this occurs is a true conjoined ten- (a branch of the external iliac artery), and the lower intercostal don formed.12 Aponeurotic fibers of the transversus abdominis also form the Quadratus structure known as the aponeurotic arch. It is theorized that con- Lumborum traction of the transversus abdominis causes the arch to move downward toward the inguinal ligament, thereby constituting a form of shutter mechanism that reinforces the weakest area of the L3 groin when intra-abdominal pressure is raised. The area beneath Iliohypogastric the arch varies. Many authorities believe that a high arch, resulting Nerve Genitofemoral in a larger area from which the transversus abdominis is by defin- Nerve ition absent, is a predisposing factor for a direct inguinal hernia. Ilioinguinal The transverse aponeurotic arch is also important because the Nerve term is used by many authors to describe the medial structure that Sympathetic Trunk is sewn to the inguinal ligament in many of the older inguinal her- nia repairs. Psoas Muscle The rectus abdominis forms the central anchoring muscle mass of the anterior abdomen. It arises from the fifth through seventh Genital Branch costal cartilages and inserts on the pubic symphysis and the pubic of Genitofemoral Nerve crest. It is innervated by the seventh through 12th intercostal nerves, which laterally pierce the aponeurotic sheath of the muscle. The semilunar line is the slight depression in the aponeurotic fibers Iliohypogastric coursing towards the muscle. In a minority of persons, the small Nerve pyramidalis muscle accompanies the rectus abdominis at its inser- Ilioinguinal tion.This muscle arises from the pubic symphysis. It lies within the Nerve rectus sheath and tapers to attach to the linea alba, which repre- Lateral Femoral External sents the conjunction of the two rectus sheaths and is the major site Cutaneous Nerve Spermatic Nerve of insertion for three aponeuroses from all three lateral muscle lay- Femoral Branch ers.The line of Douglas (i.e., the arcuate line of the rectus sheath) of Genitofemoral is formed at a variable distance between the umbilicus and the Nerve inguinal space because the fasciae of the large flat muscles of the Figure 2 Shown are the important nerves of the lower abdomi- abdominal wall contribute their aponeuroses to the anterior sur- nal wall.
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 5 arteries.The lower intercostal arteries enter the sides of the muscle after traveling between the oblique muscles; the superior and the Table 4—Commercially Available Synthetic inferior epigastric arteries enter the rectus sheath and anastomose Prostheses for Abdominal Wall Hernia Repair near the umbilicus. The endoabdominal fascia is the deep fascia covering the inter- Polypropylene/polyester nal surface of the transversus abdominis, the iliacus, the psoas Bard Composix E/X Mesh (PPL + ePTFE) major and minor, the obturator internus, and portions of the Bard Dulex Mesh (dual-sided) (PPL + ePTFE) periosteum. It is a continuous sheet that extends throughout the Bard Kugel Hernia Patch (PPL + ePTFE + PPL ring) extraperitoneal space and is sometimes referred to as the wallpaper Bard Ventralex (PPL + ePTFE + PPL tail) Sofradim Parietene (PPL + hydrophilic collagen) of the abdominal cavity. Commonly, the endoabdominal fascia is Sofradim Parietex (PPL + hydrophilic collagen) subclassified according to the muscle being covered (e.g., iliac fas- Genzyme Sepramesh (PPL + Seprafilm) cia or obturator fascia). Ethicon Prolene Soft Mesh (PPL) The transversalis fascia is particularly important for inguinal Ethicon Proceed (PPL + PDS + ORC) hernia repair because it forms anatomic landmarks known as ana- Ethicon Ultrapro (PPL + poliglecaprone 25) logues or derivatives. The most significant of these analogues for Ethicon Vicryl Knitted Mesh groin hernia surgeons are the iliopectineal arch, the iliopubic tract, Gore-Tex Soft Tissue Patch (ePTFE) the crura of the deep inguinal ring, and Cooper’s ligament (i.e., the Gore-Tex DualMesh (ePTFE) pectineal ligament). The superior and inferior crura form a Gore-Tex DualMesh Plus (ePTFE + silver + chlorhexidine) “monk’s hood”–shaped sling around the deep inguinal ring. This Gore-Tex MycroMesh (ePTFE) sling has functional significance, in that as the crura of the ring are PPL—polypropylene ePTFE—expanded polytetrafluoroethylene ORC—oxidized pulled upward and laterally by the contraction of the transversus regenerated cellulose PPL—polypropylene abdominis, a valvular action is generated that helps preclude indi- rect hernia formation.The iliopubic tract is the thickened band of the transversalis fascia that courses parallel to the more superfi- of Bogros. The preperitoneal space is of particular importance for cially located inguinal ligament. It is attached to the iliac crest lat- surgeons because many of the inguinal hernia repairs (see below) erally and inserts on the pubic tubercle medially. The insertion are performed in this area.The inferior epigastric vessels, the deep curves inferolaterally for 1 to 2 cm along the pectineal line of the inferior epigastric vein, the iliopubic vein, the rectusial vein, the pubis to blend with Cooper’s ligament, ending at about the mid- retropubic vein, the communicating rectusioepigastric vein, the portion of the superior pubic ramus. Cooper’s ligament is actually internal spermatic vessels, and the vas deferens are all encountered a condensation of the periosteum and is not a true analogue of the in this space.13 transversalis fascia. Hesselbach’s inguinal triangle is the site of direct inguinal her- nias. As viewed from the anterior aspect, the inguinal ligament Choice of Prosthetic Material forms the base of the triangle, the edge of the rectus abdominis For most abdominal wall hernias, the procedure of choice forms the medial border, and the inferior epigastric vessels form includes the use of a prosthesis. A detailed discussion comparing the superolateral border. (It should be noted, however, that Hessel- and contrasting various prosthetic materials is beyond the scope of bach actually described Cooper’s ligament as the base.) this chapter; however, some general statements may be made. As a Below the iliopubic tract are the critical anatomic elements from rule, North American surgeons tend to consider polypropylene which a femoral hernia may develop. The iliopectineal arch sepa- mesh the favored prosthetic material, whereas European surgeons rates the vascular compartment that contains the femoral vessels are more likely to employ polyester mesh. Of course, the use of from the neuromuscular compartment that contains the iliopsoas mesh presupposes a situation in which the prosthesis can be iso- muscle, the femoral nerve, and the lateral femoral cutaneous nerve. lated from contact with intra-abdominal viscera by one or more The vascular compartment is invested by the femoral sheath, layers of human tissue (e.g., peritoneum). In situations where con- which has three subcompartments: (1) the lateral, containing the tact with intra-abdominal viscera cannot be avoided, a standard femoral artery and the femoral branch of the genitofemoral nerve; mesh prosthesis should not be used. Either the prosthesis should (2) the middle, containing the femoral vein; and (3) the medial, be composed of a nonmesh material, such as expanded polytetra- which is the cone-shaped cul-de-sac known as the femoral canal. fluoroethylene (ePTFE), or a dual-layer prosthesis should be used, The femoral canal is normally a 1 to 2 cm blind pouch that begins with a standard plastic mesh on the side facing the abdominal wall at the femoral ring and extends to the level of the fossa ovalis.The (to encourage an intense fibroplastic response) and an adhesion femoral ring is bordered by the superior pubic ramus inferiorly, the barrier of some type coating the peritoneal side. Numerous dual- femoral vein laterally, and the iliopubic tract (with its curved inser- sided prosthetics, incorporating a variety of adhesion barriers, are tion onto the pubic ramus) anteriorly and medially. The femoral now available [see Table 4]. It has consistently been shown that canal normally contains preperitoneal fat, connective tissue, and when these materials are used, adhesions are not only less common lymph nodes (including Cloquet’s node at the femoral ring), which but also less tenacious than when mesh alone is used. Often, bowel collectively make up the femoral pad.This pad acts as a cushion for adhesions can be literally wiped from the peritoneal surface of a the femoral vein, allowing expansion such as might occur during a dual-layer prosthesis with gentle blunt traction, in sharp contrast to Valsalva maneuver, and serves as a plug to prevent abdominal con- the typically tedious and sometimes impossible dissection of bowel tents from entering the thigh. A femoral hernia exists when the loops from a mesh prosthesis. Although all of the dual-layer pros- blind end of the femoral canal becomes an opening (the femoral theses currently on the market are approved for decreasing adhe- orifice) through which a peritoneal sac can protrude. sions to the adhesion barrier side, no manufacturer has sought Between the transversalis fascia and the peritoneum is the approval for complete prevention of adhesions. Consequently, the preperitoneal space. In the midline behind the pubis, this space is long-term effects of these less severe (but still present) adhesions known as the space of Retzius; laterally, it is referred to as the space are unknown; further study is required to address this issue.
