Laparoscopic Hernia Surgery

Laparoscopic hernia
surgery
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Laparoscopic hernia
surgery
An operative guide
Edited by
Karl A. LeBlanc MD MBA FACS

Minimally Invasive Surgery Institute, Inc.
Baton Rouge, Louisiana, USA
Clinical Assistant Professor, Surgery,
Louisiana State University School of Medicine,
New Orleans, Louisiana, USA
Past President of the American Hernia Society
A member of the Hodder Headline Group

LONDON
First published in Great Britain in 2003 by

Arnold, a member of the Hodder Headline Group
338 Euston Road, London NW1 3BH
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2003 Arnold
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I wish to dedicate this book to Zinda, my wife. Please forgive my absence in

so many things in our lives so that this textbook could become a reality.
Your support and love is never forgotten and always appreciated.
Contents
Contributors
Preface
PART 1
xi
xiii
Abbreviations
xv
Manufacturers
xvii
OVERVIEW
Laparoscopic general surgery

Roger K.J. Simmermacher
Technological and instrumentation aspects of laparoscopic hernia surgery

Gina L. Adrales and Adrian E. Park
Prosthetic biomaterials for hernioplasty

Karl A. LeBlanc
17
Fixation devices for laparoscopic hernioplasty

Karl A. LeBlanc
25
LAPAROSCOPIC INGUINAL/FEMORAL HERNIOPLASTY
31
History
Michael S. Kavic and Stephen M. Kavic
33
Anatomy and physiology

B. Page and Patrick J. ODwyer
41
Intraperitoneal onlay mesh approach

Morris Franklin
47
Transabdominal pre-peritoneal approach

Reinhard Bittner, Claus-Georg Schmedt and Bernhard Josef Leibl
53
Totally extraperitoneal approach

Ed Felix
65
10
Femoral and pelvic herniorrhaphy

Christine A. Ely and Maurice E. Arregui
75
11
Results of laparoscopic inguinal/femoral hernia repair

Ketan M. Desai and Nathaniel J. Soper
83
12
Complications and their management

Ricardo V. Cohen, Carlos A. Schiavon, Srgio Roll and Jos C.P. Filho
89
PART 2
viii Contents
PART 3
LAPAROSCOPIC INCISIONAL AND VENTRAL HERNIOPLASTY
97
13
History
Kristi L. Harold, Brent D. Matthews and B. Todd Heniford
99
14

Karl A. LeBlanc
103
15
Laparoscopic repair in the emergent setting

Guy R. Voeller
111
16
Herniorrhaphy with the use of transfascial sutures

Karl A. LeBlanc
115
17
Pre-peritoneal herniorrhaphy
Srgio Roll, Wagner C. Marujo and Ricardo V. Cohen
125
18
Hernioplasty with the double-crown technique

Salvador Morales-Conde and Salvador Morales-Mndez
133
19
Parastomal hernia repair

Karl A. LeBlanc
143
20
Lumbar hernia and denervation hernia repair

Karl A. LeBlanc
151
21
Results of laparoscopic incisional and ventral hernia repair

Rodrigo Gonzalez and Bruce J. Ramshaw
155
22

Samuel K. Miller, Stephen D. Carey, Francisco J. Rodriguez and Roy T. Smoot, Jr
161
PART 4
LAPAROSCOPIC TREATMENT OF DIAPHRAGMATIC HERNIATION
171
23
History
Raymond C. Read
173
24

Mark A. Reiner
179
25
Preoperative evaluation
Marco G. Patti and Piero M. Fisichella
187
26
Gastroesophageal reflux disease

J. Barry McKernan and Charles R. Finley
193
27
Para-esophageal hernias
Hugo Bonatti, Beate Neuhauser and Ronald A. Hinder
201
28
Traumatic and unusual herniation

Sergio G. Susmallian and Ilan Charuzi
209
29
Etiology of recurrent gastroesophageal reflux disease

Ziad T. Awad and Charles J. Filipi
217
30
Reoperation for recurrent gastroesophageal reflux disease

Thomas R. Eubanks
227
31
Results of laparoscopic treatment of hiatal hernias

Patrick R. Reardon and Stirling E. Craig
235
32

Santiago Horgan and Robert Berger
239
Contents ix
PART 5
LAPAROSCOPY IN THE PEDIATRIC HERNIA PATIENT
249
33
History
Rajeev Prasad and Thom E. Lobe
251
34

255
35
Diaphragmatic herniation
257
36

261
PART 6
FUTURE CONSIDERATIONS
263
37
Robotics and hernia surgery

Amit Trivedi and Garth H. Ballantyne
265
38
Socioeconomic issues
Karl A. LeBlanc, Andrew N. Kingsnorth and Zinda Z. LeBlanc
273
Index
283
Contributors
Gina L. Adrales MD
Clinical Instructor, University of Kentucky Medical Center; and
Research Fellow, Center for Minimally Invasive Surgery,
University of Kentucky, Lexington, KY, USA
Maurice E. Arregui MD FACS
Director of Fellowship in Laparoscopy, Endoscopy and
Ultrasound, St. Vincent Hospital and Health Care Center,
Indianapolis, IN, USA
Ziad T. Awad MD FRCSI FICS
General Surgery Resident, Omaha, NE, USA
Garth H. Ballantyne MD FACS FASCRS
Professor of Surgery, Division of Minimally Invasive and
Telerobotic Surgery, Hackensack University Medical Center,
Hackensack, NJ, USA
Robert Berger MD
Fellow in Laparoscopic Surgery, Department of Surgery,
University of Illinois, Chicago, IL, USA
Reinhard Bittner MD FRCS
Head of Department of General and Visceral Surgery,
Marienhospital Stuttgart, Stuttgart, Germany
Hugo Bonatti MD
Department of Surgery, Mayo Clinic, Jacksonville, USA
Stephen D. Carey MD FACS
Nanticoke Surgical Associates, Seaford, DE, USA
Ilan Charuzi MD
Chairman, Department of Surgery, Wolfson Medical Center,
Holon, Israel
Ricardo V. Cohen MD FACS
Department of Surgical Endoscopy, Sao Camilo Hospital, Sao
Paulo, Brazil
Stirling E. Craig MD BA
Research assistant, Methodist Reflux Center, The Methodist
Hospital, Texas Medical Center, Houston, Texas
Ketan M. Desai MD
Department of Surgery, Washington University School of
Medicine, St Louis, MO, USA
Christine A. Ely MD
Fellow in Laparoscopy and Endoscopy, St Vincent Hospital and
Health Care Center, Indianapolis, IN, USA
Thomas R. Eubanks MD DO
Portland Surgical Specialists, Portland, OR, USA
Ed Felix MD
California Institute of Minimally Invasive Surgery, Fresno,
CA, USA
Jos Carlos Pinheiro Filho MD
Department of Surgical Endoscopy, Sao Camilo Hospital, Sao
Paulo, Brazil
Charles J. Filipi MD
Professor, Department of Surgery, Creighton University, Omaha,
NE, USA
Charles R. Finley MD FACS
Videoscopic General Surgeon, Atlanta, GA, USA
Piero M. Fisichella MD
Fellow, Swallowing Center, University of California, San
Francisco, CA, USA
Morris Franklin MD
Professor of Surgery, University of Texas Health Science Center,
and Director, Texas Endosurgery Institute, San Antonio,
TX, USA
Rodrigo Gonzalez MD
Fellow, Emory Endosurgery Unit, Surgery Department, Emory
University School of Medicine, Atlanta, GA, USA
Kristi L. Harold MD
Laparoscopic Fellow, Carolinas Laparoscopic and Advanced
Surgery Program, Carolinas Medical Center, Charlotte,
NC, USA
B. Todd Heniford MD
Chief of Minimal Access Surgery, Co-Director Carolinas
Laparoscopic and Advanced Surgery Program, Carolinas Medical
Center, Charlotte, NC, USA
Ronald A. Hinder MD PhD
Professor and Chairman, Department of Surgery, Mayo Clinic,
Jacksonville, FL, USA
Santiago Horgan MD
Director of Minimally Invasive Surgery and Assistant Professor
of Surgery, Department of Surgery, University of Illinois,
Chicago, IL, USA
Michael S. Kavic MD
Professor of Clinical Surgery and Vice Chair, Department of
Surgery, Northeastern Ohio Universities College of Medicine,
and Director of Education, General Surgery, St Elizabeth Health
Center, Youngstown, OH, USA
xii Contributors
Stephen M. Kavic MD
Department of Surgery, Yale University School of Medicine,
New Haven, CT, USA
Marco G. Patti MD
Associate Professor of Surgery, Director, Swallowing Center,
University of California, San Francisco, CA, USA
Andrew N. Kingsnorth BSc MD MS FRCS FACS

Professor of Surgery and Consultant Surgeon, Plymouth
Postgraduate Medical School, Derriford Hospital, Plymouth, UK
Rajeev Prasad MD
Fellow in Pediatric Surgery, University of Tennessee College of
Medicine, and Le Bonheur Childrens Medical Center, Memphis,
TN, USA
Karl A. LeBlanc MD MBA FACS

