laparoscopic repair of supra pubic ventral hernias

LA

TTcptnirlunasansastnsl

uhovBipcprphtdar

D

A

1

aparoscopic Repair of Suprapubic Ventral Herniaslfredo M. Carbonell, DO

thc

ctcCoaeo

mbmoiptoti

PPitruppamrhcwmhptasp

he laparoscopic approach to ventral hernia repair ap-pears to be superior to the traditional open operation.

he use of laparoscopy is associated with less pain, a betterosmetic result, a lower incidence of mesh and wound com-lications, and possibly a lower recurrence rate. As a result ofheir low prevalence, hernias located in atypical areas mayot be seen as frequently by surgeons, leading to a relative

nexperience in their repair; and a subsequent higher recur-ence rate. The suprapubic incisional hernia is one which isocated in close proximity to the pubic bone, arising afterrologic or gynecologic procedures. The repair of these her-ias can be difficult because of the complexity of dissectionnd their anatomic proximity to bony, vascular, and nervetructures. This technique article gives the operating surgeonthorough understanding of the nature of suprapubic her-ias and an illustrated step by step approach to the laparo-copic repair of this difficult problem; particularly the trans-bdominal suture fixation to the bony and ligamentoustructures of the pelvis. Although technically demanding andime-consuming, the laparoscopic repair of suprapubic her-ias yields a durable hernia repair. It is safe, technically fea-ible, results in a low recurrence rate, and is applicable toarge or multiply recurrent hernias.

Incisional hernias can develop in up to 20% of patientsndergoing laparotomy, and, after a primary repair, theseernias may recur in up to 63% of patients.1 With the devel-pment of laparoscopic techniques, the recurrence rate forentral hernia repair is frequently reported to be below 4%.2-5

ased on the open, retrorectus, Rives-Stoppa6 repair mandat-ng wide coverage of the hernia defect, the laparoscopic ap-roach is associated with few recurrences, rapid hospital dis-harge, improved cosmesis, a reduced risk of infection, andossibly less postoperative pain.2-5 Certain critical steps areequired to ensure a reliable laparoscopic ventral hernia re-air, such as a minimum of 4 to 5 cm mesh overlap of theernia defect, and mesh fixation with both full-thicknessransabdominal sutures and helical tacks.7,8 Although no ran-omized, prospective studies have been performed, a strongssociation has been made in the literature between herniaecurrences and the lack of mesh fixation with full-thickness

ivision of General Surgery, Minimally Invasive Surgery Center, VirginiaCommonwealth University Medical Center, Richmond, VA.

ddress reprint requests to Alfredo M. Carbonell, D.O., Division of GeneralSurgery, Virginia Commonwealth University Medical Center, 1200East Broad Street, PO Box 980519, Richmond, VA 23298. E-mail:

[email protected]

0 1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2006.04.005

ransabdominal sutures.2,7,8 Additionally, animal studiesave demonstrated the superior fixation strength of suturesompared with tacks for mesh fixation.9,10

The terms suprapubic and parapubic are often used inter-hangeably. When used to describe hernias, they refer tohose located just above the symphysis pubis. They may oc-ur as a result of low mid-line, Pfannenstiel, Maylard, andherney incisions used principally for gynecologic, prostatic,r rectal procedures.11 These hernias have also been reportedfter suprapubic catheterization.12 There is limited experi-nce with the repair of these difficult hernias using both thepen11,13-15 and laparoscopic approach.16-18

The abdominal oblique aponeurosis, rectus abdominususculature, and rectus sheath insert on the symphysis pu-

is. In the event an incision is placed in proximity to thisusculotendinous insertion, a hernia may develop as a result

f inadequate tissue purchase inferiorly when re-approximat-ng the fascia. The complexity of dissection and the closeroximity of these hernias to bony, vascular, and nerve struc-ures make the repair of suprapubic hernias a formidableperation. We developed a unique technique in the repair ofhese hernias, and present our 10-year experience, discussingn detail the operative approach.