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 6 Table 5—Commercially Available Biologic space, the posterior space, or both and (2) whether a prosthesis is Prostheses for Abdominal Wall Hernia Repair included or omitted [see Table 6]. In reality, most of the numerous eponyms used to name inguinal herniorrhaphies refer not to fun- Approximate Price damentally distinct operations but, rather, to relatively minor mod- Prosthesis ($/cm2) ifications of standard hernia procedures [see Table 6]. Accordingly, rather than address every known variant, we describe only the Cook Surgisis Freeze-Dried Soft Tissue Graft (porcine 3.40 major repairs on which these variants are based. small intestine) The most important consideration in choosing an inguinal her- LifeCell AlloDerm (human cadaver skin) 26.08 nia procedure is the experience of the surgeon. Knowing the ideal operation for a given clinical scenario is of no significance if the sur- Tissue Science Laboratory Permacol (porcine dermis) 8.33 geon is not skilled in performing it. On the assumption that the sur- TEI Bioscience SurgiMend (fetal calf) 22.00 geon’s expertise is equal to the task, the next consideration should Synovis Surgical Veritas (bovine pericardium) 8.60 be to tailor the operation to the patient’s particular hernia. For example, a simple Marcy repair would be completely adequate for Tutogen Tutopatch (bovine pericardium) — a pediatric patient with a Nyhus type 1 hernia [see Table 1] but not Bard Tutomesh/Allomax (human dermis) 26.00 for an elderly patient who has an indirect hernia in conjunction with extensive destruction of the inguinal floor. The conventional Bard Collamend (porcine dermis) 16.00 anterior prosthetic repairs are particularly useful in high-risk patients because they can easily be performed with local anesthe- sia.19 On the other hand, giant prosthetic reinforcement of the vis- A number of so-called biologic prostheses have been developed ceral sac (GPRVS), especially when bilateral, necessitates general that are designed to promote vessel ingrowth and eventual remod- or regional anesthesia and thus is best for patients with bilateral eling of tissue to resemble the native type [see Table 5]. Although direct or recurrent hernias or, perhaps, for patients with connective biologic prostheses are much more expensive than synthetic pros- tissue disorders that appear to be associated with their hernia. If theses, they may be the better choice when the operative field is surgery has previously been done in either the anterior or the contaminated or when an abdominal wall defect is so large that the preperitoneal space, the surgeon should choose a procedure that prosthesis cannot be covered by skin. Clearly, more study is uses the undissected space. If local or systemic infection is present, required before their exact place in the armamentarium of the a nonprosthetic repair is usually considered preferable, though the abdominal wall hernia surgeon can be determined. newer biologic prostheses now being evaluated may eventually At present, there is some controversy regarding the weight of the change this view. Uncorrected coagulopathy is a contraindication polypropylene mesh used in abdominal wall hernia repairs. (The to elective repair. controversy almost certainly applies to the other types of mesh prosthesis as well.) Data from randomized studies indicate that use of a lightweight mesh results in less long-term pain than use of a Inguinal Hernia Repair: Operative Technique normal mesh, without having any negative effect on the recurrence rate.14,15 Lighter-weight mesh also addresses the theoretical con- ANTERIOR HERNIORRHAPHY cern about the possible carcinogenic effects of polypropylene, as has been suggested by experimental studies in rats, though it Steps Common to Prosthetic and Nonprosthetic Repairs should be kept in mind that there has never been a documented The various anterior herniorrhaphies have a number of initial case of a sarcoma developing in a human being as a result of an technical steps in common; they differ primarily with respect to the inguinal hernia prosthesis.16 To illustrate the difference between a specific details of floor reconstruction. lightweight mesh and a normal one, a 7.5 × 15 cm piece of polypropylene mesh (Prolene; Ethicon, Inc., Somerville, New Step 1: choice of anesthetic Local anesthesia is entirely ade- Jersey) weighs about 80 g/m2, whereas a similarly sized piece of a quate, especially when combined with intravenous sedation. In polypropylene–poliglecaprone 25 (Monocryl; Ethicon, Inc., specialty hernia clinics, it is the approach most commonly Somerville, New Jersey) lightweight mesh (UltraPro; Ethicon, Inc., employed. In general practice, however, general anesthesia is the Somerville, New Jersey) weighs less than 30 g/m2 after absorption rule. This approach is reasonable in fit patients but is associated of the poliglecaprone 25 component. North American surgeons with a higher incidence of postoperative urinary retention.20 If gen- have been slow to accept the use of lightweight mesh for inguinal eral anesthesia is used, a local anesthetic should be given at the end hernia repair, fearing a higher recurrence rate (as was suggested by of the procedure as an adjuvant to reduce immediate postoperative one of the earlier randomized trials).17 Many also have some con- pain. Regional (spinal or epidural) anesthesia can also be used, but cerns about possible bias in the data, noting that the research sup- it is less popular, having the highest incidence of systemic side porting the use of lightweight mesh has been almost exclusively effects (primarily cardiovascular).19 funded by industry. Nevertheless, the randomized trials mentioned We prefer local anesthesia combined with I.V. infusion of a earlier cannot be entirely discounted. rapid-acting, short-lasting, amnesic, and anxiolytic agent (e.g., propofol).This technique affords the patient all the benefits of gen- eral anesthesia in terms of comfort, without the higher incidence Inguinal Hernia Repair: Choice of Procedure of urinary retention seen with regional or general endotracheal Practical considerations do not allow a description of every sin- anesthesia. An added benefit is that the patient can be aroused gle named inguinal hernia repair in the literature. The nonpros- from sedation periodically to perform Valsalva maneuvers to test thetic named repairs alone number more than 70.18 For the pur- the repair. poses of this chapter, inguinal hernia repairs may be grouped The techniques and drug dosages employed by different experts according to (1) whether the operation makes use of the anterior vary considerably. Compounding factors include the age of the
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 7 patient and the amount of I.V. sedation used. Our preference is to sistent correlation with postoperative groin pain either way. The use a solution containing 50 ml of 0.5% lidocaine with epineph- ilioinguinal and genitofemoral nerves are usually left with the cord rine and 50 ml of 0.25% bupivacaine with epinephrine. The epi- structures. The genitofemoral nerve cannot always be identified nephrine is optional and may be omitted if the patient has a histo- with certainty. It will be sacrificed in those procedures that include ry of coronary artery disease or if there is concern about delayed division of the cremaster muscle (e.g., Shouldice repair). bleeding. In an adult of normal size, 70 ml of this solution is inject- ed before preparation and draping: 10 ml is placed 1 cm medial Step 4: mobilization of cord structures The cord struc- and 1 cm inferior to the anterior superior iliac spine in an attempt tures are bluntly dissected away from the inferior flap of the exter- to block the major nerves innervating the groin area [see nal oblique aponeurosis to expose the inguinal ligament (shelving Abdominal Wall Anatomy, above], and the other 60 ml is used as a edge) and the iliopubic tract.This dissection is continued over the field block along the orientation of the eventual incision in the sub- pubic tubercle and onto the anterior rectus sheath for at least 2 cm, cutaneous and deeper tissues. Care is taken to ensure that some of defining the point where the most medial edge of a prosthesis will the material is injected into the areas of the pubic tubercle and eventually be sutured if a Lichtenstein prosthetic repair is being Cooper’s ligament, which are easily identified by tactile sensation performed. This measure facilitates en masse lifting of the cord (except in very obese patients). The remaining 30 ml of the solu- structures with the fingers of one hand at the pubic tubercle so that tion is reserved for discretionary use during the procedure. the index finger can be passed underneath to meet the ipsilateral thumb or the fingers of the other hand. Mobilization of the cord Step 2: initial incision Traditionally, the skin is opened by structures is completed by means of blunt dissection, and a making an oblique incision between the anterior superior iliac Penrose drain is placed around them so that they can be retracted spine and the pubic tubercle. For cosmetic reasons, however, many during the procedure. surgeons now prefer a more horizontal skin incision placed in the natural skin lines. In either case, the incision is deepened through Step 5: division of cremaster muscle For decades, com- Scarpa’s fasciae and the subcutaneous tissue to expose the exter- plete division of the cremaster muscle with concomitant sacrifice nal oblique aponeurosis. The external oblique aponeurosis is then of the genitofemoral nerve was common practice, especially with opened through the external inguinal ring. If a prosthesis is to be indirect hernias. The purpose of this step was to facilitate identifi- used, a large space is created beneath the external oblique aponeu- cation of the sac and to lengthen the cord for better visualization of rosis from the anterior rectus sheath medially to the anterior supe- the inguinal floor. It is clear, however, that adequate exposure can rior iliac spine laterally to prepare for the eventual placement. almost always be obtained by opening the muscle longitudinally, which reduces the chances of damage to the cord and prevents tes- Step 3: care of the sensory nerves The iliohypogastric ticular descent. Accordingly, the latter approach should be consid- nerve is identified; it can be either left in situ or freed from the sur- ered best practice unless circumstances argue for division of the rounding tissue and isolated from the operative field by passing a muscle. hemostat under the nerve and grasping the upper flap of the exter- nal oblique aponeurosis. Routine division of the iliohypogastric Step 6: management of hernial sac The term high ligation nerve along with the ilioinguinal nerve is practiced by some but is of the sac is used frequently in discussing inguinal hernia repair; its not advised by most, though there does not seem to be any con- historical significance has ingrained it in the descriptions of most of the older operations. For our purposes in this chapter, high lig- ation of the sac should be considered equivalent to reduction of the Table 6—Selected Major Inguinal sac into the preperitoneal space without excision. The two meth- Herniorrhaphy Techniques* ods work equally well and are highly effective. Proponents of sac inversion believe that this measure results in less pain (because the Category Anterior Repairs Posterior Repairs richly innervated peritoneum is not incised) and may be less likely Marcy to cause adhesive complications.To date, however, no randomized Bassini trials have been done to determine whether this is so.21 Sac ever- Nonprosthetic Nyhus-Condon (iliopubic sion in lieu of excision does protect intra-abdominal viscera in (pure tissue) Maloney darn tract repair) Shouldice cases of unrecognized incarcerated sac contents or sliding hernia. McVay Cooper’s ligament Many surgeons (especially urologists) believe that complete excision of all indirect inguinal hernial sacs, even when inguinal- Anterior approach Read-Rives scrotal, is important for preventing excessive postoperative hydro- Posterior approach cele formation.The downside of this practice is that the incidence GPRVS of ischemic orchitis from excessive trauma to the cord rises sub- Prosthetic Lichtenstein tension-free stantially.The logical sequela of ischemic orchitis is testicular atro- Modified Nyhus-Condon (tension-free hernioplasty repair) Mesh plug-and-patch Kugel-Ugahary phy, though this presumed relationship has not been conclusively Laparoscopic proved. In our view, it is better to divide an indirect inguinal her- TAPP nial sac in the midportion of the inguinal canal once it is clear that TEP the hernia is not sliding and no abdominal contents are present. IPOM The distal sac is not removed, but its anterior wall is opened as far Bilayer prosthetic repair† distally as is convenient. We have not observed an increased inci- dence of hydroceles with this approach. *Many other named repairs have been described. For the most part, however, these other Direct hernial sacs are separated from the cord and other sur- named repairs are relatively minor modifications of procedures listed in this table. †Both the anterior space and the posterior space are used. rounding structures and reduced into the preperitoneal space. GPRVS—giant prosthetic reinforcement of the visceral sac IPOM—intraperitoneal onlay Dividing the superficial layers of the neck of the sac circumferen- mesh TAPP—transabdominal preperitoneal TEP—totally extraperitoneal tially—thereby, in effect, opening the inguinal floor—usually facil-