Minimally Invasive Surgery Institute, Inc. Baton Rouge,
Louisiana, USA. Clinical Assistant Professor, Surgery, Louisiana
State University School of Medicine, New Orleans, Louisiana,
USA. Past President of the American Hernia Society
Zinda Z. LeBlanc RN BSN MD MBA
Director of Surgical Services/AICU/PACU/TX Rm.,
Womans Hospital, Baton Rouge, LA, USA
Bernhard Josef Leibl MD
Department of General and Visceral Surgery Marienhospital
Stuttgart, Stuttgart, Germany
Thom E. Lobe MD
Chairman, Section of Pediatric Surgery, and Chairman, Task
Force on Complementary and Alternative Medicine, and
Professor of Surgery and Pediatrics, University of Tennessee
College of Medicine and Le Bonheur Childrens Medical Center,
Memphis, TN, USA
Wagner C. Marujo MD
Attending Surgeon, Liver Transplantation Unit, Hospital Albert
Einstein, Sao Paulo, and Faculty of Medicine, University of Sao
Paulo, Sao Paulo, Brazil
Bruce J. Ramshaw MD FACS

Director of Education, Emory Endosurgery Unit, and Assistant
Professor, Surgery Department, Emory University School of
Medicine, Atlanta, GA, USA
Raymond C. Read MD FACS FRCS
Professor of Surgery Emeritus, University of Arkansas for
Medical Sciences, Rockville, MD, USA
Patrick R. Reardon MD
Director, Texas Institute for Advanced Minimally Invasive
Surgery Training, Texas Medical Center, Houston, Texas and
Surgical Director, Methodist Reflux Center, The Methodist
Hospital, Texas Medical Center, Houston, Texas
Mark A. Reiner MD
Assistant Clinical Professor of Surgery, Laparoscopic Surgical
Center of New York, Mount Sinai School of Medicine, New York,
NY, USA
Francisco J. Rodriguez MD FACS
Brent D. Matthews MD
Chief of Research, Carolinas Laparoscopic and Advanced
Surgery Program, Carolinas Medical Center, Charlotte, NC, USA
Srgio Roll MD
Director of Laparoscopic Surgery, Department of General
Surgery, Heliopolis Hospital, University of Santos School of
Medicine, Sao Paulo, Brazil
J. Barry McKernan MD PhD FACS

Clinical Professor of Surgery, Medical College of Georgia,
Augusta, GA, USA
Carlos A. Schiavon MD
Department of Surgical Endoscopy, Sao Camilo Hospital,
Sao Paulo, Brazil
Samuel K. Miller MD FACS

Salvador Morales-Conde MD
Laparoscopic Surgery Unit, University Hospital Virgen
Macarena, Seville, Spain
Salvador Morales-Mndez MD
Digestive and General Surgery Unit, University Hospital Virgen
Del Roco, Seville, Spain
Beate Neuhauser MD
Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
Patrick J. ODwyer MB BCh MD FRCSI MCh FRCS
Professor of Gastrointestinal Surgery, University Department of
Surgery, Western Infirmary, Glasgow, UK
B. Page BSc MD MBChB MRCS
Research Fellow, University Department of Surgery, Western
Infirmary, Glasgow, UK
Adrian E. Park MD FRCS FACS
Department of Surgery, Center for Minimally Invasive Surgery,
University of Kentucky Chandler Medical Center, Lexington, KY,
USA
Claus-Georg Schmedt MD
Department of General and Visceral Surgery
Marienhospital Stuttgart, Stuttgart, Germany
Roger K.J. Simmermacher MD PhD
General Surgeon, University Medical Centre, Utrecht,
The Netherlands
Roy T. Smoot, Jr MD FACS
Nathaniel J. Soper MD
Department of Surgery, Washington University School of
Medicine, St Louis, MO, USA
Sergio G. Susmallian MD
Department of Surgery, Wolfson Medical Center, Holon, Israel
Amit Trivedi MD
Division of Minimally Invasive and Telerobotic Surgery,
Hackensack University Medical Center, Hackensack, NJ, USA
Guy R. Voeller MD FACS
Associate Professor, Surgery, University of Tennessee, Memphis,
Memphis, TN, USA
Preface
The laparoscopic repair of inguinal hernias quickly followed the development of the laparoscopic approach to
the cholecystectomy. This operation was, and continues
to be, a controversial subject. In contrast, the adoption of
the laparoscopic methodology for the treatment of the
other hernias of the abdominal wall has experienced continued growth. While there are textbooks that have dealt
with general laparoscopic surgical techniques and others
that are comprehensive texts on the subject of hernias,
none have been dedicated solely to the laparoscopic treatment of this malady in all aspects of the abdomen.
A review of the authors that have contributed to this
work is a testament of my efforts to provide a true operative guide to those surgeons-in-training and those who
desire more detailed information on this subject matter.
An international representation is evident. These are the
opinion leaders and the surgeons that have helped to
develop this field. I appreciate their efforts to share their
knowledge.
I have tried to provide the reader with the different
techniques that are currently being used to repair the
hernias in the inguinal region, the incisional and hiatal
locations. I have also relied on different authors to provide the details of the pertinent anatomy, the current
results and the various complications and the management. The segregation of these topics should remove any
bias that may be seen in the usual textbooks of this type.
A section on the use of the laparoscope in the pediatric hernia patient is also included. In many areas of the
world, the availability of the pediatric surgeon is quite

uncommon. The information imparted in these chapters
should provide guidance to the general laparoscopic surgeon in this setting.
The era of robotics is also upon us. It may be surprising to many of us but there is utility in the repair of hernias also.
The final chapter on socioeconomics is needed to
educate the surgeon as he or she makes the operative
choices that are available. Many issues will be regional
while others are national and international. We are all
continually faced with the economic realities of the practice of surgery. More attention should be given to this
subject in the training programs. It is hoped that this
book provides a sound basis to begin this process.
I wish to thank all of the contributors for their persistence in this work. It is rather difficult and time-consuming to provide a chapter of the detail and with the
significant references that I desired. It is the expertise of
these authors that will truly make this text a reference
source. I would also express my appreciation of all of the
staff from Arnold Publishers and Naughton Management
that have helped in the production of this text. I hope that
the reader will realize the goals that I set forth upon the
commencement of this operative guide to laparoscopic
hernia surgery.
Karl A. LeBlanc
Louisiana
July 2003
Abbreviations
CGRP
CT
DES
DPL
ECG
ECMO
EGD
ePTFE
GER
GERD
GPRVS
HAL
IEM
IPOM
LES
LIVH
MIS
MRI
NSEMD
PCA
PEH
PFA
PONV
PPM
PTFE
TAPP
TEP
TLESR
calcitonin gene-related peptide

computerized tomography
diffuse esophageal spasm
diagnostic peritoneal lavage
electrocardiogram
extracorporeal membrane oxygenation
esophagogastroduodenoscopy
expanded polytetrafluoroethylene
gastroesophageal reflux
gastroesophageal reflux disease
giant prosthetic reinforcement of the
visceral sac
hand-assisted laparoscopy
ineffective esophageal motility
intraperitoneal onlay of mesh
lower esophageal sphincter
laparoscopic incisional and ventral
hernioplasty
minimally invasive surgery
magnetic resonance imaging
non-specific esophageal motility
disorder
patient-controlled analgesia
para-esophageal hernia
platelet function assay
postoperative nausea and vomiting
polypropylene mesh
polytetrafluoroethylene
transabdominal pre-peritoneal
total extraperitoneal
transient lower-esophageal sphincter
relaxation
Manufacturers
Angiologica, S. Martino Sicc., Italy

Applied Medical, Rancho Santa Margarita, CA, USA
Atrium Medical Corp., Hudson, NH, USA
Autosuture, Norwalk, CT, USA
BARD, Loomis, CA, USA
Brennen Medical, Inc., St Paul, MN, USA
Coalescent, Sunnyvale, CA, USA
Cook Surgical, Inc., Bloomington, IN, USA
Computer Motion, Inc., Santa Barbara, CA, USA
Cousin Biotech, Wervicq-Sud, France
C. R. Bard, Inc., Cranston, NJ, USA
Curon Medical, Sunnyvale, CA, USA
Ethicon, Inc., Somerville, NJ, USA
Ethicon Endosurgery, Inc., Cincinnati, OH, USA
Genzyme Corp., Cambridge, MA, USA
HerniaMesh, S.R.L., Turin, Italy
Intuitive Surgical, Mountain View, CA, USA
Lifecell, Inc., Branchburg, NJ, USA
Louisville Laboratories, Inc., Louisville, KY, USA
3M Healthcare, St Paul, MN, USA
Meadox Medical Corp., Oakland, NJ, USA
Onux Medical, Inc., Hampton, NJ, USA
Organogenesis, Inc., Canton, MA, USA
Origin Medsystems, Menlo Park, CA, USA
Phillips Petroleum Co., Bartlesville, OK, USA
Sanofi Winthrop Pharmaceuticals, New York, NY, USA
Sofradim International, Villfranche-sur-Sane, France
Storz Endoscopy, Los Angeles, CA, USA
Tissue Science Laboratories plc, Covington, GA, USA
U.S. Surgical Corp./Tyco International, Inc., Norwalk, CT, USA
W. L. Gore & Associates, Inc., Flagstaff, AZ, USA
PART
Overview
1 Laparoscopic general surgery