reoperative Workupatient selection for the laparoscopic approach is up to the

ndividual surgeon. Preoperative workup should include ahorough history of all past surgeries and review of operativeeports, particularly if a previous hernia repair with mesh wasndertaken. On physical examination the surgeon shouldalpate the entire incision both in the supine and uprightosition. Provocative maneuvers should be used to accentu-te the hernia bulge and attempt to delineate the inferior-ost edge of the defect. For the laparoscopic ventral hernia

epair, a minimum 4 cm overlap of mesh past the edge of theernia defect is recommended; as a result, hernias less than 4m from the pubic symphysis are defined as suprapubic andill require this modified approach to repair. Computed to-ography (CT) is helpful in determining the exact size of theernia, its contents, and the relation of the inferior edge to theubic symphysis. Although we do not typically have the pa-ient undergo CT before hernia repair, we will do so if there isquestion regarding proximity of the hernia to the pubic

ymphysis or if there has been a previous mesh repair. Arevious repair with mesh may make the laparoscopic ap-
roach difficult, particularly if polypropylene mesh was used

ot

EIlttwtmclaubinsseTosdsc#a(sasu

PAp

bdtmaptfpuisplda

TTtptPvsa

LTiicbhatt

Laparoscopic repair of suprapubic ventral hernias 11

r a previous laparoscopic repair attempted. This informa-ion helps plan out the operative approach.

quipmentnstrumentation for the repair is similar to that of the typicalaparoscopic ventral hernia repair. We use from three to fourrocars for the procedure; at least one being 10 mm in size,he rest may be 5 mm. Because most of the trocars are 5 mm,e use a 5 mm, 30-degree angled laparoscope that will allow

he surgeon to change the position of the camera betweenultiple ports. The angle allows the surgeon to “look around

orners” during difficult portions of the procedure. A Mary-and dissector, atraumatic graspers, and laparoscopic shearsre required for the lysis of adhesions. We refrain from these of ultrasonic coagulating shears to take down adhesionsecause this can result in an unnoticed thermal injury to the

ntestine. Sharp division of adhesions is advised. Simple mo-opolar cautery attached to the scissors should suffice if nui-ance bleeding arises. The use of a 5 mm clip applier canerve as an added measure for hemostasis. For mesh we usexpanded polytetrafluoroethylene (ePTFE, DualMesh Gore-ex, WL Gore & Associates, Flagstaff, AZ), however, severalther tissue-separating mesh products are available that areafe to use in direct contact with the intestine. The four car-inal sutures used to initially hold the mesh in place are CV-0utures constructed of ePTFE (Gore-Tex, WL Gore & Asso-iates). The additional fixation sutures should be size #0 or1 polypropylene or polybutester that are both nonabsorb-ble. Our preferred fixation construct device is the ProTackUnited States Surgical, Norwalk, CT) that employs titaniumpiral tacks. Several other fixation construct devices are avail-ble as well. For passing and retrieving the transabdominalutures, a Gore Suture Passer (WL Gore & Associates) issed.

atient Set-upfter anesthetic induction, a three-way Foley catheter is
laced into the bladder. This is used to instill saline into the i
ladder as a tumescent to aid in determination of the blad-er’s location in the preperitoneal space so as to avoid injuryo it during the procedure. Should an injury be suspected,ethylene blue can be instilled in the irrigant to help identifycystotomy. The patient is positioned supine with both armsadded and tucked. This allows the surgeon and the assistanto work on the same side of the patient without interferencerom the patient’s extended arm. With more obese patients,adding to elevate the tucked arm will ensure there is nondue traction placed on the brachial plexus. The pubic hair

s shaven to ensure complete access to the area of the pubicymphysis during the operation. Using a standard iodine skinrep, the abdomen is prepped up to the nipple line, as far

ateral as the arms allow, and down onto the thighs. An io-ine-impregnated skin drape is used on the abdomen for andded antimicrobial barrier.