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 8 Nonprosthetic Repairs Marcy repair The Marcy repair is the simplest nonprosthet- ic repair performed today. Its main indication is for treatment of Nyhus type 1 hernias (i.e., indirect inguinal hernias in which the internal ring is normal). It is appropriate for children and young adults in whom there is concern about the long-term effects of prosthetic material. The essential features of the Marcy repair are high ligation of the sac and narrowing of the internal ring. Displacing the cord structures laterally allows the placement of sutures through the muscular and fascial layers [see Figure 3]. Bassini repair Edoardo Bassini (1844–1924) is considered the father of modern inguinal hernia surgery. It was during the 19th century that many of the great anatomists—Scarpa, Cooper, Hesselbach, Bogros, Retzius, Cloquet, Gay, and others—made their discoveries. By combining high ligation of the hernial sac with reconstruction of the inguinal floor (based on the principles for- mulated by the 19th-century anatomists), as well as taking advan- tage of the developing disciplines of antisepsis and anesthesia, Bassini was able to reduce recurrence and morbidity substantially. Before Bassini’s achievements, elective herniorrhaphy was almost never recommended, because the results were so bad. Bassini’s operation, known as the radical cure, became the gold standard for Figure 3 Marcy repair. The deep inguinal ring is narrowed inguinal hernia repair for most of the 20th century. medially with several sutures that approximate the trans- The initial steps in the procedure are as previously described [see verse aponeurotic arch to the iliopubic tract. Steps Common to Prosthetic and Nonprosthetic Repairs, above]. Bassini felt that the incision in the external oblique aponeurosis should be as superior as possible while still allowing the superficial itates reduction and helps to maintain it while the prosthesis is external ring to be opened, so that the reapproximation suture line being placed.The opening in the inguinal floor also allows the sur- created later in the operation would not be directly over the suture geon to palpate for a femoral hernia. Sutures can be used to main- line of the inguinal floor reconstruction.22 Whether this technical tain reduction of the sac, but they have no real strength in this set- point is significant is debatable. Bassini also felt that lengthwise ting; their main purpose is to allow the repair to proceed without division of the cremaster muscle followed by resection was impor- being hindered by continual extrusion of the sac into the field, tant for ensuring that an indirect hernial sac could not be missed especially when the patient strains. and for achieving adequate exposure of the inguinal floor. After performing the initial dissection and the reduction or liga- Step 7: repair of inguinal floor Methods of repairing the tion of the sac, Bassini began the reconstruction of the inguinal inguinal floor differ significantly among the various anterior floor by opening the transversalis fascia from the internal inguinal herniorrhaphies and thus are described separately under the rele- ring to the pubic tubercle, thereby exposing the preperitoneal fat, vant headings [see Nonprosthetic Repairs and Prosthetic Repairs, which he then bluntly dissected away from the undersurface of the below]. superior flap of the transversalis fascia [see Figure 4a]. This step allowed him to properly prepare the deepest structure in his Step 8: relaxing incision A relaxing incision is employed famous “triple layer” (comprising the transversalis fascia, the trans- only if a nonprosthetic repair is being performed. The incision is versus abdominis, and the internal oblique muscle). made through the anterior rectus sheath and down to the rectus The first stitch in Bassini’s repair includes the triple layer supe- abdominis, extending superiorly from the pubic tubercle for a riorly and the periosteum of the medial side of the pubic tubercle, variable distance, as determined by the degree of tension present. along with the rectus sheath. In current practice, however, most A so-called hockey-stick incision oriented laterally at the superior surgeons try to avoid the periosteum of the pubic tubercle so as to end is a common choice. The posterior rectus sheath is strong decrease the incidence of osteitis pubis. The repair is then contin- enough to prevent future incisional herniation. The relaxing inci- ued laterally, and the triple layer is secured to the reflected inguinal sion works because as the anterior rectus sheath separates, the ligament (Poupart’s ligament) with nonabsorbable sutures. The various components of the abdominal wall are displaced laterally sutures are continued until the internal ring is closed on its medi- and inferiorly. al side [see Figure 4b]. A relaxing incision was not part of Bassini’s original description but now is commonly added. Step 9: closure Closure of the external oblique fascia serves Concerns about injuries to neurovascular structures in the to reconstruct the superficial (external) ring. The external ring preperitoneal space and to the bladder led many surgeons, espe- must be loose enough to prevent strangulation of the cord struc- cially in North America, to abandon the opening of the transver- tures yet tight enough to ensure that an inexperienced examiner salis fascia. The unfortunate consequence of this decision is that will not confuse a dilated ring with a recurrence. A dilated external the proper development of the triple layer is severely compromised. ring is sometimes referred to as an industrial hernia, because over In lieu of opening the floor, a forceps (e.g., an Allis clamp) is used the years it has occasionally been a problem during preemploy- to grasp tissue blindly in the hope of including the transversalis fas- ment physical examinations. Scarpa’s fascia and the skin are closed cia and the transversus abdominis.The layer is then sutured, along to complete the operation. with the internal oblique muscle, to the reflected inguinal ligament
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 9 Transversus Abdominis Internal Oblique a Muscle b Transversalis Fascia Figure 4 Bassini repair. (a) The transversalis fascia has been opened and the preperitoneal fat stripped away to prepare the deepest structure in Bassini’s triple layer (comprising the transversalis fascia, the transversus abdominis, and the internal oblique muscle). (b) The triple layer superiorly is approximated to the inguinal ligament, beginning medially at the pubic tubercle and extending laterally until the deep inguinal ring is sufficiently narrowed. as in the classic Bassini repair.The structure grasped in this mod- steps of the procedure.24 A continuous nonabsorbable suture (typ- ified procedure is sometimes referred to as the conjoined tendon, ically of monofilament steel wire) is used to repair the floor. The but this term is not accurate, because of the variability in what is Shouldice surgeons believe that a continuous suture distributes actually grasped in the clamp. This imprecise “good stuff to good tension evenly and prevents potential defects between interrupted stuff” approach almost certainly accounts for the inferior results sutures that could lead to recurrence. achieved with the Bassini procedure in the United States. Maloney darn The Maloney darn derives its name from the way in which a long nylon suture is repeatedly passed between the tissues to create a weave that one might consider similar to a mesh. After initial preparation of the groin (see above), a continuous nylon suture is used to oppose the transversus abdominis, the rec- tus abdominis, the internal oblique muscle, and the transversalis fascia medially to Poupart’s ligament laterally. The suture is con- tinued into the muscle around the cord and is woven in and out to form a reinforcement around the cord [see Figure 5]. On the later- al side of the cord, it is sutured to the inguinal ligament and tied. The darn is a second layer. The sutures are placed either parallel or in a criss-cross fashion and are plicated well into the inguinal lig- ament below.The darn must be carried well over the medial edge of the inguinal canal. Once the darn is complete, the external oblique fascia is closed over the cord structures.The Maloney darn can be considered a forerunner of the mesh repairs, in that the pur- pose of the darn is to provide a scaffold for tissue ingrowth.23 Shouldice repair Steps 1 through 6 of this repair are per- formed essentially as previously described [see Steps Common to Prosthetic and Nonprosthetic Repairs, above]. Particular impor- tance is placed on freeing of the cord from its surrounding adhe- Figure 5 Maloney darn. The weave is made from a continuous sions, resection of the cremaster muscle, high dissection of the her- nylon suture and is considered by many to be the precursor of nial sac, and division of the transversalis fascia during the initial the mesh repairs.
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 10 a b Figure 6 Shouldice repair. (a) The first suture line starts at the pubic tubercle by approximating the iliopubic tract laterally to the undersurface of the lateral edge of the rectus abdominis. The suture is continued laterally, approximating the iliopubic tract to the medial flap (made up of the transversalis fascia, the internal oblique mus- cle, and the transversus abdominis). (b) The second suture line begins after the stump of the divided cremaster muscle has been picked up. The direction of the suture is reversed back toward the pubic tubercle, approximating the medial edges of the internal oblique muscle and the transversus abdominis to Poupart’s ligament. Two more suture lines will be constructed by approximating the internal oblique muscle and the transversus abdominis to a band of the inferior flap of the external oblique aponeurosis superficial and parallel to Poupart’s ligament—in effect, creating a second and a third artificial Poupart’s ligament. The repair is started at the pubic tubercle by approximating the and continue to be so today. For a time, the Shouldice repair was iliopubic tract laterally to the undersurface of the lateral edge of the the gold standard against which all newer procedures were com- rectus abdominis [see Figure 6a]. The suture is continued laterally, pared. The major criticism of this operation is that it is difficult to approximating the iliopubic tract to the medial flap, which is made teach because surgeons have problems understanding what is real- up of the transversalis fascia, the internal oblique muscle, and the ly being sewn to what. Unless one is specifically trained at the transversus abdominis. Eventually, four suture lines are developed Shouldice clinic and has the opportunity to work with the surgeons from the medial flap. The continuous suture is extended to the there, one may find it hard to identify the various layers in the internal ring, where the lateral stump of the cremaster muscle is medial flap reliably and reproducibly—a step that is crucial for picked up to form a new internal ring. Next, the direction of the developing the multiple suture lines. To compound the difficulty, suture is reversed back toward the pubic tubercle, approximating modifications developed outside the Shouldice clinic have given the medial edges of the internal oblique muscle and the transver- rise to different versions of the procedure. For example, some sur- sus abdominis to Poupart’s ligament, and the wire is tied to itself geons use three continuous layers instead of four for reconstruc- and then the first knot [see Figure 6b]. Thus, two suture lines are tion of the inguinal floor. formed by the first suture. A second wire suture is started near the internal ring, approx- McVay Cooper’s ligament repair This operation is similar imating the internal oblique muscle and the transversus abdo- to the Bassini repair, except that it uses Cooper’s ligament instead minis to a band of external oblique aponeurosis superficial and of the inguinal ligament for the medial portion of the repair. parallel to Poupart’s ligament—in effect, creating a second, arti- Interrupted sutures are placed from the pubic tubercle laterally ficial Poupart’s ligament. This third suture line ends at the pubic along Cooper’s ligament, progressively narrowing the femoral ring; crest.The suture is then reversed, and a fourth suture line is con- this constitutes the most common application of the repair— structed in a similar manner, superficial to the third line. At the namely, treatment of a femoral hernia [see Figure 7].The last stitch Shouldice clinic, the cribriform fascia is always incised in the in Cooper’s ligament is known as a transition stitch and includes thigh, parallel to the inguinal ligament, to make the inner side of the inguinal ligament.This stitch has two purposes: (1) to complete the lower flap of the external oblique aponeurosis available for the narrowing of the femoral ring by approximating the inguinal these multiple layers. In general practice, however, this step is ligament to Cooper’s ligament, as well as to the medial tissue, and commonly omitted. (2) to provide a smooth transition to the inguinal ligament over the The results at the Shouldice clinic have been truly outstanding femoral vessel so that the repair can be continued laterally (as in a
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 11 Bassini repair). Given the considerable tension required to bridge such a large distance, a relaxing incision should always be used. In the view of many authorities, this tension results in more pain than is noted with other herniorrhaphies and predisposes to recurrence. For this reason, the McVay repair is rarely chosen today, the main exception being for treatment of a patient with a femoral hernia or a patient with specific contraindications to mesh repair. Prosthetic Repairs Lichtenstein repair This operation is now considered the gold standard for inguinal herniorrhaphy.The initial preparation of the inguinal floor does not differ substantially from that carried out in a nonprosthetic repair.The transversalis fascia is not opened—a practice that has occasionally been criticized on the grounds that it might cause an occult femoral hernia to be missed. To date, how- ever, an excessive incidence of missed femoral hernias has not been reported in men. The situation may be different in women: evi- dence from the large population-based Swedish study cited earlier suggests that femoral recurrence is much more common than one might assume when the entire myopectineal orifice is not addressed (as is the case with a McVay procedure or any of the preperitoneal operations).3 The key to the operation is the placement of a large prosthesis (at least 15 × 10 cm for an adult) extending from a point 2 cm Figure 8 Lichtenstein repair. A mesh prosthesis is positioned medial to the pubic tubercle (to prevent the pubic tubercle recur- over the inguinal floor and secured to the rectus sheath with a rences all too commonly seen with other operations) to the ante- continuous suture. A slit is made in the mesh to accommodate the rior superior iliac spine laterally. The medial end is rounded to cord structures, and the two tails are secured to each other and to correspond to the patient’s particular anatomy, and a continuous the shelving edge of the inguinal ligament with a single interrupt- suture of either nonabsorbable or long-lasting absorbable mater- ed suture. The superior and medial aspects of the prosthesis are ial is begun between the prosthesis and the anterior rectus sheath secured to the internal oblique muscle and the rectus fascia with a 2 cm medial to the pubic tubercle [see Figure 8]. The suture is few interrupted sutures. continued laterally in a locking fashion, securing the prosthesis to either side of the pubic tubercle (not into it) and then to the above and a narrower one below. The tails are positioned around shelving edge of the inguinal ligament. The suture is tied at the the cord structures and placed beneath the external oblique internal ring. aponeurosis laterally to about the anterior superior iliac spine, with A slit is made on the lateral side of the prosthesis to create two the upper tail placed on top of the lower. A single interrupted tails, a wider one (approximately two thirds of the total height) suture is placed to secure the lower edge of the superior tail to the lower edge of the inferior tail and the inguinal ligament—thereby, in effect, creating a shutter valve.This step is considered crucial for preventing the indirect recurrences occasionally seen when the tails are simply reapproximated. The maneuver provides a cradling effect as well, preventing direct contact between the cut edges of the prosthesis and the cord structures, which could result in dam- age when linear approximation is used. The suture also incorpo- rates the shelving edge of the inguinal ligament so as to create a domelike buckling effect over the direct space, thereby ensuring that there is no tension, especially when the patient assumes an upright position. The Lichtenstein group has developed a cus- tomized prosthesis with a built-in domelike configuration, which, in their view, makes suturing the approximated tails to the inguinal ligament unnecessary. A few interrupted sutures are placed to attach the superior and medial aspects of the prostheses to the underlying internal oblique muscle and rectus fascia. Care is taken to tie these loosely (with an “air knot”) and to avoid placing them laterally so as to minimize the risk of damaging the intramuscular and therefore invisible por- tions of the important nerves. On occasion, the iliohypogastric nerve, which courses on top of the internal oblique muscle, pene- trates the medial flap of the external oblique aponeurosis. In this situation, the prosthesis should be slit to accommodate the nerve. The prosthesis can be trimmed in situ, but enough laxity must be Figure 7 McVay Cooper’s ligament repair. The lateral stitch is the maintained to allow for the difference between the supine and transition stitch to the femoral sheath and the inguinal ligament. upright positions, as well as for possible shrinkage of the mesh.