2 Technological and instrumentation aspects of
laparoscopic hernia surgery
3
7
3 Prosthetic biomaterials for hernioplasty

4 Fixation devices for laparoscopic hernioplasty
17
25
1
Laparoscopic general surgery
ROGER K.J. SIMMERMACHER
References
Fortunately the time when many surgeons and their

patients thought that laparoscopy should be a purpose
rather than a means to an end has passed. Although the
scopic approach has become the gold standard for some
indications, it has not brought completely new ideas on
how to handle surgical diseases, but it has changed our
certain approach in order to facilitate the postoperative
recovery of the patient. Principally, a surgical disease
should be managed by a surgeon. Who, in order to treat
his or her patient optimally, is not limited by technology
(a scalpel for open surgery or the laparoscope for some of
us) rather than trying to find the best treatment modality by chance, which might include techniques still to be
envisioned.1 For many of us, laparoscopy is, or was, the
first expansion of our rather limited armamentarium.
As with many things in surgery, Hippocrates is credited
as the first physician to have used a tool to obtain a better
view of the human interior, in his case the rectum.2 Further development of this idea, however, was hampered for
nearly 2000 years due to a lack of progression in technological innovation.3 The evolution of laparoscopic surgery
parallels the evolution of two distinct technical factors,
which are the basis for all current endoscopic interventions: the invention and development of a lens system that
could be connected to a computer-chip television camera
and an effective lighting system via fiber-optic delivery
were the essential prerequisites for the current possibilities
of laparoscopic technology. This allowed other surgeons
and their assistants to handle the endoscope while actively
participating and assisting in the scopic procedures. It is
difficult to state with certainty who should be credited with
performing the first human laparoscopy, complete with
pneumoperitoneum. However, at the beginning of the
twentieth century, three names are mentioned: Kelling,4
Jacobaeus5 and Ott.6 Jacobaeus was the first physician to
mention thoracoscopy, a procedure that he initially felt had

a better chance than laparoscopy for further development.
In 1927, the first textbook dealing with thoracoscopy
and laparoscopy was published by Korbsch in Munich,
Germany. After World War II, the development of laparoscopic investigations into the human body was led mainly
by European gynecologists. An extensive overview of their
contributions into the development of endoscopic surgery is beyond the scope of this chapter, but some of their
advancements are interesting and worth consideration.7
Once technical innovations allowed more than one person to view through the laparoscope at the same time, it
was only a few years before Phillipe Mouret of Lyon,
France performed the first human laparoscopic cholecystectomy in 1987. This event initiated an explosion of
experiments that has brought us to the current position of
laparoscopy as an important part of the surgical armamentarium. Nowadays, laparoscopic cholecystectomy, by
far the most extensively described and most frequently
performed laparoscopic procedure, is the gold standard
treatment for most diseases that merit removal of the
gallbladder,8 irrespective of age and comorbidity.9 Additionally, cholecystectomy is very often the first laparoscopic operation that trainees are taught. It should
be emphasized that the principles and indications for
cholecystectomy have not changed because of the laparoscopic approach. However, the old controversy of whether
intraoperative cholangiography should be a routine part
of the procedure returned early in the development of this
procedure.10 Additional concerns were exposed, partly
because the laparoscopic exploration of the common bile
duct was in its infancy.11,12 Even today, these arguments
are not resolved.10
Within a short period of time, the scopists turned their
interest towards another frequent surgical procedure,
4 Overview
appendectomy.13 Laparoscopic appendectomy had been

reported as early as 1977 in a paper from The Netherlands,14
and since then there has been an ongoing discussion about
the merits of the laparoscopic approach in the surgical
treatment of appendicitis. A recent review by Fingerhut
concluded that because many of the surgical aspects of
the open appendectomy have improved so greatly, the
apparent advantages of a laparoscopic approach are hard
to demonstrate.15 It is acknowledged, however, that local
cultural factors, as well as operative experience, are important considerations that should dictate the strategic
decisions of any individual surgeon and/or hospital.15
Recently, a randomized clinical trial in children, which
compared both approaches, demonstrated clearly that
laparoscopic appendectomy did not offer advantages
over the open method.16 These findings are disputed
heavily by others.17 Advantages of laparoscopic appendectomy appear to be limited to obese patients and
patients whose preoperative diagnosis is not clear-cut.18
Another organ system that received a lot of attention
in the early years of laparoscopy was the upper gastrointestinal tract.19 The initial interest began with the treatment of duodenal ulcers and gastroesophageal reflux
disease.20 Since its introduction of laparoscopic surgery of
the upper gastrointestinal tract, has become the gold standard for the surgical treatment of gastroesophageal reflux
disease (GERD).21 It is frequently performed in daycare
situations,22 although there can be persistent complaints
years after the operation.23
According to the French literature, gastric ulcers
should be approached laparoscopically at the initial operation,24 as both retrospective25 and prospective26 analyses
have shown excellent results and low conversion rates.25
Other diseases of the stomach for which laparoscopy is
frequently performed in some centers with standardized
laparoscopic methods include achalasia,26,27 perforated
peptic ulcer,28 and gastric cancer. With respect to bariatric
surgery, there appear to be current differences between
the use of the gastric bypass (more popular in the USA)
and the application of adjustable bands on the stomach
(more popular in Europe). The laparoscopic approach for
both procedures continues to grow rapidly, but randomized controlled trials comparing the different methods are
needed urgently.29
Laparoscopy offers an important advantage in the
treatment of many types of intra-abdominal cancers, as
it allows staging of the disease prior to any intended
resection. However, careful patient selection is necessary
to effectively limit the number of unnecessary laparotomies.30,31 Additionally, intraoperative laparoscopic ultrasonography may become mandatory in the future because
it allows more accurate pretreatment staging.32 Preoperative staging will allow the correct operation to be chosen
from one of the many different types of resections that
are feasible.3336
Introduction of improved techniques for intracorporeal hemostasis, stapling and knot-tying make it possible
to treat many colorectal diseases laparoscopically,37 even
in the presence of generalized peritonitis.38 Despite initial doubts about the maintenance of oncological resection principles, it has been shown that both types of
operations, laparoscopic and open, do not differ greatly
in this respect.39 The incidences of anastomotic leakage,
morbidity and mortality are not significantly different
between the two methodologies, but the laparoscopic
approach requires more operative time.39
Laparoscopic resection of cystic and solid liver tumors,
curative or palliative, is receiving increasing interest
as reports of the different techniques and their pitfalls
are accumulating.4043 Staging, of course, has also been
shown to be feasible.44 The spleen has also been the target
of the laparoscopist. Currently, open splenic resection is
usually reserved for treating a very large spleen with hypersplenism and in the acute trauma setting.45
Retroperitoneal organs, such as the pancreas, adrenal
glands and prostate, have also become the domain of
laparoscopically trained surgeons.4649 Admittedly, these
more advanced procedures require sufficient training
and skills in both laparoscopic and open surgery.
Vascular surgeons are now evaluating the newest
treatment modalities of endovascular procedures and
endoscopic techniques. Veins50 and the aorta51 can be
handled via a laparoscope, although this is still experimental in most cases.52
Future developments will probably focus on the
improvement of intraoperative imaging techniques,
improved tactile feedback through the so-called endohand,53 navigation,54 and robotic assistance.55 The primary efforts of the developments of laparoscopic surgery
focused upon the improvements for the care of the
patients, which of course continues today (e.g. the development of gasless pneumoperitoneum by lifting of the
abdominal wall).42,53 Current innovative attention seeks
to improve the range of motion, precision and control of
the surgeon through the development of intracorporeal
instruments that are handled via the endo-hand or revolutionary improvements of the tip of the laparoscopic
instruments53 as the endo-wrist of the da Vinci robotic
system.55 Furthermore, gastroenterologists might be challenged as some surgeons turn their interest into endoorgan laparoscopic management. However, there are
only limited anecdotal reports of resections of gastric
leiomyomas56 or small neoplasms, which predicts that
further investigations will be undertaken in the future.57
In conclusion, it is evident that laparoscopy is currently part of the surgical armamentarium as much as
the hand and scalpel have always been. Due to the current availability of rapid communication facilities,58 the
development of laparoscopy has been quicker than that
of any other innovation within surgery. In fact, this may
Laparoscopic general surgery 5
have pushed some surgeons to use laparoscopy for very

