Laparoscopic management of supra pubic hernia

1. vivkaje@gmail.com
Unique Features of Suprapubic
Hernia

2. vivkaje@gmail.com
• Term ‘‘suprapubic hernia’’ is defined by
Carbonell et al. and Palanivelu et al
• Hernia defect located 3–4 cm above the
symphysis pubis
• Most common cause - postoperative
incisional hernia
Unique problems
• Complexity of dissection
• Anatomic proximity to bladder, bony, vascular
and nerve structures
Surg Clin N Am 93 (2013) 1135–1162

3. vivkaje@gmail.com
Ports
• Usually midline ports
• Larger suprapubic hernias can be repaired
three left-flank trocars, with the uppermost
port closer to the midline
Surg Clin N Am 93 (2013) 1135–1162
Hernia June 2008, Volume 12, Issue 3, pp 251-
256

4. vivkaje@gmail.com
Extent of dissection
• Mobilize the median and medial umbilical
ligaments, prevesical space of Retzius is
entered, exposing the posterior aspect of the
pubic bone, Cooper’s ligaments and the
inferior epigastric vessels bilaterally
• Peritoneum carefully dissected out as a flap
inferiorly aided by adding 300 mL of sterile
normal saline into bladder

5. vivkaje@gmail.com
• Sac excision reduces seroma incidence
• Mesh size: 5 cm coverage beyond defect on all
sides
Fixation
• 2 Transfascial sutures for midline in the upper
part of mesh and suprapubic region.
• The lower end of the mesh should be fixed to
the Cooper’s ligament and the pubic bone.
Hernia June 2008, Volume 12, Issue 3, pp 251-
256

6. vivkaje@gmail.com
Variations in port placement and Ot set up

7. vivkaje@gmail.com
Position of patient
• Supine and in the Trendelenburg
position with both arms outstretched
• Tucking and padding both arms help the
surgeon and assistant move freely
Surg Clin N Am 93 (2013) 1135–1162
Hernia June 2008, Volume 12, Issue 3, pp 251-
256

8. vivkaje@gmail.com
Port position
• 3 ports
• One 10-mm trocar for 30° angled laparoscope
placed 2 cm above the umbilicus in case of
Pfannenstiel scars
• Two 5-mm trocars for the right and left
working hands
assistant
surgeon
nurse
monitor
Hernia June 2008, Volume 12, Issue 3, pp 251-
256

9. vivkaje@gmail.com
• In the patients with the previous scar
occupying midline
- All ports are shifted to the upper abdomen
- Or left abdominal wall with the monitor on the
right side
assistant
surgeon
nurse
monitorSurg Clin N Am 93 (2013) 1135–1162

10. vivkaje@gmail.com
• Larger suprapubic hernias can be repaired
three left-flank trocars, with the uppermost
port closer to the midline
assistant
surgeon
nurse
monitor
Surg Clin N Am 93 (2013) 1135–1162

11. vivkaje@gmail.com
• 3 transfascial fixation at
upper margin of mesh
• 1 transfascial fixation at
suprapubic region
• Lower edge is sutured
to Cooper’s lig b/l and
pubic bone
Transfascial fixations
where and how many?
Hernia June 2008, Volume 12, Issue 3, pp 251-
256

12. vivkaje@gmail.com
Unique features of Epigastric hernias

13. vivkaje@gmail.com
• Preperiotneal fat herniation common
• True hernia with sac less common
• Multiple defects common
• Falciform restricts mesh placement
• Transfascial sutures to be placed just below or
side of xyphoid and in subcostal regions
Surg Clin N Am 93 (2013) 1057–1089

14. vivkaje@gmail.com
• Subxiphoid hernias are a rare complication of
median sternotomy with an incidence 1%-4.2%
• Repair of subxiphoid hernias is technically
demanding with recurrence rates of 42%
following open and 30% in laparoscopic repairs
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 26, Number 2, 2016

15. vivkaje@gmail.com
Ports
• Left lateral ports ( as lateral as possible)
• Some use lower midline ports with lithotomy
position ( if tackers prefered)
Dissection
• Complete mobilization of Falciform ligament
• Upper 5 cm cover needed for defect
Surg Clin N Am 93 (2013) 1057–1089

16. vivkaje@gmail.com
Fixation of mesh
• Upper transfascial sutures in subxiphoid and
subcostal regions
• Lower midline single transfascial suture suture
• In subxyphoid defects, upper extent of mesh fixed
to diagphragm with intracorporeal sutures
( tackers can puncture the pericardium)
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 26, Number 2, 2016 Laparoscopic Subxiphoid Hernia Repair with intracorporeal
Suturing of Mesh to the Diaphragm as a Means to Decrease Recurrence

17. vivkaje@gmail.com
• Important key to successful laparoscopic repair - to
ensure adequate mesh overlap up to the diaphragm
even if it cannot be adequately fixed
• Mesh is pushed up by the liver and allows for wide
overlap of the hernia
• Alternatively the excess mesh above the costal margin
and xiphoid can be glued to abdominal wall
JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 26, Number 2, 2016 Laparoscopic Subxiphoid Hernia Repair with intracorporeal
Suturing of Mesh to the Diaphragm as a Means to Decrease Recurrence

18. vivkaje@gmail.com
Variation in port placement
and Ot set up
• Patient position – Supine reverse
Trendelenberg with arm out stretched
assistant
surgeon
nurse
monitor

19. vivkaje@gmail.com
• lower midline ports with lithotomy position
( if tackers prefered)
assistant
surgeon
nurse
monitor
Surg Clin N Am 93 (2013) 1057–1089

20. vivkaje@gmail.com
Transfascial fixations
where and how many?
Lateral ports surgery
• Three near the left margin of the mesh
• One in the mid right margin of the mesh

21. vivkaje@gmail.com
Transfascial fixations where
and how many?
• Midline ports
• 3 subxiphoid and
subcostal
• 1 in the mid point of
lower margin
Surg Clin N Am 93 (2013) 1057–1089

22. vivkaje@gmail.com
• References