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 12 bulk. Many surgeons consider this step important for preventing erosion into surrounding structures (e.g., the bladder); indeed, such complications have been reported, albeit rarely. Millikan further modified the procedure by recommending that the inside petals be sewn to the ring of the defect. For an indirect hernia, the inside pedals are sewn to the internal oblique portion of the internal ring; this forces the outside of the prosthesis under- neath the inner side of the defect and makes it act like a preperi- toneal underlay. For direct hernias, the inside petals are sewn to Cooper’s ligament and the shelving edge of the inguinal ligament, as well as to the conjoined tendon; this, again, forces the outside of the prosthesis to act as an underlay. The patch portion of the procedure is optional and involves placing a flat piece of polypropylene in the conventional inguinal space so that it widely overlaps the plug, much as in a Lichtenstein repair.The difference with a plug-and-patch repair is that only one or two sutures—or, sometimes, no sutures—are used to secure the flat prosthesis to the underlying inguinal floor. Some surgeons, however, place so many sutures that they have in effect performed a Lichtenstein operation on top of the plug (sometimes referred to as a “plugstenstein” repair). To the credit of its proponents, the plug-and-patch repair, in all of its varieties, has been skillfully presented and has rapidly taken a Figure 9 Gilbert plug-and-patch repair. Depicted is the mesh significant share of the overall inguinal hernia market. It is not only plug technique for repair of an inguinal hernia. A flat sheet of fast but also extremely easy to teach, which has made it popular in polypropylene mesh is rolled up like a cigarette or formed into a both private and academic centers. A randomized, controlled trial cone (as shown here), inserted into the defect, and secured to has shown it to be equivalent to the Lichtenstein repair in terms of either the internal ring (for an indirect hernia) or the neck of the recurrence and morbidity.28 However, numerous case reports in defect (for a direct hernia) with interrupted sutures. the literature have described removal of plugs for pain, migration, Prefabricated mesh plugs are now available. or erosion, and as a result, the plug-and-patch repair has been the focus of considerable medicolegal scrutiny. If a femoral hernia is recognized, the transversalis fascia is POSTERIOR (PREPERITONEAL) HERNIORRHAPHY opened and the hernia reduced to expose Cooper’s ligament. The Lichtenstein group’s approach is still to suture the inferior edge of Nonprosthetic Repairs the prosthesis to the inguinal ligament. The femoral space is then A key technical issue in a preperitoneal hernia repair is how the addressed by suturing the posterior surface of the prosthesis to surgeon chooses to enter the preperitoneal space. In fact, within this Cooper’s ligament, thereby covering the entire myopectineal ori- general class of repair, it is the method of entry into this space that fice, and finally by completing the superior and lateral sutures.We constitutes the major difference between the various procedures. prefer to forgo the approximation of the inferior edge of the pros- Many approaches to the preperitoneal space have been thesis to the inguinal ligament in favor of using interrupted sutures described. For example, the space can be entered either anteriorly between that edge and Cooper’s ligament, much as in a McVay or posteriorly. If an anterior technique is to be used, the initial steps repair (the “Fitztenstein” technique). A transition stitch is required of the operation are similar to those of a conventional anterior between the inferior edge of the prosthesis, Cooper’s ligament, and herniorrhaphy. If a posterior technique is to be used, any of sever- the inguinal ligament on the medial side of the femoral vein. This al incisions (lower midline, paramedian, or Pfannenstiel) will allow stitch closes the femoral canal and sets the stage for the lateral side an extraperitoneal dissection. The preperitoneal space can also be of the prosthesis to be sutured to the inguinal ligament.The rest of entered transabdominally.This approach is useful when the patient the operation then proceeds in the same manner as a classic is undergoing a laparotomy for some other condition and the her- Lichtenstein repair. nia is to be repaired incidentally. Of course, the transabdominal preperitoneal laparoscopic repair described elsewhere [see 5:28 Plug-and-patch repair The mesh plug technique was first Laparoscopic Hernia Repair], by definition, enters the preperitoneal developed by Gilbert and subsequently modified by Rutkow and space from the abdomen. Robbins, Millikan, and others [see Figure 9].25-27 The groin is entered via a standard anterior approach. The hernial sac is dis- sected away from surrounding structures and reduced into the preperitoneal space. A flat sheet of polypropylene mesh is rolled up Table 7—Contraindications to Use of like a cigarette, tied, inserted in the defect, and secured with inter- Prosthesis for Herniorrhaphy rupted sutures to either the internal ring (for an indirect hernia) or the neck of the defect (for a direct hernia). Local infection* Allergy A prefabricated prosthesis that has the configuration of a flower Systemic infection Patient preference (phobia) Economic constraints is commercially available and is recommended by Rutkow and Robbins. This prosthesis is tailored to each patient’s particular *The newer biologic prostheses may be acceptable. anatomy by removing some of the “petals” to avoid unnecessary
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 13 Reed credits Annandale as being the first surgeon to describe the anterior method of gaining access to the preperitoneal space.29 Bassini’s operation, as classically performed, is technically an ante- rior preperitoneal operation, but it is never discussed in this group, because in the American variant of the procedure, the preperi- toneal space is not entered. Cheatle suggested the posterior approach to the preperitoneal space for repair of an inguinal her- nia but used a laparotomy to do it.30 Cheatle and Henry subse- quently modified the operation so as to render it entirely extraperi- toneal (the Cheatle-Henry approach), which made the procedure more acceptable to surgeons.31 The preperitoneal nonprosthetic method remained popular into the second half of the 20th century, championed by propo- nents such as Nyhus and Condon, who emphasized the impor- tance of the iliopubic tract as the inferior border in primary closure of direct or indirect hernia defects.32 Today, however, these opera- tions are of little more than historical significance, because it is now universally agreed that better results are obtained in this space when a prosthesis is used. Indeed, after 1975, Nyhus and Condon began routinely placing a 6 × 14 cm piece of polypropylene mesh to buttress the primary repair for all recurrent hernias.33 When contraindications to a prosthesis are present [see Table 7], most sur- geons would opt for a conventional anterior herniorrhaphy (e.g., a Bassini or Shouldice repair) rather than a preperitoneal nonpros- thetic herniorrhaphy. Prosthetic Repairs The most important step in any preperitoneal prosthetic repair Figure 10 Depicted is the myopectineal orifice of Fruchaud. is the placement of a large prothesis in the preperitoneal space on The area is bounded superiorly by the internal oblique muscle the abdominal side of the defect.The theoretical advantage of this and the transversus abdominis, medially by the rectus abdominis measure is that whereas in a conventional repair, abdominal pres- and the rectus sheath, laterally by the iliopsoas muscle, and infe- sure might contribute to recurrence, in a preperitoneal repair, the riorly by Cooper’s ligament. Critical anatomic landmarks (e.g., abdominal pressure would actually help fix the mesh material the inguinal ligament, the spermatic cord, and the femoral ves- against the abdominal wall, thereby adding strength to the repair. sels) are contained within this structure. The hernia defect itself may or may not be closed, depending on the preference of the surgeon. The strength of the repair depends on the prosthesis rather than on closure of the defect; however, Instead of subdividing hernias into direct, indirect, and femoral such closure may decrease the seroma formation that inevitably and then examining their specific causes, he emphasized that the occurs at the site of the undisturbed residual sac. Although these common cause of all inguinal hernias was the failure of the trans- seromas almost always are self-limiting and disappear with time, versalis fascia to retain the peritoneum.This concept led Stoppa to they can be confused with recurrences by both patients and refer- develop GPRVS, which reestablishes the integrity of the peritoneal ring physicians. Accordingly, some surgeons prefer to take every sac by inserting a large permanent prosthesis that entirely replaces step possible to prevent them. the transversalis fascia over the myopectineal orifice of Fruchaud with wide overlapping of surrounding tissue. With GPRVS, the Read-Rives repair The posterior space is accessed directly exact type of hernia present (direct, indirect, or femoral) is unim- through the groin, and thus, the initial part of a Read-Rives repair, portant, because the abdominal wall defect is not addressed. including the opening of the inguinal floor, is much like that of a classic Bassini repair. The inferior epigastric vessels are identified Step 1: skin incision. A lower midline, inguinal, or Pfannenstiel and the preperitoneal space completely dissected. The spermatic incision may be used, depending on the surgeon’s preference.The cord is parietalized by separating the ductus deferens from the inguinal incision is placed 2 to 3 cm below the level of the anteri- spermatic vessels. A 12 × 16 cm piece of mesh is positioned in the or superior iliac spine but above the internal ring; it is begun at the preperitoneal space deep to the inferior epigastric vessels and midline and extended laterally for 8 to 9 cm.35 secured with three sutures placed in the pubic tubercle, in Cooper’s ligament, and in the psoas muscle laterally.The transver- Step 2: preperitoneal dissection. The fascia overlying the space of salis fascia is closed over the prosthesis and the cord structures Retzius is opened without violation of the peritoneum. A combi- replaced.The rest of the closure is accomplished much as in a con- nation of blunt and sharp dissection is continued laterally posteri- ventional anterior prosthetic repair. or to the rectus abdominis and the inferior epigastric vessels. The preperitoneal space is completely dissected to a point lateral to the Stoppa-Rignault-Wantz repair (GPRVS) GPRVS has its anterior superior iliac spine [see Figure 11]. The symphysis pubis, roots in the important contribution that Henri Fruchaud made to Cooper’s ligament, and the iliopubic tract are identified. Inferiorly, herniology. In describing the myopectineal orifice that bears his the peritoneum is generously dissected away from the vas deferens name [see Figure 10], Fruchaud, who was Stoppa’s mentor, popu- and the internal spermatic vessels to create a large pocket, which larized a different viewpoint on the etiology of inguinal hernias.34 will eventually accommodate a prosthesis without the possibility of
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 14 rollup. In the inguinal approach, the anterior rectus sheath and the oblique muscles are incised for the length of the skin incision.The lower flaps of these structures are retracted inferiorly toward the pubis.The transversalis fascia is incised along the lateral edge of the rectus abdominis, and the preperitoneal space is entered; dissec- tion then proceeds as previously indicated. Step 3: management of hernial sac. Direct hernial sacs are reduced during the course of the preperitoneal dissection. Care must be taken to stay in the plane between the peritoneum and the transversalis fascia, allowing the latter structure to retract into the hernia defect toward the skin. The transversalis fascia can be thin, and if it is inadvertently opened and incorporated with the peri- toneal sac during reduction, a needless and bloody dissection of the abdominal wall is the result. Indirect sacs are more difficult to deal with than direct sacs are, in that they often adhere to the cord structures.Trauma to the cord Figure 13 Preperitoneal inguinal prosthetic herniorrhaphy. Illustrated is parietalization of the spermatic cord. The spermatic vessels and the vas deferens are mobilized so that they move later- ally. This step is carried out so that the surgeon can place a large prosthesis that widely overlaps the myopectineal orifice without having to slit the prosthesis to accommodate the cord structures. must be minimized to prevent damage to the vas deferens or the tes- ticular blood supply. Small sacs should be mobilized from the cord structures and reduced back into the peritoneal cavity. Large sacs Figure 11 Preperitoneal inguinal prosthetic herniorrhaphy. The may be difficult to mobilize from the cord without undue trauma if preperitoneal space is widely dissected from the pubic tubercle to an attempt is made to remove the sac in its entirety. Accordingly, the anterior superior iliac spine. Shown here is isolation of an large sacs should be divided, with the distal portion left in situ and indirect hernial sac. the proximal portion dissected away from the cord structures. Division of the sac is most easily accomplished by opening the sac on the side opposite the cord structures. A finger is placed in the sac to facilitate its separation from the cord. Downward traction is then placed on the cord structures to reduce any excessive fatty tissue (so-called lipoma of the cord) back into the preperitoneal space. This step prevents the “pseudorecurrences” that may occur if the abnormality palpated during the preoperative physical examination was not a hernia but a lipoma of the cord. Step 4: management of abdominal wall defect. It is this step that varies most from one author to another. In Nyhus’s approach, the defect is formally repaired, and only then is a tailored mesh pros- thesis sutured to Cooper’s ligament and the transversalis fascia for reinforcement [see Figure 12]. Rignault prefers to close the defect loosely to prevent an unsightly early postoperative bulge.36 In Stoppa’s and Wantz’s technique, the defect is usually left alone, but the transversalis fascia in the defect is occasionally plicated by suturing it to Cooper’s ligament to prevent the bulge caused by a Figure 12 Preperitoneal inguinal prosthetic herniorrhaphy. seroma in the undisturbed sac. Illustrated is the placement of a mesh prosthesis in the preperi- toneal space. The prosthesis is sewn to Cooper’s ligament inferior- Step 5:parietalization of spermatic cord. The term parietalization ly and to the transversalis fascia well above the hernia defect of the spermatic cord, popularized by Stoppa, refers to a thorough anteriorly, in the fashion described by Nyhus. dissection of the cord aimed at providing sufficient length to per-