many different indications with, in some cases, less than
optimal preparation.59 Laparoscopy is well established
for cholecystectomy and gastric fundoplication,18 but for
many other indications its position still has to be determined, because many reports of successful laparoscopic
management for various indications are either from
anecdotal or personal experiences. The following chapters of this book indicate the current state of the art concerning hernia surgery. Certainly, there is enough evidence
to direct a choice. Thus far, the discussion regarding the
value of laparoscopy in trauma has yet to be finalized with
respect to its indications60,61 and its potential risks.62 The
alleged or partly demonstrated advantages of laparoscopic
surgery, such as reductions in postoperative morbidity,63
postoperative intra-abdominal adhesions,64 postoperative
analgesia requirements, sleep disturbances,65 blood loss,
and moderate immunological responses, and, increasingly, lower costs66 are not proven completely,18 despite the
fact that others test endoscopic surgery in rather extreme
circumstances.67 Training of our future colleagues should
be standardized with well-organized hands-on courses
combined with pelvic trainers and animal models. This
issue is a matter of concern that still needs attention.68 In
order to convince the surgical community of its advantages, randomized clinical trials and thorough analyses of
the outcomes from these procedures are mandatory.
Nevertheless, one must not forget the real experts wisdom
and warnings.1
11
12
13
14
15
16
17
18
19
20
21
22
23
24
REFERENCES
1
2
3
4
5
10
Scott-Conner CEH, Arregui M. Visions of things that will come to

pass. Surg Laparosc Endosc Percutan Tech 1999; 9: 856.
Edmondson JM. History of the instruments for gastrointestinal
endoscopy. Gastrointest Endosc 1991; 37: S2757.
Gunning JE. The history of laparoscopy. J Reprod Med 1974; 12:
2226.
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6 Overview
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2002; 167: 21357.
2
Technological and instrumentation
aspects of laparoscopic hernia surgery
GINA L. ADRALES AND ADRIAN E. PARK
Instrumentation
Fixation
Videoendoscopic system
Other enabling technologies
7
11
12
12
Laparoscopic hernia surgery, like other types of minimally

invasive surgery (MIS), has been shaped and impacted
by the emergence of new surgical techniques and the
assimilation of new and evolving medical technologies.
To address the technological and instrumentation aspects
of laparoscopic herniorrhaphy comprehensively could
extend the discussion from a macro-perspective dealing
with issues of operative suite design and integration of
technology to a micro-view focusing on, for example, the
tines of a dissecting instrument. Such a dissertation is
beyond the scope of this chapter. Instead, we will focus
upon the instruments, equipment and material used in
laparoscopic hernia surgery and the related technological
advances that have facilitated a widening adoption of
various laparoscopic hernia procedures. Some topics that
are dealt with in greater detail in later chapters, such as
methods of mesh fixation and surgical energy sources, will
receive more cursory mention in this chapter, in the context of specific instrument use and development. Ergonomic considerations in surgical instrument and equipment
design, so often overlooked yet so vital to optimal surgical
performance, will also be addressed.
Ergonomics
Conclusion
References
13
13
14
invasive approaches to a variety of surgical therapies. The

development of new dissecting tools and the incorporation of various energy sources into laparoscopic procedures have greatly enhanced the physicians capability for
fine dissection and rapid hemostasis. Despite these achievements, the basic design of laparoscopic instruments and
the associated ergonomic constraints have evolved little
over the past century. Laparoscopic instrument design is
still based upon a template consisting of a handle connected to a long, slender shaft, which then engages an endeffector unit. Like all surgical instruments, laparoscopic
instruments should be cost-effective, low-maintenance,
functional tools that achieve the intended purpose safely,
easily and reliably, as Melzer has stipulated.1 Over the past
two decades, an abundance of end-effectors with varied
functions has been developed. As a result, a wide array of
instruments is currently available to the surgeon performing laparoscopic hernia repair. A brief discussion of
the various characteristics and distinguishing features of
laparoscopic instrumentation relevant to hernia repair
follows.
Disposable instruments
INSTRUMENTATION
The rapid expansion of available laparoscopic instrumentation has fueled the widespread application of minimally
Supported in part by an educational grant from Tyco/US Surgical
Corporation.
Disposable instruments may increase operative efficiency

by eliminating the need for sterilization of reusable
instruments perioperatively. This convenience comes at a
significant cost in terms of equipment expenditure and
environmental impact. In a cost-comparison of procedural equipment, the cost of disposable equipment
exceeded that of reusable instrumentation by a factor of
8 Overview
1020.2 Although reusable instrumentation is subject

to the wear and tear of repeated use and sterilization,
disposable instruments may be imprecise.3 Reposable
instruments, which combine reusable and disposable
components, represent a compromise between the two
instrument types.
Laparoscopic dissecting and grasping

instruments
Although laparoscopic dissectors and graspers conform
to a basic design, the configurations of the end-effectors
vary in terms of size, shape and surface. Different types
of dissection (sharp or blunt dissection, micro- or
macro-exposure) require instruments with different dissecting tips. Sharp-tipped instruments, including laparoscopic shears and needle-nose dissectors, facilitate fine
spreading and micro-dissection. Blunt dissectors, such as
the Reddick-Olsen, may reduce the risk of inadvertent
injury to adjacent structures, but their utility in fine dissection and micro-exposure is limited. Tapered tips that
fall somewhere in the continuum from sharp to blunt
end-effectors constitute the majority of commonly used
dissectors. Tapered, narrow-tipped dissectors, such as the
Maryland/Kelly or DeBakey laparoscopic instruments,
have proved useful during laparoscopic hernia repair, from
dissection in para-esophageal herniorrhaphy to creation
of the peritoneal flaps in transabdominal pre-peritoneal
inguinal herniorrhaphy. Additionally, the Maryland/Kelly
dissectors have curved jaws, which facilitate dissection
around structures. The curved tips of the Maryland/Kelly
dissector allow clear visualization of the operative target
and the tip of the instrument, unlike the shadowing that
may occur about the symmetrically tapered, flat-tipped,
duckbill dissector.
Effective tissue grasping is made possible by the surface
topography of the instrument tips. The fine ridges and
grooves provide friction during grasping, limiting slippage
and therefore tissue trauma. The delicate serrations of the
DeBakey clamp provide atraumatic tissue handling. This
curved instrument is thus ideally suited for the fine dissection and the gentle manipulation of the bowel required
during adhesiolysis and reduction of hernia contents. In
contrast, ratcheted instruments with thick serrations are
poorly suited for bowel handling, but they are designed for
constant grasping, such as gallbladder retraction. Other
dissectors have tines that appose incompletely along the
proximal jaws of the instrument, allowing the instrument
to hold tissue atraumatically in that space.
The laparoscopic handle and the hinge mechanism
of the jaws greatly impact the function of grasping and
dissecting instruments. Instruments with coaxial or
articulating shafts provide the surgeon with greater freedom of movement in restricted working spaces. Locking
or ratcheted instruments may reduce muscular fatigue

during grasping, but they are not appropriate for dissection, which requires more dynamic handling. Similarly,
single-action jaws, in which one jaw remains fixed, are
effective for grasping but less so for dissection. Furthermore, the symmetry of double-action jaws makes these
instruments better suited for fine dissection.
The diameter of the instrument also affects function
and performance. Micro-instruments (23 mm diameter) have been applied to a variety of minimally invasive
procedures, including laparoscopic hernia repair.4,5 These
needlescopic dissectors have relatively elastic shafts and
short end-effectors with limited spread. Thus, limitations
inherent in the design of 2-mm graspers and dissectors
have in turn limited the use of such needlescopic instruments in laparoscopic hernia surgery.
Unique to laparoscopic totally extraperitoneal inguinal
hernia repair is the balloon dissector, commonly used in
North America to develop the pre-peritoneal plane. A
variety of balloon dissectors are available, most furnished
with a guiding trocar and obturator for initial placement
beneath the rectus muscle. With inflation of the balloon,
a pre-peritoneal working space is created. Although this
device provides a simpler and more timely alternative
to manual dissection, it is imperative that the surgeon is
familiar with the laparoscopic pre-peritoneal anatomy to
recognize the appropriate plane of dissection and to avoid
associated complications.
Trocars
Careful consideration of trocar type and placement is
imperative in the successful conduct of laparoscopic hernia repair. Quite simply, trocars are the portals through
which the laparoscopic instruments are passed. At the
same time, trocars represent potential weapons, and their
misplacement can contribute to the morbidity and even
mortality of a laparoscopic procedure. The incidence of
trocar-related injury is low but significant. The incidence
of hollow viscus perforation varies between 0.04 and
0.14 per cent.613 Major retroperitoneal vascular injury has
been reported in 0.030.1 per cent, carrying a substantial
mortality rate of nine per cent.912,14 Major vascular
injury is a very common cause of death in laparoscopy,
second only to anesthetic complications.14 In an effort to
increase the safety of trocar insertion, a variety of trocar
designs has been introduced.
The previously stated pros and cons of reusable
instrumentation also hold for trocars. Reusable, metal
trocars may provide better grip to the skin and abdominal wall compared with plastic, disposable trocars.
Several trocar designs have been developed to prevent
slippage and leakage of pneumoperitoneum. The Hasson
trocar, typically used as an initial trocar after peritoneal
Technological and instrumentation aspects 9
access via an open technique, has threads along the end of