rocar Placementhe procedure commences with an open cutdown to enter

he abdomen safely away from any previous incisions andlacement of a 10-mm trocar. The incision can be made inhe midline above the umbilicus, distant to the hernia defect.lacing the first trocar this far above allows a more expandediew of the abdomen and ensures the trocar is out of the wayhould it be required to place a large piece of mesh. Twodditional 5 mm trocars are placed in a horizontal line.

ysis of Adhesionshe procedure proceeds with a sharp enterolysis, avoiding

njury to any hollow viscus. Care should be taken in dissect-ng the inferior-most aspect of the hernia because it oftenontains herniated bladder. The herniated contents shoulde completely reduced, and no effort made to remove theernia sac. At this point, a metric ruler is placed into thebdomen to determine the proximity of the inferior edge ofhe hernia defect to the pubic symphysis. If this measures lesshan 4 cm, plans should be made to proceed with this mod-
fied technique.

12 A.M. Carbonell

Operative Technique

Figure 1 After initial access to the abdomen via an open cutdown technique, laparoscopic ports are placed in ahorizontal configuration far above the hernia defect to allow manipulation and placement of a large enough piece ofmesh without interfering with the ports. This picture demonstrates the surgeon working in the pelvis on a suprapubichernia associated with a large Pfannenstiel incision. (Color version of figure appears online.)


Figure 2 With suprapubic hernias the inferior edge of the defect may be intimately associated with the superior edge ofthe bladder. (A) The intraoperative photo demonstrates the bladder filled with saline and the hernia defect completelyabutting the pubic bone. (B) The CT shows a portion of the bladder herniating into the defect. When the hernia edgelies within 4 cm of the superior most aspect of the pubic bone the surgeon must create a peritoneal flap to enter theprevesical space of Retzius so as to identify the proper bony and vascular structures for safe suture mesh fixation. (Colorversion of figure appears online.)

14 A.M. Carbonell

Figure 3 If the hernia defect edge is less than 4 cm from the pubis, then a peritoneal flap will need to be created to enterthe space of Retzius and Bogros to expose the posterior aspect of the pubic bone, Cooper’s ligaments, and the inferiorepigastric vessels bilaterally. Identification of these key structures will allow the surgeon to place the transabdominalsutures and tacks with pinpoint precision, avoiding injury to any of the surrounding neurovascular structures. Theperitoneum is grasped in the midline at the median umbilical ligament at a level immediately below the hernia defectedge. The surgeon can avoid injury to the bladder at this point by instilling approximately 200 mL of saline through thethree-way Foley catheter, allowing the bladder to become more visible. The peritoneum is sharply incised in ahorizontal fashion toward the epigastric vessels (Lateral umbilical ligaments) on either side. The prevesical space ofRetzius is entered and blunt dissection similar to that used for the laparoscopic, transabdominal, preperitoneal,
inguinal hernia repair is performed. (Color version of figure appears online.)
Figure 4 The flap is raised inferiorly to expose the underlying bony pelvic structures. The dissection proceeds until theposterior aspect of the pubic bone, Cooper’s ligaments, and the inferior epigastric vessels are identified bilaterally.
(Color version of figure appears online.)


Figure 5 (A) After completely delineating the edges of the hernia, 3.5� long 20 gauge spinal needles are placed at theextreme edges of the hernia defect. These spinal needles mark the edges of the hernia, helping to measure the exact sizeof the hernia using an intracorporeally placed thin, plastic, metric ruler. Once the maximum vertical and horizontalmeasurements of the hernia are taken, the overlap superiorly and laterally should be no less than 4 cm. (B) Inferiorly,the overlap onto the pubic bone is calculated as the distance from the edge of the hernia to the superior most aspect ofthe pubic bone plus 1 to 2 cm for overlap below the pubis. (Color version of figure appears online.)