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 15 mit lateral movement of the structure [see Figure 13]. In Stoppa’s and the lateral side is longer than the medial side. In Wantz’s tech- view, this step is essential, in that it allows a prosthesis to be placed nique, three absorbable sutures are used to attach the superior bor- without having to be split laterally to accommodate the cord struc- der of the prosthesis to the anterior abdominal wall well above the tures; the keyhole defect created when the prosthesis is split has defect [see Figure 15].The sutures are placed from medial to lateral been linked with recurrences. In Rignault’s opinion, creation of a near the linea alba, the semilunar line, and the anterior superior iliac keyhole defect in the mesh to encircle the spermatic cord is prefer- spine. A Reverdin suture needle facilitates this task. Three long able, the rationale being that this gives the prosthesis enough secu- clamps are then placed on each corner and the middle of the pros- rity to allow the surgeon to dispense with fixation sutures or tacks. thesis of the inferior flap.The medial clamp is placed into the space Minimizing fixation in this area is important because of the of Retzius and held by an assistant.The middle clamp is positioned numerous anatomic elements in the preperitoneal space that can so that the mesh covers the pubic ramus, the obturator fossa, and be inadvertently damaged during suture placement. the iliac vessels and is also held by the assistant. The lateral clamp is placed into the iliac fossa to cover the parietalized cord structures Step 6: placement of prosthesis. Dacron mesh, being more pli- and the iliopsoas muscle. Care must be taken to prevent the pros- able than polypropylene, conforms well to the preperitoneal thesis from rolling up as the clamps are removed. space and is therefore considered particularly suitable for GPRVS. Stoppa’s technique is most often associated with a sin- Step 7: closure of wound. The surgical wound is closed in accor- gle large prosthesis for bilateral hernias. The prosthesis is cut in dance with anatomic guidelines once the surgeon is assured that the shape of a chevron [see Figure 14a], and eight clamps are posi- there has been no displacement or rollup of the prosthesis. tioned strategically around the prosthesis to facilitate placement into the preperitoneal space [see Figure 14b]. Kugel-Ugahary repair The Kugel and Ugahary repairs Unilateral repairs require a prosthesis that is approximately 15 × were developed to compete with laparoscopic repairs.They require 12 cm but is cut so that the bottom edge is wider than the top edge only a small (2 to 3 cm) skin incision placed 2 to 3 cm above the b a 24 cm 5 4 cm 4 8 16 cm 3 7 Figure 14 Bilateral GPRVS. The prosthesis is cut in a chevron shape (a) to 1 accommodate the urethra in the midline (b) while still extending inferiorly to cover the myopectineal orifice (broken line on the right) on either side. 6 cm The prosthesis is shaped so that its width is approximately the distance 2 6 between the two anterior superior iliac spines minus 2 cm and its height is approximately the distance between the umbilicus and the pubis.
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 16 a b c Figure 15 Unilateral GPRVS (Wantz technique). The prosthesis is so that the inferior edge is wider than the superior edge by 2 to 4 cm and the lateral side is longer than the medial side. The width at the superior edge is approximately the distance between the umbilicus and the anterior superior iliac spine minus 1 cm, and the height is approximately 14 cm. Anteriorly, three sutures are placed—near the linea alba, near the semilunar line, and near the anterior superior iliac spine—from medial to lateral to fix the superior border. Three long clamps on the inferior edge are used to implant the prosthesis deep into the preperitoneal space with the peritoneal sac retracted cranially. internal ring.37,38 In Kugel’s operation, the incision is oriented These vessels should be left adherent to the overlying transversalis obliquely, with one third of the incision lateral to a point halfway fascia and retracted medially and anteriorly. The iliac vessels, between the anterior superior iliac spine and the pubic tubercle Cooper’s ligament, the pubic bone, and the hernia defect are iden- and the remaining two thirds medial to this point. The incision is tified by palpation. Most hernial sacs are simply reduced; the deepened through the external oblique fascia, and the internal exceptions are large indirect sacs, which must sometimes be divid- oblique muscle is bluntly spread apart. The transversalis fascia is ed, with the distal sac left in situ and the proximal sac closed. To opened vertically for a distance of about 3 cm, but the internal ring prevent recurrences, the cord structures are thoroughly parietal- is not violated.The preperitoneal space is entered and a blunt dis- ized to allow adequate posterior dissection. section performed. The inferior epigastric vessels are identified to The key to Kugel’s procedure is a specially designed 8 × 12 cm confirm that the dissection is being done in the correct plane. prosthesis made of two pieces of polypropylene with a single
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 17 extruded monofilament fiber located near its edge. The construc- Inguinal Hernia Repair: Complications tion of the prosthesis allows it to be deformed so that it can fit RECURRENCE through the small incision; once inserted, it springs open to regain its normal shape, providing a wide overlap of the myopectineal ori- An analysis of nearly 18,000 herniorrhaphies in Sweden deter- fice. The prosthesis also has a slit on its anterior surface, through mined that 15% of these operations were performed to treat recur- which the surgeon places a finger to facilitate positioning. rent hernias.39 This figure is remarkably consistent with the data Ugahary’s operation is similar to Kugel’s, but it does not require from most other large series. A population-based study conducted a special prosthesis. In what is known as the gridiron technique, the by the Rand Corporation documented recurrence rates ranging preperitoneal space is prepared through a 3 cm incision, much as from 10% to 30%, depending on the characteristics of the hernia in a Kugel repair. The space is held open with a narrow (e.g., a lower rate after repair of simple small hernias and a higher Langenbeck retractor and two ribbon retractors. A 10 × 15 cm rate after repair of recurrent hernias).40 piece of polypropylene mesh is rolled onto a long forceps after the Because routine use of prosthetic material in herniorrhaphy is a edges have been rounded and sutures placed to correspond to var- comparatively recent phenomenon, most of these historical data ious anatomic landmarks. The forceps with the rolled-up mesh on have to do with sutured repairs. Many surgeons now believe that it is introduced into the preperitoneal space, and the mesh is sutured repairs inevitably result in distortion of the anatomy and in unrolled with the help of clamps and specific movements of the rib- tissue approximation under tension, leading to high recurrence bon retractors. rates. If this belief is correct, then it may be assumed that the over- Both operations have been very successful in some hands and all hernia recurrence rate should decrease dramatically over the have important proponents. However, because they are essentially next several decades as the percentage of prosthetic herniorrha- blind repairs, considerable experience with them is required before phies being performed increases.Two well-controlled, highly fund- the surgeon can be confident in his or her ability to place the patch ed, randomized trials that examined various aspects of inguinal properly. hernia management have now lent some support to this assump- tion.8,41 Both trials included the Lichtenstein tension-free repair as COMBINED ANTERIOR AND POSTERIOR (PREPERITONEAL) the control operation; the recurrence rates at 2 years were 4% and HERNIORRHAPHY 1% for that operation. Prosthetic Repair POSTHERNIORRHAPHY PAIN Bilayer prosthetic repair The bilayer prosthetic repair It is generally recognized that inguinal herniorrhaphy results in involves the use of a dumbbell-shaped prosthesis consisting of two greater morbidity than was previously appreciated. Now that mod- flat pieces of polypropylene mesh connected by a cylinder of the ern hernioplasty techniques have reduced recurrence rates to a same material. The purpose of this design is to allow the surgeon minimum, chronic postoperative groin pain syndromes have to take advantage of the presumed benefits of both anterior and emerged as the major complication facing inguinal hernia sur- posterior approaches by placing prosthetic material in both the geons. In a critical review of inguinal herniorrhaphy studies preperitoneal space and the extraperitoneal space. between 1987 and 2000, the incidence of some degree of long- The initial steps are identical to those of a Lichtenstein repair. term groin pain after surgery was as high as 53% at 1 year (range, Once the conventional anterior space has been prepared, the 0% to 53%).42 This complication is more likely to be observed in preperitoneal space is entered through the hernia defect. Indirect younger patients and in patients who report preoperative pain hernias are reduced, and a gauze sponge is used to develop the attributable to their hernia. Other risk factors have also been iden- preperitoneal space through the internal ring. For direct hernias, tified [see Table 8]. Chronic postoperative groin pain occurs without the transversalis fascia is opened, and the space between this struc- regard to the type of repair performed (tissue repair versus tension ture and the peritoneum is developed with a gauze sponge. The free; open versus laparoscopic) and does not depend on the deep layer of the prosthesis is deployed in the preperitoneal space, method by which the nerves are treated intraoperatively (division overlapping the direct and indirect spaces and Cooper’s ligament. versus preservation).43 The superficial layer of the device occupies the conventional ante- Treatment is difficult and often fails entirely. The difficulty is rior space, much as in a Lichtenstein repair. It is slit laterally or compounded when workman’s compensation issues cloud the pic- centrally to accommodate the cord structures and then affixed to ture.The first possibility that must be ruled out is a recurrent her- the area of the pubic tubercle, the middle of the inguinal ligament, nia. As a rule, all three types of pain (somatic, neuropathic, and vis- and the internal oblique muscle with three or four interrupted ceral) are best treated initially with reassurance and conservative sutures. treatment (e.g., anti-inflammatory medications and local nerve blocks); frequently, the complaint resolves spontaneously.The only exception to this rule might be the patient who complains of severe pain immediately (i.e., in the recovery room), who might be best treated with immediate reexploration before scar tissue develops. Table 8—Risk Factors for Chronic Postoperative Otherwise, reexploration is scrupulously avoided in the first year Groin Pain Syndromes42 after the procedure to allow for the possibility of spontaneous resolution. When groin exploration is required, neurectomy and Recurrent hernia Repair without mesh neuroma excision, adhesiolysis, muscle or tendon repair, and for- Preoperative pain High early pain scores eign body removal are all possibilities. The results are often less Absence of visible bulge Numbness than satisfying. Young age Delayed onset Outpatient surgery Time to return to work > 4 wk ISCHEMIC ORCHITIS AND TESTICULAR ATROPHY Infection Other chronic pain syndromes Obesity Orchitis or atrophy may result if the testicular blood supply is compromised during herniorrhaphy. Orchitis is defined as postop-
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 18 INFECTION erative inflammation of the testicle occurring within the first 2 postoperative days. Patients experience painful enlargement and Prostheses used for inguinal herniorrhaphies, unlike those used hardening of the testicle, usually associated with a low-grade fever; for ventral herniorrhaphies, rarely become infected. The reason the pain is severe and may last several weeks. Ischemic orchitis is why the groin is apparently a protected area is unclear. If a pros- most likely attributable to thrombosis of the veins draining the tes- thesis composed of a mesh material (e.g., polypropylene) becomes ticle caused by dissection of the spermatic cord. It may progress infected, it can usually be salvaged with drainage alone. This over a period of months and eventually result in testicular atrophy. should be the initial treatment for all infected mesh prostheses, This latter development is not inevitable, however. In fact, the with removal being reserved for refractory cases. If, however, a occurrence of testicular atrophy is quite unpredictable, in that most prosthesis composed of a nonmesh material (e.g., ePTFE) patients with this condition have no history of testicular problems becomes infected, it can never be sterilized and virtually always associated with the index herniorrhaphy. The vast majority of must be removed. Rejection of the prosthesis because of an aller- patients who experience testicular complications go on to recover gic response is possible but extremely rare.What patients call rejec- without atrophy. Bendavid, in a study of the incidence of testicular tion in their histories is usually the result of infection. atrophy at the Shouldice Hospital, found that this complication occurred in only 19 (0.036%) of 52,583 primary inguinal hernia repairs and in only 33 (0.46%) of 7,169 recurrent inguinal hernia Incisional Hernia Repair repairs.44 Incisional hernias occur as a complication of previous surgery. As noted, their incidence depends on how they are defined [see HEMORRHAGE Epidemiology, above]. In the literature, the incidence of incisional Postherniorrhaphy bleeding—usually the result of delayed hernia ranges from 3% to 12% of all laparotomy incisions,6,50 and bleeding from the cremasteric artery, the internal spermatic artery, it is twice as high if the operation was associated with infection. or branches of the inferior epigastric vessels—can produce a The root cause of incisional hernia is undoubtedly multifactor- wound or scrotal hematoma. Injuries to the deep circumflex artery, ial. In the past, incisional hernias were believed to be mostly iatro- the corona mortis, or the external iliac vessels may result in a large genic, related to surgical technical factors at the index operation retroperitoneal hematoma. (e.g., slippage of knots, breakage of sutures, tearing of fascia by sutures, rough handling of tissues, closure of the abdomen under OSTEITIS PUBIS tension, and poor choice of suture material).51 Today, however, it is Osteitis pubis has diminished in frequency since surgeons clear that noniatrogenic factors [see Table 9] play a much larger role