its shaft. Much like the configuration of a screw, these
threads assist in securing the trocar in the abdominal
wall. Balloon trocars utilize an attached, inflatable, intraabdominal balloon after insertion to bolster the trocar
against the abdominal wall. While these balloons add
security, they are subject to breakage and may decrease the
radial mobility often required during ventral hernia repair
to visualize and operate on the anterior abdominal wall.
Safe peritoneal entry is a particular concern during incisional hernia repair, where there is a considerable risk of
injury to adherent loops of bowel. A variety of measures
(a)
(b)
has been implemented in trocar design to reduce insertionassociated injury. The optical view trocar was developed as
an alternative to Hasson trocar placement. This single-use,
plastic trocar has a clear shaft and conical tip, allowing
visualization of the abdominal wall layers as they are traversed while inserting the laparoscope. This trocar design is
well suited for insertion after pneumoperitoneum has been
established using a Veress needle.
While the optical trocar capitalizes on the benefit of
direct visualization, other trocar designs are centered on
the tip configuration for injury prevention (Figure 2.1). In
an effort to circumvent visceral damage, the shielded trocar
(c)
(d)
(e)
Figure 2.1 A variety of trocars is available for use during laparoscopic ventral herniorrhaphy. (a) The Hasson trocar has threads to
prevent slippage from the abdominal wall (Ethicon Endosurgery, Inc.). (b) The non-cutting trocar tip is designed to split the
musculature in an effort to decrease bleeding and other trocar-related injuries (Ethicon Endosurgery, Inc.). (c) The plastic shield of
this trocar retracts during insertion to expose a cutting blade then deploys upon peritoneal entry to protect the viscera from injury
(U.S. Surgical Corp., Inc.). (d) The bladed trocar features a blade that retracts upon peritoneal entry (Ethicon Endosurgery, Inc.).
(e) The laparoscope is housed in the optical trocar to provide visual guidance during insertion of this non-cutting trocar. This is
particularly useful in the reoperative abdomen after insufflation via the Veress needle technique (Ethicon Endosurgery, Inc.).
10 Overview
consists of an exposed blade for abdominal wall entry and

a plastic shield that is released upon peritoneal entry to
safely cover the cutting blade. Many disposable trocars
incorporate this mechanism. Importantly, this feature does
not guarantee protection against trocar entry injuries.
Pyramidal and conical trocar tips have also been
examined for safety and efficacy. When use of a conical,
non-cutting reusable trocar was compared with that
of a cutting, disposable trocar during transperitoneal
inguinal herniorrhaphy, the reusable trocar resulted in a
lower complication rate.15 Trocar vascular and visceral
injuries are thought to be related to the force required
for trocar insertion. However, the size of the abdominal
wall defect created by the trocar has been shown to be
inversely proportional to the entry force.16 In an animal
study, it was demonstrated that conical tips require
greater entry force than pyramidal trocars yet subsequently produce smaller abdominal wall defects.
To decrease the insertion force and possibly reduce
visceral injury, innovative trocar designs have been
coupled with various energy sources. However, these new
designs have not yet been proven in human application
in laparoscopic hernia surgery; studies have been limited
almost entirely to animal models. Electrosurgical trocars
utilize thermal energy to create the abdominal wall opening for passage of the trocar. This has been found to
reduce the force required for entry without detrimental
effects on wound healing at the trocar site after laparoscopic cholecystectomy.17 Taking advantage of the
decreased thermal spread associated with ultrasonic dissection, an ultrasonically activated trocar has been designed
with an associated decrease in insertion time and force as
well as a smaller increase in abdominal pressure during
insertion compared with conventional conical trocars.18
The applicability of these trocars is yet to be seen in
patients with multiple previous surgeries or with ventral
hernias, where the proximity of adhered bowel may
predispose the patient to thermal visceral injury.
Another substantial concern in the treatment of
hernia patients is recurrent herniation. In a retrospective
review of 320 patients (including two patients with
concomitant para-esophageal hernia repair), the overall
incidence of trocar site herniation after laparoscopic fundoplication was found to be three per cent.19 As herniation at trocar sites has been reported repeatedly in the
literature,1921 the size of the defect created by trocars is a
key factor. The size of the trocar site defect is influenced
by the tip shape, trocar size, and mechanism of entry.
The radially expanding trocar utilizes a needle puncture
followed by insertion of a blunt, radially expanding
obturator through the needle tract. This alternative to
the traditional cutting trocar has been associated with
less postoperative pain, improved postoperative patientrated wound scores, decreased intraoperative and postoperative complications, and smaller fascial defects.2224
Similarly, other non-bladed trocars have also been

demonstrated to cause smaller abdominal wall defects
that do not require closure.25 In contrast to cutting
trocars, non-bladed trocars split the musculature rather
than cut through the abdominal wall, a technique that
may also be associated with less minor bleeding.16
Energy sources
Advances in the use of energy sources have increased the
ease and feasibility of performing MIS. While energy
sources are used largely for hemostasis, increasingly they
are employed in tissue dissection as well. Available energy
sources include both thermal and mechanical energy
devices.
Electrosurgery
Thermal energy sources rely on the passage of electrical
current through tissues and the subsequent production of
heat. Applying high-radiofrequency alternating current
results in the excitation of cellular ions and the conversion
of electrical energy to mechanical energy. The degree of
the thermal response is directly proportional to the inherent resistance of the tissues, with little heat production
in plasma but significant heat production in bone. The
electrical current can be applied with a bipolar or monopolar electrode, the most common method in general
surgery.26 Bipolar electrosurgery confines the electrical
current to the tissue between the forceps and consequently
offers the added safety of decreased thermal spread.
Electrothermal injury is a substantial concern, with the
incidence of laparoscopic electrosurgery-associated complications numbering two to five per 1000 cases.27
Ultrasonic dissection
Ultrasonic dissection is a form of mechanical dissection,
like scissor or water-jet dissection, that has gained
popularity in laparoscopy. Mechanical energy is created
by high-frequency sound-wave vibration. The highfrequency vibration produces denatured collagen and
effectively vaporizes cells. The ultrasonically activated
scalpel, the ultrasonic instrument used most commonly
in laparoscopy, has been shown to seal vessels at diameters
up to 5 mm. However, it is recommended that its use is
limited to vessels 3 mm or less in diameter.28 At 80C, the
ultrasonically activated scalpel operates at a lower temperature than electrosurgery (100C).3 Ultrasonic dissection is reported to produce decreased lateral thermal
spread when compared with traditional electrosurgery.29
However, identification of intestinal or biliary duct
injury due to the ultrasonic dissector may be delayed.
Anecdotally, the dissector may temporarily seal the
injury site, such as an enterotomy, only to open days later

with devastating consequences.
In summary, electrosurgical and ultrasonic dissection
instruments minimize blood loss and may reduce operative time in a variety of laparoscopic procedures. However,
very judicious and limited use of energy sources in ventral
and incisional hernia repair is encouraged. A higher tolerance for a small amount of oozing is accepted in exchange
for a reduced risk of intestinal, spermatic cord, or nervous
thermal injury. The morbidity of intestinal injuries, particularly missed enterotomies, is remarkably high, with a
mortality rate of at least 25 per cent.30
thin arm that is then covered by a retractable sheath

during insertion. The operation of this device is rather
counterintuitive, as retraction of the handle is required during insertion. Proper handling of the device is essential to
protect the delicate mechanism responsible for securing the
suture. A more cost-effective method of suture introduction has been illustrated elegantly by Park and colleages31
and Rosenthal and Franklin.32 Rather than employing a
suture passer, the suture is introduced on a Keith needle and
extracted through a large-gauge spinal needle.
FIXATION
In an effort to secure the prosthetic material and to facilitate its incorporation, several fixation methods have
been developed. The need for prosthetic fixation by
sutures, tacks and/or staples has been well demonstrated
for ventral and incisional herniorrhaphy, and it is now
considered indispensable to the long-term durability of
the repair.33,34 The picture is less clear with regard to
inguinal herniorrhaphy, where data regarding the utility
of tissue adhesives or even non-fixation continue to
emerge. In contrast, primary suture closure is the most
significant component of hiatal hernia repair, as prosthetic mesh is seldom used.
The development of staples and spiral tacks has
increased operative efficiency in ventral and incisional
hernia repair. A variety of tacking devices is now available, including a reusable device, the Salute (Onux
Medical, Inc.). This innovative device delivers a stainlesssteel construct that is not preformed but assumes the
final shape of a keyring. Traditional spiral tacks are
approximately 34 mm in length, limiting the depth of
fixation of the prosthetic patch into the abdominal wall.
In a study comparing titanium stapling and Prolene
suture fixation of mesh, the burst strength of mesh fixed
with suture was significantly greater (1461.7 mmHg)
than that of staple fixation with two different delivery
systems (885.5 mmHg, 665.2 mmHg).35 It is thus recommended that tack or staple fixation of the mesh be
combined with nonabsorbable suture fixation in laparoscopic ventral hernia repair.
The development of effective bioadhesives and tissue
substitutes may facilitate mesh fixation in ventral and
inguinal hernia repair and offer an alternative to prosthetic mesh in crural closure for large hiatal hernias.
Several adhesives have been studied. Fibrin sealant or fibrin glue, a hemostatic agent derived from human plasma,
has been evaluated as an alternative prosthetic fixation
tool in ventral and inguinal hernia repair. However, fibrin
application has been associated with a greater inflammatory reaction compared with staple fixation.36 In another
animal study, the incorporation of fibrin glue in ventral
hernia repair resulted in reduced intra-abdominal
Needle drivers and suture passers