16 A.M. Carbonell

Figure 6 Pretied CV-0 ePTFE sutures are placed with a 1 cm bite, 1 cm in from the mesh edge at the four corners of themesh to serve as the initial transabdominal fixation sutures. Because the inferior portion of the mesh will overlap ontothe pubic bone, the inferior suture should be placed 2 cm from the actual mesh edge. (Color version of figure appearsonline.)


Figure 7 (A) The mesh is rolled from the top and the bottom concomitantly like a scroll. (B) This allows for the meshto be dragged directly into the abdomen. (C) The mesh is then unrolled without having to reorient the mesh once it isin the abdomen. (Color version of figure appears online.)

18 A.M. Carbonell

Figure 8 After unrolling the mesh, the inferior transabdominal suture needs to be retrieved first to ensure adequateoverlap inferiorly where it is most important. (A,B) The suture passer is advanced into the abdomen, puncturing theperiosteum of the pubic bone and grasping one limb of the inferior suture, a second path through the periosteum graspsthe second limb of the suture and brings the inferior portion of the mesh against the pubic bone. (C) Note, the inferiorsuture is not tied down immediately, rather, the suture limbs are held under tension with a hemostat. (Color version offigure appears online.)


Figure 8 Continued

20 A.M. Carbonell

Figure 9 (A) The superior suture and the two lateral sutures are then retrieved transabdominally ensuring a minimumof 4 cm mesh-defect overlap. When the mesh lies tight against the anterior abdominal wall, then the superior and lateralsutures are tied. (B) The superior and lateral portion of the mesh is then fixated to the abdominal wall with spiral tacksevery 1 to 2 cm apart and interrupted #1 permanent suture every 4 to 6 cm. (Color version of figure appears online.)


Figure 10 (A–F) While holding the inferior-most midline suture untied outside the body, a minimum of two additional#1 polypropylene transabdominal sutures are passed through the periosteum of the pubis approximately 2 cm lateralto the first inferior midline suture. The suture must be taken in with the suture passer, advanced through the mesh anda second pass through the mesh retrieves the suture, forming a U-stitch. These sutures are not secured until all of theinferior sutures are placed. This allows the surgeon to hold the mesh loosely upwards with a grasper to allow directvisualization of the suture passer safely traversing the abdominal wall and periosteum. A minimum of three sutures areplaced through the periosteum. More may be placed as space allows. After placing all the inferior sutures, they are
individually tied. (Color version of figure appears online.)

22 A.M. Carbonell

Figure 10 Continued


Figure 10 Continued

24 A.M. Carbonell

Figure 11 (A,B) Further mesh fixation is achieved with spiral tacks every 1 cm and transabdominal #1 polypropylenesuture every 4 to 5 cm circumferentially around the mesh, avoiding placement of sutures or tacks below the iliopubictract. Although several tacks are placed directly into the posterior pubis and Cooper’s ligament laterally, care should betaken because of the close proximity to neurovascular structures. It is unnecessary to reconstruct the peritoneal defect.(Color version of figure appears online.)

PW1mTw(21owtop2ctrt5tsm

DHy

htTophpaRpanftbcdumw

tAqOah


rocedure Outcomese published our outcomes in 36 patients (26 females and

0 males) with a mean age of 55.9 years (range, 33-76) and aean BMI of 31.0 kg/m2 (range, 22-67) underwent LRSPH.19

wenty-two (61%) of the repairs were for recurrent hernias,ith an average of 2.3 previously failed open repairs each

range, 1-11). The mean hernia size was 191.4 cm2 (range,0-768), with an average mesh size of 481.4 cm2 (range,93-1428). All repairs were performed with ePTFE. Meanperating room time was 178.7 minutes (range, 95-290),ith a mean blood loss of 40 mL (range, 20-100). One pa-