began to realize the importance of not placing sutures through the than was previously recognized. Nevertheless, the importance of periosteum. In laparoscopic repairs, staples are used to attach the careful attention to technical detail in the closure of any abdomi- mesh to Cooper’s ligament, which may cause osteitis in some nal incision should not be minimized. cases. Surgeons’ practices in closing laparotomies tend to be far more dependent on tradition than on high-quality level I scientific evi- PROSTHESIS-RELATED COMPLICATIONS dence.52 There are, however, some general recommendations that The increasingly liberal use of prosthetic material in conven- can be made on the basis of current data and experience. Most tional herniorrhaphy and the routine use of such material in authorities believe that the best way of preventing incisional hernias laparoscopic herniorrhaphy make the discussion of complications is to close the incision with a continuous monofilament nonab- related directly to foreign material a timely one. Tissue response, sorbable suture, with the stitches placed 1 cm from the skin edge which is variable from person to person, can be so intense that the and 1 cm apart. To prevent excessive tension, the length of the prosthetic material is deformed by contraction. Erosion can result suture should be four times the length of the wound.52 in intestinal obstruction or fistulization, especially if there is physi- Monofilament sutures perform better than braided sutures because cal contact between intestine and prosthesis.45,46 Erosion into the bacteria tend to form colonies among the braids of multifilament cord structures has also been reported.47 sutures.54-57 Nonabsorbable suture material has the advantage of The other controversial issue is the possibility of damage to the greater longevity than absorbable suture material, but it is more spermatic cord caused by the normal fibroplastic response to likely to result in sinus formation and chronic wound pain.7,52 The polypropylene mesh. Such damage may lead to infertility through incidence of wound dehiscence or wound infection is not affected obstruction of the vas deferens.This was the conclusion in a 2005 by the suture material or the closure method. Studies of various paper describing 14 patients attending several specialty infertility suture materials have determined that incisional hernia rates are clinics.48 Nine of the patients had undergone bilateral tension- essentially the same with polydioxanone as with polypropylene but free inguinal herniorrhaphies with mesh; the remaining five had may be higher with polyglactin.52 undergone unilateral repairs but also had pathologic conditions Various patient-related risk factors for incisional hernia (e.g., testicular atrophy or torsion) on the opposite side. All have been identified [see Table 10].58,59 Although some contro- patients underwent surgical exploration with intraoperative versy remains, the current consensus is that there appears to vasography.The vasogram identified the site of the obstruction in be an association between these comorbid conditions and the the inguinal region, and the surgical exploration determined that incidence of incisional hernia. The type of wound incurred the mesh was the cause of the obstruction.These distressing find- also plays a role. Incisional herniation is most common after ings certainly call for continued vigilance. It has been suggested, midline laparotomies, especially upper midline incisions, and however, that there may be another explanation for infertility after less common after transverse or oblique incisions.6 An analy- mesh herniorrhaphy: this complication might be the consequence sis of 11 publications addressing ventral hernia incidence after of a more traditional injury mechanism at the time of surgery, various types of incisions found the risk to be 10.5% for mid- such as ligation, division, or cauterization, followed by scarring to line incisions, 7.5% for transverse incisions, and 2.5% for a moist, conveniently adjacent structure (which in this case would paramedian incisions.7 Over longer periods, the incidence be the mesh).49 increases, with the majority of incisional hernias developing in
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 19 cm2) had a recurrence rate of 67% when primary suture repair was Table 9—Causes of Incisional Hernias employed.63 Nevertheless, for patients who have no significant comorbid conditions [see Table 10] and who have a solitary defect Technical Genetic less than 3 cm in diameter, primary closure with nonabsorbable Patient related Molecular suture material may be considered. Some surgeons perform a sim- Wound related ple edge approximation after flaps have been developed on either side of the defect. Others use a Mayo “vest over pants” repair. Component separation repair This operation was initially described by Ramirez in 1990 and has become increasingly popu- Table 10—Comorbid Factors Associated with lar since then.64 Although first envisioned for treatment of hernias Incisional Hernia no larger than 10 cm, it is now being used to repair more sub- stantial defects. Perhaps its most common application is in conta- Male sex Malnourishment minated wounds, where a conventional prosthetic repair would be Old age Hypoalbuminemia contraindicated.65-67 Morbid obesity Anemia/transfusion A long midline incision is made through the scar to expose the Abdominal distention Malignancy hernia.The hernial sac is dissected up to its neck, deep to the fas- Cigarette smoking Jaundice cial edge. The skin and the subcutaneous fat are dissected away Pulmonary disease Corticosteroid therapy Mechanical ventilation Chemotherapy from the anterior sheath of the rectus abdominis and the aponeu- Type 2 diabetes mellitus Radiation therapy rosis of the external oblique muscle.The aponeurosis of the exter- Oral anticoagulants Renal failure nal oblique muscle is transected longitudinally just lateral to the lateral side of the rectus sheath [see Figure 16]. It is important to extend the incision onto the chest wall at least 5 to 7 cm cranial to the first 4 years after the operation.60 It is anticipated that as the costal margin. The external oblique muscle is separated from the use of minimally invasive surgical techniques increases, the internal oblique muscle as far laterally as possible.This step is the incidence of incisional hernia will drop. Hernias develop- safe because the neurovascular bundle (comprising the intercostal ing within 10 mm and 12 mm port sites are well documented; nerves and vessels) lies deep to the internal oblique muscle. The hernias in 5 mm port incisions are rare. At present, long-term result is that the internal oblique muscle and the rectus abdomin- data on the incidence and natural history of port-site hernias is slide medially, so that the edges of the hernial defect can be are lacking.61 brought together without tension and sutured primarily.68 If pri- Genetic factors are important as well: familial predisposition to mary closure still is not possible without undue tension, 2 to 4 cm incisional hernia has long been recognized by surgeons caring for of additional length can be gained by separating the posterior rec- patients with this condition. An increased incidence of incisional tus sheath from the rectus abdominis. Care must be taken not to herniation in patients with certain connective tissue diseases (e.g., damage the neurovascular bundle that runs between the internal osteogenesis imperfecta, Marfan syndrome, and Ehlers-Danlos oblique muscle and the transversus abdominis to enter the rectus syndrome) has been documented. Finally, the molecular details of sheath posterolaterally. incisional hernia causation are now beginning to be appreciated. Prosthetic Repairs Type 1–type 3 collagen imbalance, abnormal matrix metallopro- teinase (MMP) expression, and growth factor relations are among The use of prosthetic material to reduce tension has unques- the molecular-level processes that are currently under intense tionably reduced the recurrence rate after incisional hernia repair, scrutiny by the scientific community with regard to the etiology of especially in single-center series.69 For example, in a Finnish study incisional hernia. of 84 consecutive patients treated with a retromuscular polypropy- Not every patient who presents to a surgeon with an incisional lene mesh repair and followed for 3 years, the recurrence rate was hernia is necessarily a candidate for surgical repair.There are three 5%. In a separate U.S. study, no recurrences were reported in 102 indications for operation: (1) a hernia that is symptomatic, causing patients after 28 months of follow-up.70 pain, discomfort, or changes in bowel habits; (2) a hernia resulting Prosthetic material may be positioned in three different ways for in an unsightly bulge that affects the patient’s quality of life; (3) a an incisional herniorrhaphy—namely, as an overlay (onlay), an hernia that poses a significant risk of bowel obstruction (e.g., a inlay, or an underlay (sublay) [see Figure 17]. A mesh overlay may large hernia with a narrow neck). be placed on top of any of a variety of simple repairs. Although some series have reported that this approach yields acceptable OPERATIVE TECHNIQUE results in selected patients, most surgeons feel that it offers little advantage over the simple repair that the prosthesis overlies and Nonprosthetic Repairs that it typically is associated with a similarly disappointing recur- Primary suture repair Historically, primary suture repair rence rate.11 was the procedure of choice for most incisional hernias; prosthetic Prosthetic inlay (bridging) repair became popular in the 1990s, material was reserved for particularly difficult cases. In the latter in keeping with the tension-free ideal for inguinal herniorrhaphy. part of the 20th century, large population-based studies changed The principle underlying this technique is that for a prosthetic this way of thinking, revealing that primary suture repair was asso- repair to be truly tension free, the defect should be bridged. ciated with a much higher recurrence rate then most surgeons Although this repair is theoretically attractive, it has not been near- would have assumed (25% to 55%).11 Studies comparing primary ly as successful for incisional hernias as for inguinal hernias. The suture with prosthetic repair showed that the recurrence rate was recurrence rate is especially high in obese patients. Recurrences dramatically lower with the latter.62 In a randomized, controlled invariably develop at the mesh–native tissue interface. In the pre- study from the Netherlands, even small incisional hernias (< 10 viously cited study from the Netherlands,63 the recurrence rate
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 20 a sion-free concept. An example is the so-called keel operation of Rectus Abdominis Maingot, which was popular in the middle of the 20th century.The anterior rectus sheath is incised longitudinally, and the medial edge 1. is allowed to rotate behind the rectus abdominis. This, in effect, lengthens the posterior rectus sheath, allowing it to be closed pri- marily, which isolates the intra-abdominal viscera. If possible, the A1 A2 lateral edges of the incised rectus sheath on each side are approxi- B1 mated to each other. Otherwise, an inlay prosthesis may be used in B2 the hope that the closure of the posterior sheath will render failure less likely than it would be with a simple bridging onlay repair [see 2. External Oblique Muscle Figure 18]. Internal Oblique Muscle Sublay prosthetic repair Sometimes referred to as the Transversus Abdominis retromuscular approach, a sublay prosthetic repair is characterized by the placement of a large prosthesis in the space between the abdominal muscles and the posterior fascia—or the transversalis b fascia or the peritoneum, depending on what part of the abdomen is being repaired (there is no posterior fascia inferior to the arcuate line).27 In this chapter, we illustrate the version of the operation described by Flament [see Figure 19], but very similar operations have been attributed to Velamenta, Stoppa, and Wantz.71-73 The operation was originally envisioned for treatment of large and mul- A1 tiply recurrent hernias in cases where most of the abdominal wall 1 B A2 had to be reconstructed. Because it has proved so successful, it is 2 B now being increasingly used to repair ever smaller defects. Sublay prosthetic repair is currently considered the most effective conven- tional incisional hernia repair and is therefore the one against which all other procedures must be measured. Extensive flaps are created by dissecting the skin and subcuta- neous tissue off the external fascia well lateral to the hernia defect on either side.This step often allows the musculoaponeurotic com- ponents of the abdominal wall to be advanced to the point where Figure 16 Component separation repair. Depicted is the technique the posterior and anterior fascial layers can be closed primarily. of component separation, as described by Ramirez and colleagues.64 Once the flaps have been created, the fascia is opened at the edges (a) A longitudinal incision is made in the aponeurosis of the exter- of the defect, thereby affording entry into the plane between the nal oblique muscle (1) approximately 2 cm lateral to the rectus sheath, overlapping the hernia defect caudally and extending 5 to 7 cm cranial to the costal margin. Additional length can be gained by incising the posterior rectal sheath (2). (b) The external oblique muscle is separated from the internal oblique muscle as far later- ally as possible. Care must be taken not to damage the neurovas- cular structures that run between the internal oblique muscle and Overlay the transversus abdominis to enter the rectus sheath on its pos- terolateral side (black line). (A1, A2—cut edges of external oblique aponeurosis; B1, B2—cut edges of posterior rectus sheath) even with mesh repairs (mostly onlay and inlay) was 32% for large defects and 17% for small (< 10 cm2) defects. When a hernia defect is bridged with a mesh prosthesis, every attempt should be made to isolate the material from the intra- abdominal viscera so as to prevent erosion and subsequent fistula Inlay formation or adhesive bowel obstruction. Such isolation may be accomplished with a peritoneal flap constructed from the peri- toneal sac or with omentum. When contact with intra-abdominal organs cannot be avoided, ePTFE should be strongly considered for the prosthesis. Alternatively, one of the dual-layer prostheses that have mesh on one side and some type of adhesion barrier to protect the viscera on the other may be considered [see Table 4]. As yet, however, none of the dual-layer prostheses have a long enough Underlay track record to ensure that they will be safer than polypropylene alone would be. The issue of contact between the intra-abdominal viscera and Figure 17 Incisional hernia repair. Depicted are three potential the prosthesis has been further addressed by techniques that com- positions for placement of a prosthesis for repair of ventral bine some features of component separation repair with the ten- abdominal wall defects.