The employment of needle drivers and suture passers during laparoscopic hernia repair will be discussed in more
detail in subsequent chapters. A variety of needle drivers
and aids to suturing (e.g. Endostitch, Surg-assist) is available for use during laparoscopic hiatal hernia repair. These
devices were developed to assist the surgeon with intracorporeal suturing, an advanced laparoscopic technique.
Sutured mesh fixation is imperative in laparoscopic ventral hernia repair. This crucial component of ventral
herniorrhaphy can be accomplished via various suturepassing devices. These reusable, low-profile, sharp instruments pierce the abdominal wall through small stab
incisions and transfer the suture to secure the mesh to the
abdominal wall (Figure 2.2). The suture is held in place by a
Figure 2.2 Gore suture passer (W.L. Gore & Associates, Inc.).
Fixation devices
12 Overview
adhesions.37 While an inflammatory reaction was also

noted in this study, the density of adhesions and the
percentage of expanded polytetrafluoroethylene (ePTFE)
prosthetic patch coverage by adhesions was decreased in
the fibrin glue cohort. The majority of fibrin sealant
studies associated with hernia repair have been conducted in animal models. The hemostatic properties of
fibrin glue in hernia repair were notable in one of the few
published human studies. In patients with coagulopathic
disorders, fibrin glue was noted to reduce postoperative
bleeding after inguinal herniorrhaphy.38
The cyanoacrylates, a class of tissue adhesives traditionally used in wound management, have been examined
for use in laparoscopic hernia repair. Internal use
of this tissue adhesive was previously limited due to
the potential toxicity associated with early formulations.
However, newly designed formulations have been studied
for their applicability in hernia repair, although these studies remain limited to animal models. In an examination of
octylcyanoacrylate tissue adhesive for fixation of ePTFE in
a rabbit incisional hernia model, less force was required for
displacement of adhesive-fixed mesh than for suture or
spiral tack fixation.39 In addition, the octylcyanoacrylate
adhesive stimulated an inflammatory reaction that
delayed cellular migration into the ePTFE interstices, so
the clinical implications of this finding are unclear.
VIDEOENDOSCOPIC SYSTEM
The videoendoscopic system has become the eyes of
the laparoscopic surgeon. With the limited tactile feedback inherent in MIS, the quality of the surgical image is
crucial. The present limitations of the imaging system
include detrimental reductions in resolution, field of
view, contrast, and depth perception. These limitations
are the result of optical distortion by the camera and
monitor systems, and the loss of monocular and stereoscopic visual cues.
The current videoendoscopic system begins with a
rod-lens laparoscope with coaxial illumination and fiberoptic light bundles. Illumination is provided by a highintensity but cold broadband light source. Most systems
employ a high-quality solid-state camera equipped with
a charged-coupled device and a three-chip array for
color separation (red, green, blue). This provides optimal
color fidelity. Standard display systems utilize National
Television Committee Standard video with a resolution
of no less than 640 ! 480 pixels. Improving upon standard composite video systems, which combine luminance
and chrominance signals, S-video separates the signals and
offers superior color saturation. Most cathode-ray tube
monitors in use are curved and are therefore associated
with a degree of distortion. Flat-screen monitors eliminate
this distortion, but they remain cost-prohibitive in

many institutions and may provide poorer resolution and
movement lag.
Advances in imaging technology have led to the development of new systems to address current optical and
ergonomic limitations. Head-mounted displays reduce
the displacement associated with standard video towers
positioned at a distance from both the surgeon and the
operative field. However, the results of head-mounted
displays have been mixed; at least one report notes
decreased eyestrain and improved operative efficiency,
but another study fails to duplicate these results.40,41
Three-dimensional imaging systems have also been
constructed to provide stereoscopic perceptual cues.
However, the spacing between the component imaging systems is generally limited and is significantly smaller than
the normal interpupillary distance. This restriction limits
the depth perception provided by the three-dimensional
optical systems. Additionally, the accompanying headmounted display results in degradation in image quality,
limiting the widespread incorporation of this innovative
system.
It is hoped that with the adoption of high-definition
television standards and new research in advanced
digital signal processing technology, many limitations of
videoendoscopic imaging will be eliminated.42 This has
important implications for laparoscopic hernia surgery.
Real-time reversal of the video display could avoid the
mirror-image effect of working against the camera in ventral herniorrhaphy. These new systems could also correct
for perceptual distortion, such as the lack of shadowing
and other depth cues, and could facilitate the performance of more complex laparoscopic procedures.
OTHER ENABLING TECHNOLOGIES

Hand-assisted laparoscopy
The technique of hand-assisted laparoscopy (HAL) has
been applied to a variety of laparoscopic procedures, in
some cases avoiding certain laparotomy. With HAL, the
surgeons hand is inserted into the peritoneal cavity to
assist in dissection and retraction. Various port systems
that maintain pneumoperitoneum are used for hand
placement. In HAL, the incision size is limited to the
surgeons hand size, and this incision may be later used
for specimen extraction.
The application of the hand-assisted technique in
laparoscopic hernia repair has been limited. In 2000, Litwin
and colleagues reported one repair of a post-traumatic
left diaphragmatic hernia in a series of HAL cases.43 The
patient was noted to have incarcerated colon, spleen and
small intestine. This repair was facilitated by the entry
of the surgeons hand via an upper midline incision with

a resultant operative time of 206 minutes, estimated
blood loss of 50 ml, and a length of stay in hospital of four
days. Hand-assisted ventral herniorrhaphy has not been
reported. There does not appear to be a clear role for HAL
in the repair of ventral or inguinal hernias.
Robotic surgery
The feasibility of robotic-assisted surgery has been
examined for a variety of laparoscopic procedures. In
2001, Cadire and colleagues published a robotic-assisted
laparoscopic surgery series using the Da Vinci system (Intuitive Surgical), including three inguinal hernia repairs.44
Although the robotic articulating instruments facilitated
dissection in a variety of procedures, one system limitation noted by the authors was the narrow field of vision
provided by the three-dimensional optical system.
ERGONOMICS
Research in the field of surgical ergonomics may have
a far greater impact on MIS than will some of the technological advancements addressed previously. In the
manufacturing industry, it is well recognized that paying
proper attention to postural mechanics and the health
impact of instrumentation and machinery can significantly increase the productivity, efficiency and longevity
of workers. There are comparatively few available data on
the ergonomic risk factors associated with surgery. The
performance of surgery can be both mentally and physically demanding, and there is an alarming incidence of
musculoskeletal complaints among laparoscopic surgeons.45 Ergonomic risk factors (prolonged static postures, awkward stances, extreme joint angles, pressure
points from instrumentation, etc.) are pervasive in MIS
as a result of long instrumentation with reduced degrees
of freedom and displaced imaging (Figure 2.3). More
specifically, there are ergonomic issues that are unique to
laparoscopic hernia repair, such as the strain of working
against the camera (mirror-image effect) and the complex movements required to repair hernia defects from
underneath the anterior abdominal wall during ventral herniorrhaphy. While changes in instrument design
and imaging are forthcoming, the incorporation of these
changes will take time and the ergonomic hazards will
persist until they take effect. In the interim, attention to the
current operative environment and the selection of appropriate available instrumentation may improve operative
efficiency and protect the health of the surgeon.
The etiology of the ergonomic problem in laparoscopy is multifactorial. Consideration should be given to
instrumentation, image quality, and the positioning of
Figure 2.3 Minimally invasive surgery often requires awkward

positioning.
the patient, the surgical staff, and the equipment. Within

the current ergonomic constraints of laparoscopy, changes
can and should be made to increase the comfort of the
surgeon and reduce muscular fatigue. Instrumentation
should be selected not only for function but also for ease of
use and proper individual surgical fit. Currently, this selection may not be accomplished easily for surgeons with
smaller hands. The operating table should be positioned
so that the instrument handles are at the surgeons elbow
level.46 Similarly, the video monitor should be positioned
at or slightly above eye level. Suspended mobile monitors
may facilitate this adjustment. The monitor should be in
alignment with the operative target and the surgeon. Foot
pedals that control energy sources should be placed within
a small radius from the surgeons feet to avoid stiffening
and straining to maintain balance.
Patient position is also crucial. The patient should
be positioned to allow gravity to assist with operative
exposure, reducing the exertion needed from the surgeon
and assistants for retraction. For example, the patient
is placed in mild reverse Trendelenburg position during para-esophageal hernia repair. Similarly, the patients
arms should be tucked during ventral herniorrhaphy to
provide freedom of movement by the surgeon and assistants about the operating table. Attention to these details
in positioning and operative set-up should greatly
improve operative efficiency.
CONCLUSION
As with other types of MIS, laparoscopic hernia repair
evolved through the merger of innovative technology
and new surgical techniques. The wide array of available
instrumentation for tissue dissection, the development of
14 Overview
new tools for mesh fixation, and the application of novel