ient undergoing her fifth repair required conversion becausef adhesions to previously placed polypropylene mesh. Hos-ital stay averaged 2.4 days (range, 1-7). Mean follow up was1.1 months (range, 1-70). Complications (16.6%) in-luded: deep venous thrombosis,1 prolonged pain greaterhan 6 weeks,1 trocar site cellulitis,1 ileus,1 prolonged se-oma,1 and Clostridium difficile colitis.1 Hernias recurred inwo of our first nine patients, for an overall recurrence rate of.5%. Since initiating the technique of applying multiple su-ures directly to the pubis and Cooper’s ligament (in theubsequent 19 patients), no recurrences have been docu-ented.

iscussionermann Johann Pfannenstiel’s first description of his epon-

Figure 12 At the conclusion of the procedure the 10 mmpasser. All sutures are tied, skin is closed in the standardadmitted to the hospital and discharged once their painappears online.)

mous incision in 51 patients in 1900, reported no incisional p

ernias after a 2-year follow up.20 Recent authors cite a 0.04%o 2.1% incisional hernia rate after Pfannenstiel incision.21,22

here is a paucity of literature regarding the technical aspectsf the repair of suprapubic ventral hernias. Bendavid11 re-orted the Shouldice Clinic experience repairing parapubicernias via an open technique in seven patients. All of hisatients presented with a denuded pubis lacking fascia. Hepproached the defect preperitoneally through the space ofetzius, and placed a polypropylene mesh anchored to theubis and Cooper’s ligaments inferiorly, and full-thicknessbdominal wall sutures superiorly. Although recurrence wasot reported, his results were favorable after a 5 to 48 month

ollow-up with no infections or seromas. Hirasa17 reportedhe first laparoscopic experience with the repair of suprapu-ic hernias. They employed a composite mesh with a 2 to 3m overlap, fixated only with spiral tacks and no transab-ominal sutures in seven patients. After a 4 to 9 month followp in six of the patients, one hernia (14.3%) recurred at 8onths as a result of the mesh pulling off of the abdominalall.There is some evidence to support the use of full-thickness

ransabdominal sutures to ensure adequate mesh fixation.2,7,8

nother important aspect of ventral hernia repair is an ade-uate overlap of mesh from the edge of the hernia defect.2,7

btaining adequate overlap to provide the necessary surfacerea for mesh-host tissue integration is difficult to achieve inernias occurring just above the pubic bone. We develop a

r site is closed with a permanent suture using a suture, and sterile dressings are applied. Patients are typicallytrolled and a diet is tolerated. (Color version of figure

trocafashionis con

eritoneal flap inferiorly similar to the dissection plane for

lrtlsrmtretcpbm

fpha

R

1

11

1

1

1

1

1

1

1

2

2

2

26 A.M. Carbonell

aparoscopic, transabdominal, preperitoneal, inguinal herniaepair to identify the critical pelvic structures, and allow forhe safe placement of fixation constructs directly to Cooper’sigaments and the pubic bone. We believe this represents thetrongest tissue of the pelvis, holding suture well enough toely on them almost exclusively for the inferior fixation of theesh. The two recurrences reported in our series occurred in

he first nine patients (5.5% overall recurrence rate).19 Theecurrences occurred just above the pubis before we began tomploy full-thickness, transabdominal sutures incorporatinghe periosteum of the pubis. After this modification, no re-urrences have been documented. This underscores the im-ortance of adequate mesh fixation with sutures to the strongony or ligamentous structures as opposed to the attenuateduscle at the hernia’s border.Although technically demanding, the LRSPH is technically

easible, safe, and results in a low recurrence rate. It can beerformed with low morbidity in very large and recurrenternias. Transabdominal suture fixation to the bony and lig-mentous structures yields a durable hernia repair.