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 21 a b c d Figure 18 Incisional hernia repair. Depicted is a modified onlay technique. (a) The hernia defect and sac are shown, with the intact anterior rectus sheath on either side. (b) The sac has been reduced and the ante- rior rectus sheath incised on either side of the defect. (c) The anterior rectus sheath is rotated medially and closed in the midline—in effect, lengthening the posterior rectus sheath and isolating the intra-abdominal contents from the repair. (d) A prosthesis is sutured to the cut edges of the anterior rectus sheath. posterior surface of the deepest muscle and the underlying peri- operation, reporting a 7.3% recurrence rate for sublay prosthetic toneum and posterior fascia. A combination of blunt and electro- repair, compared with 19.3% for onlay mesh repair and 29.1% for cautery dissection works best for creating this large space, which suture repair.75 Sublay prosthetic repair has been successfully will eventually accommodate a sizable prosthesis (at least 5 cm long employed to treat massive hernias with substantial loss of and wide).74 The posterior rectus sheaths are approximated to each domain.76 Laparoscopic incisional hernia repair was designed with other primarily if possible. If the posterior sheath cannot be approx- the principles of this operation in mind. Indeed, current experi- imated because of tension, then the use of ePTFE or a dual-layer ence with laparoscopic methods has encouraged surgeons to place prosthesis should be considered instead of the standard mesh.The prosthetic material intraperitoneally even when performing con- prosthesis is then placed in the space beneath the muscle and ventional open ventral herniorrhaphies, so as to minimize the need secured in this position with sutures that are placed with a suture for extensive abdominal wall dissection.77,78 passer through small stab incisions at the periphery of the retro- COMPLICATIONS muscular pocket. The sutures pull the prosthesis well lateral and firmly affix it to the abdominal wall; they are then tied in the sub- There is overwhelming proof that tension-free prosthetic cutaneous tissue above the fascia.To prevent excessive skin flap dis- repairs yield lower recurrence rates than direct suture repairs section, it is usually best to bring the two tails through the full thick- do. In a Medline search for complications of incisional hernia ness of the abdominal wall, including the skin. The tails must exit repair, recurrence rates ranged from 31% to 63% for direct through two separate fascia sites but through the same small skin suture repairs and from 0% to 32% (mostly less than 10%) for incision, so that when the knot is tied, it resides in the subcutaneous prosthetic repairs.63,79 Although the primary adverse outcome tissue. Some surgeons prefer to avoid using full-thickness sutures of hernia repair is recurrence, the short-term morbidity of open because of concern over the possibility of wound pain resulting hernia repair must also be assessed. In one meta-analysis, the from neuromuscular entrapment.The prosthesis is therefore either overall complication rate after open repair was 27%.80 Ileus, sutured or stapled to the posterior fascia as far laterally as possible. postoperative pain, sepsis, fistulization, and necrotizing fasciitis An increasingly popular choice for the most complicated hernias is have all been documented. A 3.5% rate of enterocutaneous fis- to incorporate component separation into the procedure. tula formation within a 3-year follow-up period has also been A 2006 study from Sweden confirmed the superiority of this reported.81 Prothesis-related infection, though rare with
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 22 a b c d Figure 19 Incisional hernia repair. Illustrated is a retromuscular approach. (a) The anterior rectus sheath has already been incised and rotated medially and closed in the midline [see Figure 18]. The space beneath the rectus abdominis is being developed. Dissection should continue to the lateral edge of the posterior rectus sheath, but care should be taken to prevent injury to the neurovascular bundles; denervation or abdominal wall necrosis is possible if these bundles are injured. (b) The prosthesis is prepared with U-shaped sutures. (c) A suture passer is used to push the two tails of each U stitch through separate musculofascial sites. However, the two tails exit through the same skin incision; this eventually allows the prosthesis to be firmly secured deep in the pocket. The sutures are tied above the skin, and the knot is secured down to the fascial level. The suture is cut under tension so that the tails will retract back into the skin incision, which is then closed. If the flaps permit, the sutures can be tied in the subcutaneous tissue and not passed through the skin at all. The disadvantage of this latter approach is that there are likely to be more problems with seromas because of the more extensive dissection. (d) A penetrating towel clip is used to release the skin dimples created by the gathering of subcutaneous tissue when the full-thickness sutures are tied. This measure prevents a potentially permanent deformity. It is important to inspect the sutures to confirm that they have not been disrupted. inguinal hernia repairs, remains a major problem with incision- flap dissection of the subcutaneous layer from the fascia. al hernia repairs. It occurs in as many as 25% of repairs in some Untreated seromas commonly become infected secondarily. series, delays healing for prolonged periods, and is one of the Suction drains can be useful but are likely to result in prosthe- most important risk factors for re-recurrence. Higher rates of sis infection if left in place too long. Strategies for preventing prosthesis infection are associated with preexisting infection, and managing seromas are largely based on empiricism and ulceration of the skin overlying the hernia, obesity, incarcerated personal opinion; objective data are virtually nonexistent. It is or obstructed bowel within the hernia, and perforation of the not always necessary to remove the mesh if infection develops. bowel during hernia repair. Seromas are common, especially A trial of local wound care after opening the incision and when a large prosthesis is required or there has been extensive debriding the infected area is warranted. Some authorities
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 23 believe that ePTFE prostheses are less prone to infection; how- fixed in this position with nonabsorbable mattress sutures. ever, once infection is established, ePTFE prostheses, unlike Because the Mayo repair results in increased tension, there has mesh prostheses, are almost never salvageable. been controversy about its efficacy in adults. In various series, A dilemma arises when a patient has a large incisional hernia recurrence rates ranging from 1% to 40% have been reported and the wound is contaminated either by skin infection or by in adult patients.82 injury to the bowel during the repair at the time of adhesiolysis. In For larger umbilical and paraumbilical hernias, particularly this situation, a nonabsorbable mesh would have a significant those in adults, a mesh repair is preferred. The sac is dissected chance of becoming infected, and an enterocutaneous fistula could away from the undersurface of the rectus and the linea alba cir- complicate matters further. In the past, the use of absorbable mesh cumferentially, then reduced into the abdomen. If the peritoneum made of polyglycolic acid was recommended to prevent eviscera- remains intact, a mesh prosthesis may be placed in a subfascial tion. Granulation tissue forms over the mesh, making skin grafting position and secured with sutures. Alternatively, a mesh plug may possible. The mesh itself is absorbed in about 3 weeks, leaving no be inserted and secured to the edges of the defect with a series of permanent foreign body to serve as a persistent focus of infection. sutures.83 If the abdomen is entered, a dual-layer prosthesis with Unfortunately, however, recurrence of the incisional hernia is an adhesion barrier on the visceral side is recommended. In a inevitable. Currently, many surgeons prefer to use one of the newer series of 100 adult patients with a median follow-up period of 4.5 biologic prostheses in this setting. This has now become the best years, the recurrence rate was 11.5% for suture repairs and 0% for indication for these very expensive materials. Long-term data are mesh repairs.84 not yet available. Miscellaneous Ventral Abdominal Wall Hernia Repairs Periumbilical Hernia Repair EPIGASTRIC HERNIA GASTROSCHISIS Epigastric hernias occur through a single defect or multiple This life-threatening condition is seen in the newborn. It may defects in the linea alba. In most patients with these hernias, only also be found in the fetus during ultrasound examination of a preg- a single decussation of the fibers of the linea alba is present, as nant patient.There is an all-layer deficiency of the abdominal wall, opposed to the triple decussation seen in most persons.85 The to the right of a normal umbilicus, through which the bowels pro- reported incidence of epigastric hernia ranges from less than 1% trude. There is no hernial sac. Gastroschisis is discussed in more to as high as 5%. They are two to three times more common in detail elsewhere [see 9:2 The Pediatric Surgical Patient]. men than in women, and 20% are multiple. Most defects are smaller than 1 cm and contain only incarcerated preperitoneal fat, OMPHALOCELE (EXOMPHALOS) with no peritoneal sac. For this reason, they generally cannot be Like gastroschisis, this condition is seen in the fetus in utero and visualized laparoscopically. in the newborn. It is a hernia into the umbilical cord; the hernial The usual complaint is a painful nodule in the upper midline. contents are therefore covered by Wharton’s jelly and amnion. As a rule, reduction of the preperitoneal fat followed by simple clo- Omphalocele is also discussed in more detail elsewhere [see 9:2 The sure of the defect resolves the complaint. Given the relatively high Pediatric Surgical Patient]. recurrence rate (up to 10%), some surgeons prefer to place a postage stamp–sized piece of prosthetic material in the preperi- UMBILICAL AND PARAUMBILICAL HERNIA toneal space to reinforce the repair. Others bridge the defect by Unlike an omphalocele, an umbilical hernia is covered by skin. suturing the prosthesis circumferentially. Some authorities recom- If the defect is located to one side of the umbilicus, it is called a mend exposure of the entire linea alba because of the incidence of paraumbilical hernia (this variant is more common in adults). multicentricity. We believe that this practice leads to unnecessary Umbilical hernias developing during childhood are congenital, morbidity. Instead, we make a small incision with the patient under whereas those developing during adult life are acquired. local anesthesia and explain to him or her that additional repairs Accordingly, in adult patients, it is important to look for an under- may be required later. lying cause of increased intra-abdominal pressure (e.g., ascites or Left untreated, an epigastric hernia can become large enough to an intra-abdominal tumor).The differential diagnosis of an umbil- develop a peritoneal sac into which intra-abdominal contents can ical hernia includes a caput medusae of varices at the umbilicus protrude. Usually, however, the sac is wide, and serious complica- from portal hypertension, a metastatic tumor deposit (so-called tions are infrequent. Sister Mary Joseph node), a granuloma, an omphalomesenteric DIASTASIS RECTI duct cyst, and a urachal cyst. Management of umbilical hernia is determined by the age of In diastasis recti, the two rectus abdominis muscles are separat- the patient. The majority of hernias occurring in children ed quite widely, and the linea alba is stretched and protrudes like younger than 2 years will heal spontaneously; therefore, watch- a fin. Although the protrusion is easily reducible and almost never ful waiting is the rule, and only symptomatic hernias are oper- produces complications, many patients find it unsightly and ated on. In children older than 2 years and in adults, surgical request treatment. The usual therapy involves removing a strip of correction is required, with the type of repair employed depend- the weakened linea alba and reapproximating it; however, this ing on the size of the hernia. If the defect is small (< 3 cm), a could result in tension, which in turn might lead to recurrence. direct suture repair may be performed. Alternatively, the Mayo The alternative would be a mesh repair. repair may be used. A subumbilical semilunar incision is made, PARASTOMAL HERNIA the hernial sac is opened, the contents of the sac are reduced into the abdomen, and the sac is excised. An overlapping or Parastomal hernia is one of the most common complications of waistcoating technique is employed, in which the upper edge of stoma formation. Its incidence is much higher than is generally the linea alba is placed so as to overlap the lower and then is appreciated. There is good evidence to suggest that more than