techniques have all facilitated and expanded the role of
laparoscopy in the treatment of a variety of hernia defects.
With continuing technological advances and attention to
ergonomic factors, the outcome and efficiency of laparoscopic hernia repair are certain to improve.
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3
Prosthetic biomaterials for hernioplasty
KARL A. LEBLANC
Synthetic prosthetic biomaterials: flat, single-component
products
17
Synthetic prosthetic biomaterials: preformed products
21
Synthetic prosthetic biomaterials: composite products
21
Almost all hernia repairs that are performed laparoscopically utilize some form of prosthetic biomaterial. One
notable exception is the infrequent small hernias found
during laparoscopic incisional and ventral hernioplasty,
which are merely sutured. The early pioneers in laparoscopic inguinal hernia repair generally used polypropylene mesh (PPM) products, but a few attempted to use
expanded polytetrafluoroethylene (ePTFE). Incisional
and ventral hernioplasty utilized ePTFE when it was first
described. Currently, PPM and ePTFE prostheses are
the preferred biomaterials for the laparoscopic repair of
inguinal and incisional hernias, respectively. The preferences for each of these operations and the choice of
prostheses are described in the following chapters. This
chapter will present the currently available materials that
are used for the laparoscopic repair of hernias.
The biomaterials can be subdivided into many classes.
The broadest distinction is between synthetic and nonsynthetic products. These can be subdivided further into
products used for inguinal and non-inguinal hernia
repair. While any prosthetic biomaterial could be used in
the repair of any hernia, the common preferences noted
above will be assumed.
SYNTHETIC PROSTHETIC BIOMATERIALS:

FLAT, SINGLE-COMPONENT PRODUCTS
Most of these products are manufactured from polypropylene. The major differences between the meshes are
the size of the monofilaments used in the structure of the
mesh and the size of the pores (interstices) of the mesh
Non-synthetic prosthetic biomaterials

Conclusion
References
22
24
24
Table 3.1 Flat, single-component polypropylene biomaterials

and manufacturers
Biomaterial
Manufacturer
Angimesh
Biomesh P1
Biomesh P3
Biomesh 3D
Hertra 1, 2
Hermesh 3, 4, 5
Intramesh NK1, NK2, NK8
Marlex
Parietene
Prolene
Prolene Soft Mesh
Prolite
Prolite Ultra
Surgipro (Monofilament)
Surgipro (Multifilament)
Trelex
Angiologica
Cousin Biotech
Cousin Biotech
Cousin Biotech
HerniaMesh
HerniaMesh
Cousin Biotech
C. R. Bard, Inc.
Sofradim International
Ethicon
Ethicon
Atrium Medical Corp.
Atrium Medical Corp.
U.S. Surgical Corp., Inc./Tyco
U.S. Surgical Corp., Inc./Tyco
Meadox Medical Corp.
itself (i.e. the weight of the mesh). These two factors influence the thickness, stiffness, shrinkage rates, inflammatory
response, potential for development of adhesions to the
product, and resulting changes in the elasticity of the
abdominal wall. These products are listed in Table 3.1, and
the differences in the weave and pore sizes of some of them
are noted in Figure 3.1.
One of the problems that has been seen in the past
with the repair of incisional hernias is fistulization.1 This
has also been seen with laparoscopic inguinal repair.2
These real and potential complications of PPM may be
18 Overview
(a)
(d)
(b)
(c)
(e)
(f)
Figure 3.1 Comparison of the weaves of PPM products: (a) Hetra 1, (b) Hetra 2,
(c) Prolene, (d) Prolene Soft Mesh, (e) Marlex, and (f) NK Mesh.
related to the weight of the polypropylene within the

mesh. Newer, lighter-weight meshes have been developed
(Table 3.1) that, theoretically, are designed to overcome
many of the adverse effects of the heavier meshes.
However, the lighter products are very soft and pliable,
and consequently the use of them within the pre-peritoneal space created for the repair of inguinal hernias can
be somewhat difficult. Manipulation can be particularly
troublesome because of other difficulties, such as obtaining the correct spatial and linear orientation. To overcome this, innovations such as Prolene Soft Mesh have
blue lines incorporated within the biomaterial, which
provides a degree of ease for laparoscopic inguinal hernia
repair.
Although not as prevalent or plentiful as PPM, polyester products are used in the repair of inguinal hernia in
several countries (Table 3.2). The use of polyester is generally prescribed because of its pliability and conformability to the inguinal floor. However, the use of polyester
biomaterial has been associated with fistulas.3 Figure 3.2
shows the differences between the polyester products.
The Parietex and Biomesh meshes are woven into a threedimensional weave rather than the two-dimensional
weave that is most familiar to flat meshes. This is said to
make them even more pliable and to allow a greater
degree of tissue penetration.
As with other biomaterials, ePTFE products were
initially developed many years ago for open repair of
inguinal hernias. The use of these single-component
Table 3.2 Polyester prostheses and manufacturers

Biomaterial
Manufacturer
Biomesh A1
Biomesh A3
Biomesh 3D
Mersilene
Parietex TEC
Parietex TECR
Parietex TET
Cousin Biotech
Cousin Biotech
Cousin Biotech
Ethicon
patches compromises about 85 per cent of the published

reports on the repair of incisional and ventral hernias.
The prevalence of use of ePTFE is based upon the fact
that there has never been a reported case of fistulization
subsequent to the intraperitoneal placement of this
product. In addition, ePTFE results in very minimal
adhesions to itself. The currently available products
are listed in Table 3.3 and shown in Figure 3.3. There
has been some concern regarding the extent and nature
of tissue penetration into ePTFE. However, this was
based upon an earlier product that is no longer used in
the laparoscopic arena. Recent studies have confirmed
that the level of tissue penetration and attachment
strength of the newer DualMesh is superior to that of
PPM at only three days post-implant.4 Other postoperative data also support the inhibition of adhesions to
ePTFE.5
Prosthetic biomaterials for hernioplasty 19

Table 3.3 ePTFE biomaterials and manufacturers
(a)
(b)
(c)
Figure 3.2 Comparison of polyester biomaterials: (a) Mersilene,

(b) Parietex TEC, and (c) Parietex TET.
Biomaterial
Manufacturer
DualMesh
DualMesh Emerge
DualMesh Plus
DualMesh Plus Emerge
DualMesh with Holes
DualMesh Plus with Holes
Dulex
Mycromesh
Mycromesh Plus
Reconix
Soft Tissue Patch
W. L. Gore & Associates

C. R. Bard, Inc.
C. R. Bard, Inc.
There is a distinctive difference between DualMesh

and Dulex products. As can be seen in Figure 3.3, the
rough surface of the latter is more like that of sandpaper
than the corduroy appearance of the former. Close-up
views reveal that these differences in appearance are
due to the laminar construction of the Dulex and the
transverse interstices of the DualMesh. Collagen penetration will be throughout the entire structure of the
latter and will be stopped at the visceral surface of
the biomaterial.
Another unique feature of the DualMesh is that it is
available impregnated with silver and chlorhexidine,
antimicrobial agents that are added for the obvious purpose of preventing infection. Long-term data on the benefits of impregnating these substances into the product
are difficult to document due to the low rate of infection
that is associated with laparoscopic hernioplasty. The
brown color of the material does, however, present a significant improvement in the use of the prosthesis, as it
results in a reduction in the glare that is apparent with
the non-impregnated product; this eases its use during
laparoscopy.
DualMesh Emerge and DualMesh Plus Emerge comprise DualMesh standard or DualMesh Plus biomaterial
that has an attached removable layer of silicone on its
surface (Figure 3.4a). This is currently available on the
15 ! 19-cm patch, but other sizes should become available
soon. This stiffens the product significantly, such that it
cannot be inserted into the abdomen via a 5-mm port
site. The purpose of this additional layer is to act as an aid
in the manipulation and fixation of the DualMesh during incisional hernia repair. Once the product is secured
to the abdominal wall, the silicone layer is peeled off the
ePTFE and removed (Figure 3.4b).
DualMesh with Holes and DualMesh Plus with Holes
are similar to the above products but with perforations at
evenly spaced intervals throughout the biomaterial. These
products are 1.5-mm thick, compared with the DualMesh
products without holes, which are 1-mm thick.
20 Overview
(a)
(b)
(d)
(c)
(a)
Figure 3.3 ePTFE biomaterials: (a) DualMesh, (b) DualMesh Plus,

(c) DualMesh Plus with Holes, and (d) Dulex.
(b)
Figure 3.4 Emerge biomaterial (a) with the silicone unpeeled and (b) as it is peeled off the DualMesh.
Figure 3.6 Anatomical Mesh.
Table 3.4 Composite biomaterials and manufacturers
Figure 3.5 3D Max.