eferences1. Burger JW, Luijendijk RW, Hop WC, et al: Long-term follow-up of a

randomized controlled trial of suture versus mesh repair of incisionalhernia. Ann Surg 240:578-583, 2004; discussion 583-585

2. Heniford BT, Park A, Ramshaw BJ, Voeller G: Laparoscopic repair ofventral hernias: Nine years’ experience with 850 consecutive hernias.Ann Surg 238:391-399, 2003; discussion 399-400

3. DeMaria EJ, Moss JM, Sugerman HJ: Laparoscopic intraperitoneal poly-tetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia.Prospective comparison to open prefascial polypropylene mesh repair.Surg Endosc 14:326-329, 2000

4. Park A, Birch DW, Lovrics P: Laparoscopic and open incisional herniarepair: A comparison study. Surgery 124:816-821, 1998; discussion821-822

5. Ramshaw BJ, Esartia P, Schwab J, et al: Comparison of laparoscopic andopen ventral herniorrhaphy. Am Surg 65:827-831, 1999; discussion
831-832
6. Stoppa RE: The treatment of complicated groin and incisional hernias.World J Surg 13:545-554, 1989

7. Koehler RH, Voeller G: Recurrences in laparoscopic incisional herniarepairs: A personal series and review of the literature. JSLS 3:293-304,1999

8. LeBlanc KA: The critical technical aspects of laparoscopic repair ofventral and incisional hernias. Am Surg 67:809-812, 2001

9. Joels CS, Matthews BD, Kercher KW, et al: Evaluation of adhesionformation, mesh fixation strength, and hydroxyproline content afterintraabdominal placement of polytetrafluoroethylene mesh secured us-ing titanium spiral tacks, nitinol anchors, and polypropylene suture orpolyglactin 910 suture. Surg Endosc 19:780-785, 2005

0. van’t Riet M, de Vos van Steenwijk PJ, Kleinrensink GJ, et al: Tensilestrength of mesh fixation methods in laparoscopic incisional herniarepair. Surg Endosc 16:1713-1716, 2002

1. Bendavid R: Incisional parapubic hernias. Surgery 108:898-901, 19902. Lobel RW, Sand PK: Incisional hernia after suprapubic catheterization.

Obstet Gynecol 89(Pt 2):844-846, 19973. Losanoff JE, Richman BW, Jones JW: Parapubic hernia: Case report and

review of the literature. Hernia 6:82-85, 20024. Norris JP, Flanigan RC, Pickleman J: Parapubic hernia following radical

retropubic prostatectomy. Urology 44:922-923, 19945. el Mairy AB: A new procedure for the repair of suprapubic incisional

hernia. J Med Liban 27:713-718, 19746. Carbonell AM, Kercher KW, Matthews BD, et al: The laparoscopic

repair of suprapubic ventral hernias. Surg Endosc 19:174-177, 20057. Hirasa T, Pickleman J, Shayani V: Laparoscopic repair of parapubic

hernia. Arch Surg 136:1314-1317, 20018. Matuszewski M, Stanek A, Maruszak H, Krajka K: Laparoscopic treat-

ment of parapubic postprostatectomy hernia. Eur Urol 36:418-420,1999

9. Huang CS, Huang CC, Lien HH: Prolene hernia system compared withmesh plug technique: A prospective study of short- to mid-term out-comes in primary groin hernia repair. Hernia 9:167-171, 2005

0. Pfannenstiel H: Ueber die vortheile des suprasymphysaren fascienquer-schnitts fur die gynakologischen koliotomien. Samml Klin Vortr 268:1735-1756, 1900

1. Luijendijk RW, Jeekel J, Storm RK, et al: The low transverse Pfannen-stiel incision and the prevalence of incisional hernia and nerve entrap-ment. Ann Surg 225:365-369, 1997

2. Griffiths DA: A reappraisal of the Pfannenstiel incision. Br J Urol 48:
469-474, 1976

laparoscopic repair of supra pubic ventral hernias

Documents