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 24 50% of patients will eventually be found to have a paracolostomy Table 11—Indications for Repair of hernia if followed for longer than 5 years.86 The rate of herniation Parastomal Hernia with small bowel stomas is also discouraging, though less so than that with colostomies. The results of parastomal hernia repair are Obstruction particularly dismal, with recurrence being the rule rather than the Absolute indications Incarceration with strangulation exception. Some parastomal hernias can be accounted for by poor site Incarceration Prolapse selection or technical errors (e.g., making the fascial opening too Stenosis large or placing a stoma in an incision), but the overall incidence is Intractable dermatitis too high to be explained by these causes alone. Placement of the Relative indications Difficulty with appliance management stoma lateral to the rectus sheath is widely touted as a cause of Large size parastomal hernia, but high-quality scientific evidence to support Cosmesis this claim is not available. Obesity, malnutrition, advanced age, col- Pain lagen abnormalities, postoperative sepsis, abdominal distention, constipation, obstructive uropathy, steroid use, and chronic lung disease are also contributing factors.87,88 in recurrence. Either ePTFE or polypropylene mesh with an Newer techniques for stomal construction, such as extraperi- adhesion barrier can be used for the prosthesis. One technique is toneal tunneling, have had little impact on the incidence of para- to slit the prosthesis and create a keyhole in its center, then stomal hernia. Fortunately, patients tolerate these hernias well, and suture this directly around the peritoneal side of the stoma so life-threatening complications, such as bowel obstruction and that it widely overlaps the hernia defect. Sugarbaker’s practice is strangulation, are rare. Most are asymptomatic. Routine repair, to mobilize the bowel thoroughly, then lateralize it with the pros- therefore, is not recommended; repair is appropriate only when thesis—in effect, creating a long tunnel in addition to covering there is an absolute or relative indication [see Table 11]. If repair is the hernia defect.90 The detractors of the intra-abdominal considered, patients must be informed that there is a significant approach argue that the risk of complications (e.g., adhesive chance that the hernia will recur. bowel obstruction and fistula formation) outweighs the advan- Three general types of parastomal hernia repairs are currently tages. The intra-abdominal approach is particularly well suited performed: (1) fascial repair, (2) stomal relocation, and (3) pros- for adaptation to laparoscopic methods.91-93 thetic repair. Fascial repair involves local exploration around the SPIGELIAN HERNIA stoma site, with primary closure of the defect. This approach should be considered of historical interest only because the results A spigelian hernia, first described 400 years ago by the Flemish are so poor. Stomal relocation yields much better results and is anatomist Adriaan van den Spiegel,94 is a hernia through a defect considered the procedure of choice by many surgeons. This in the spigelian fascia. The spigelian fascia is the area between the approach is especially appropriate for patients who have other semilunar line and the lateral border of the rectus abdominis. The stomal problems, such as skin excoriation or suboptimal stomal majority of spigelian hernias occur just below the arcuate line, construction.The use of a prosthesis with a stomal relocation is not where the posterior rectus sheath becomes deficient. This region, generally recommended, because of the inherent danger of con- known as the spigelian belt, is a band between the iliac crest and a tamination. In the past few years, the popularity of stomal reloca- line drawn 6 cm above [see Figure 20].95 These rare hernias are tion has waned because of the realization that patients who under- being reported with increasing frequency: there are more than 100 go this procedure are subjected to a triple threat of hernia recur- cases in the surgical literature. rence: (1) at the old stoma site, (2) at the new stomal site, (3) in A spigelian hernia may present as a bulge lateral to the rectus. the laparotomy incision used to move the stoma. However, because many of these hernias are interparietal, they Prosthetic repair appears to be the most promising approach, but may not be clinically apparent; often, they are picked up inciden- it is necessary to accept the complications inherent in the placement tally during laparoscopy. A significant percentage of patients pre- of a foreign body.The stomal exit site must be isolated from the sur- sent with an incarcerated or even strangulated hernia. If such a her- gical field to lower the risk of prosthesis infection. The prosthesis nia is interparietal, the diagnosis frequently is not made until a can be placed extraperitoneally by making a hockey-stick incision laparotomy is done for treatment of the acute process. around the stoma, with care taken to ensure that the incision is out- The standard treatment is operative repair.96 A transverse inci- side the periphery of the stomal appliance. Once the subcutaneous sion is made over the bulge. The anterior rectus sheath is incised tissue is divided, dissection proceeds along the fascia until the sac is transversely, and the sac is dissected as far as its neck and either identified and removed.The defect is then closed with an overlying excised or inverted. The defect is then repaired with a continuous prosthesis buttress sutured in place. Alternatively, the fascial defect suture of nonabsorbable material. Alternatively, a mesh plug may is bridged with the prosthesis for a tension-free repair. be placed in the defect and sutured to the edges of the defect. The extraperitoneal approach seems logical but can be tech- Laparoscopic methods are increasingly being employed to repair nically demanding, in that it is sometimes difficult to define the spigelian hernias.97 entire extent of the hernia defect. Moreover, the considerable RICHTER’S HERNIA undermining involved can lead to seroma formation and even- tual infection. As an alternative, an intra-abdominal prosthetic In a Richter’s hernia, part of the bowel wall herniates through the approach has been described that is theoretically attractive defect. The herniated bowel wall may become ischemic and gan- because it avoids the local complications of the extraperitoneal grenous, but intestinal obstruction does not occur. The overlying operation and incorporates the mechanical advantage gained by skin may be discolored. The herniated bowel wall is exposed by placing the prosthesis on the peritoneal side of the abdominal opening the sac, and the neck of the sac is enlarged to allow deliv- wall.89,90 Intra-abdominal pressure then serves to fuse the pros- ery of the bowel into the wound. The gangrenous patch is excised thetic material to the abdominal wall rather than being a factor and the bowel wall reconstituted.The hernia is then repaired.
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 25 Spigelian Fascia 2 Semilunar Line (of Spiegel) 1 1 Umbilical Plane 3 6 cm Spigelian 4 4 Hernia Belt { Monro Line Hesselbach Triangle Inferior Epigastric Vessels Figure 20 Depicted is the spigelian hernia belt, with a diagrammatic representation of the relevant components of the anterior abdominal wall, including (1) the transversus abdominis, (2) the dorsal lamella of the rectus sheath (the rectus abdominis itself having been cut away), (3) the semicircular line (of Douglas), and (4) the spigelian aponeurosis. SUPRAVESICAL HERNIA to the iliac crest. There are three varieties of lumbar hernia. Supravesical hernias develop anterior to the urinary bladder as 1. The superior lumbar hernia of Grynfelt. In this variety, the a consequence of failure of the integrity of the transversus abdo- defect is in a space between the latissimus dorsi, the serratus minis and the transversalis fascia, both of which insert into posterior inferior, and the posterior border of the internal Cooper’s ligament.The preperitoneal space is continuous with the oblique muscle. retropubic space of Retzius, and the hernial sac protrudes into this 2. The inferior lumbar hernia of Petit. Here the defect is in the area.The sac is directed laterally and emerges at the lateral border space bounded by the latissimus dorsi posteriorly, the iliac crest of the rectus abdominis in the inguinal region, the femoral region, inferiorly, and the posterior border of the external oblique mus- or the obturator region. It may therefore mimic a hernia from any cle anteriorly. of these areas, and it sometimes is associated with a hernia from 3. Secondary lumbar hernia that develops as a result of trauma— one of these regions. It is important to recognize this hernia dur- mostly surgical (e.g. renal surgery)—or infection.98 In the past, ing groin exploration for a suspected groin hernia and then to it was encountered relatively frequently as a consequence of repair the defect appropriately. spinal tuberculosis with paraspinal abscesses, but it is less com- A variant of this hernia, known as an internal supravesical her- mon today. Surgical repair is discouraged because the natural nia, may also arise. These hernias are classified according to history is more consistent with that of diastasis recti than that of whether they cross in front of, extend beside, or pass behind the a true hernia. Denervation appears to play a significant role in bladder. Bowel symptoms predominate in patients with these the pathogenesis. In other words, this “hernia” really reflects a defects, and urinary tract symptoms may develop in as many as weakness in the abdominal wall more than it does a dangerous 30%.Treatment is surgical and is accomplished transperitoneally hernia defect. Therefore, appropriate repair is commonly fol- via a low midline incision. The sac can usually be reduced with- lowed by gradual eventration, which is perceived by the patient out difficulty, and the neck of the sac should be divided and as a recurrence. closed. Lumbar hernias should be repaired if they are large or sympto- LUMBAR HERNIA matic. A prosthesis or a tissue flap of some kind is usually required The lumbar region is the area bounded inferiorly by the iliac for a successful repair. A rotation flap of fascia lata can be used for crest, superiorly by the 12th rib, posteriorly by the erector inferior lumbar hernias. Laparoscopic repair of lumbar hernias is spinae group of muscles, and anteriorly by the posterior border now being performed with increasing frequency and is proving of the external oblique muscle as it extends from the 12th rib successful.99
  • © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 27 OPEN REPAIR OF ABDOMINAL WALL HERNIA — 26 References 1. Rutkow IM: Demographic and socioeconomic of inguinal hernia. Int Surg 71:141, 1986 tula after laparoscopic inguinal hernia repair. Br J aspects of hernia repair in the United States in 23. Lifschutz H, Juler GL: The inguinal darn. Arch Surg 81:1213, 1994 2003. Surg Clin North Am 83:1045, 2003 Surg 121:717, 1986 46. Miller K, Junger W: Ileocutaneous fistula forma- 2. Bay-Nielsen M, Kehlet H, Strand L, et al: Quality 24. Bendavid R: The Shouldice technique: a canon in tion following laparoscopic polypropylene mesh assessment of 26,304 herniorrhaphies in hernia repair. Can J Surg 40:199, 1997 hernia repair. Surg Endosc 11:772, 1997 Denmark: a prospective nationwide study. Lancet 47. Silich RC, McSherry CK: Spermatic granuloma. 358:1124, 2001 25. Gilbert AI: Sutureless repair of inguinal hernia. 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