PREFORMED PRODUCTS
These products have been manufactured to conform, in
one way or another, to the inguinal floor. They are placed
specifically via the laparoscopic approach, either by a
transabdominal or a totally extraperitoneal technique.
The most common of these prostheses is the 3D Max
(C. R. Bard, Inc.) (Figure 3.5). This polypropylene product is available in two sizes. Because of the curve within
the product, left and right prostheses are available for use
on the left and right sided inguinal hernia, respectively.
The orientation of this biomaterial is critical to ensure
adequate coverage of the myopectineal orifice. The larger
product may be used without the need for fixation; the
intra-abdominal pressure and the stickiness of the PPM
are said to allow for this.6 The smaller biomaterial does
require fixation because of its potential to migrate within
the pre-peritoneal space.
Another preformed device is the Anatomical Mesh
(Sofradim International) (Figure 3.6). The flat portion of
the prosthesis is made of PPM, while the portion that is
made to lie over the iliac vessels is made of polyester. The
sutures intertwined into the mesh are drawn together to
compress the product to ease its introduction through a
trocar. This is then cut to deploy the full surface of the
biomaterial. At the time of writing, there are no longterm follow-up data on the use of this product.
Biomaterial
Manufacturer
Composix
Composix EX
Paritex Composite
Paritene Composite
Sepramesh
Glucamesh
Glucatex 3D
C. R. Bard, Inc.
C. R. Bard, Inc.
Genzyme Corp.
Brennen Medical, Inc.
Brennen Medical, Inc.

COMPOSITE PRODUCTS
The introduction of the laparoscopic approach to incisional hernioplasty has identified the need to protect the
intra-abdominal viscera from contact with the mesh
materials that are used in the repair. Table 3.4 lists the
products that are composed of two different biomaterials.
The construction of these biomaterials is designed to allow
the in-growth of tissue while protecting the opposite surface from adhesion formation during the healing phase.
The concept differs in the individual products.
The first of these to be manufactured was that of the
Composix mesh (Figure 3.7a). A thin layer of ePTFE is
heat-sealed on to two layers of Marlex mesh. This is a very
thick product that requires at least a 12-mm trocar site
hole in which to introduce it. There have been reports of
adhesion formation and postoperative pain with the use
of this biomaterial.7 A thinner product, Composix EX
(Figure 3.7b), is comprised of one layer of Marlex and a
thicker layer of ePTFE. The ePTFE on this prosthesis is
sutured on to the PPM to provide secure fixation between
the two products. There is an overlap of the ePTFE past
the PPM to minimize the risk of exposure of the edges
of the PPM to the viscera. Therefore, one should avoid
cutting the mesh to conform to a non-standard shape,
22 Overview
(a)
Figure 3.8 Sepramesh.
PPM similar to the other two products above. The

manufacturer recommends that the mesh be covered
by the omentum at the completion of the laparoscopic
incisional hernia repair. There is some dispute as to
the success of this biomaterial in the prevention of
adhesions.8,9
Glucamesh and Glucatex 3D are, at the time of writing, very new polypropylene and polyester biomaterials
that are impregnated with oat beta glucan. Oat beta glucan is a purified complex carbohydrate that is isolated
from the cell wall of oats. It is absorbed following introduction of the product.
(b)
Figure 3.7 Comparison of (a) Composix and (b) Composix EX.
which could expose the PPM. The products are available

in numerous sizes, so cutting will seldom be necessary.
The last five products listed in Table 3.4 have absorbable
components. Parietex composite consists of a threedimensional polyester mesh (listed in Table 3.3) that has
been incorporated by hydrophilic collagen. Paritene composite uses the PPM that is listed in Table 3.1 and has the
same collagen layer as Parietex composite. The absorbable
collagen is no longer present by the fourteenth postoperative day. At the time of writing, long-term studies using
these biomaterials are in progress.
Sepramesh (Figure 3.8) is PPM coated on one surface
with carboxymethylcellulose and hyaluronate foam. This
foam will be absorbed in about seven days to leave the
NON-SYNTHETIC PROSTHETIC
BIOMATERIALS
Several products based upon biological materials are
now available (Table 3.5). The use of a non-synthetic
biomaterial for the repair of hernias may be the better
approach. However, long-term studies and biocompatibility evaluations will be needed to confirm their usefulness. All have been processed to eliminate the risk of
transmission of viral or other diseases. These generally
are pure or nearly pure collagen that will be incorporated
and/or replaced by the patients own collagen over time.
The hernia is repaired by the neofascia that subsequently
develops. The majority of implantations of these biomaterials have been via open operation, but their use
with laparoscopic technique is undergoing evaluation.

Table 3.5 Biological prosthetic biomaterials and manufacturers
Biomaterial
Manufacturer
Surgisis ES and Surgisis

Gold
FortaPerm
FortaGen
Permacol
Alloderm
Cook Surgical, Inc.

Organogenesis, Inc.
Organogenesis, Inc.
Tissue Science Laboratories plc
Lifecell, Inc.
(a)
Figure 3.9 Alloderm.
(a)
(b)
Figure 3.11 (a) Fortagen and (b) Fortaperm.
(b)
Figure 3.10 (a) Surgisis ES and (b) Surgisis Gold.
Alloderm (Figure 3.9) is manufactured from cadaveric skin. Its width is limited by the size of the dermatome that is used to harvest the material. Surgisis ES
and Surgisis Gold (Figure 3.10) are four- and eight-ply,
respectively, porcine small-intestinal submucosa. The
manufacturing process causes the nodules that are seen
on the Surgisis Gold. Fortagen and Fortaperm are also
processed porcine submucosa of the small intestine
(Figure 3.11). These latter two products are very similar
Figure 3.12 Permacol.
in appearance. They are five layers thick, the layers being

cross-linked together to provide greater strength. Fortagen
will be replaced by the native collagen, similar to Surgisis,
but Fortaperm becomes a permanent prosthetic similar
to that of the synthetic biomaterials described above.
Permacol (Figure 3.12) is porcine dermis with indications similar to the other products.
24 Overview
At the time of writing, all of these biomaterials are relatively new and clinical experience is generally limited.
There may be particular application in the site of infections
that are associated with tissue loss or following hernia
repair with synthetic meshes. These cannot be used in
the presence of an intestinal fistula because the enteric
contents will dissolve the collagen in the product.
REFERENCES
1
CONCLUSION
Laparoscopic hernioplasty is dependent upon the use of
prosthetic biomaterial and the in-growth that ensues. A
variety of synthetic and non-synthetic biomaterials are
available for implant. Surgeons should be aware of all of
the available products. The selection of the ideal prosthesis should be based upon experimental, clinical and longterm follow-up data. Newer biomaterials will probably
be developed in the future that may enhance the repair of
hernias.
6
7
8
9
Losanoff JE, Richman BW, Jones JW. Entero-colocutaneous fistula: a

late consequence of polypropylene mesh abdominal wall repair:
case report and review of the literature. Hernia 2002; 6: 1447.
Klein AM, Banever TC. Enterocutaneous fistula as a postoperative
complication of laparoscopic inguinal hernia repair. Surg Laparosc
Endosc 1999; 9: 602.
Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications
associated with prosthetic repair of incisional hernias. Arch Surg
1998; 133: 37882.
LeBlanc KA, Bellanger DE, Rhynes VK, et al. Tissue attachment
strength of prosthetic meshes used in ventral and incisional hernia
repair. Surg Endosc 2002; 16: 15426.
Koehler RH, Begos D, Berger D, et al. Adhesion formation to
intraperitoneally-placed mesh: reoperative clinical experience after
laparoscopic ventral incisional hernia repair. Am J Surg; in press.
Pajotin P. Laparoscopic groin hernia repair using a curved prosthesis
without fixation. J Coelio-Chir 1998; 28: 648.
LeBlanc KA. Tack hernia a new entity. JSLS 2003; in press.
Kramer K, Senninger N, Herbst H, Probst W. Effective prevention of
adhesions with hyaluronate. Arch Surg 2002; 137: 27882.
Amid P. Hyaluronate does not prevent adhesions. Arch Surg 2002;
137: 131314.
4
Fixation devices for laparoscopic hernioplasty
KARL A. LEBLANC
Early devices
Later devices
Latest devices
25
27
27
Laparoscopic hernioplasty requires the use of a prosthetic biomaterial. Consequently, a method of fixation
will be necessary for all but the smallest of incisional and
some of the inguinal hernia prostheses. The earliest
attempts to repair inguinal hernias laparoscopically were
performed with the suture fixation of the mesh to the
structures of the inguinal floor. This was a very tedious
task, which greatly hindered the adoption of this new
technology. Manufacturers of instruments responded
with the development of different devices that delivered
metal fixation to secure the biomaterial to the inguinal
floor. The use of these devices is, of course, an integral
part of all laparoscopic hernia repairs. There have been a
number of these products that have not been successful
or even brought to large-scale production. These and the
newer instruments are discussed below.
The classification of these devices is arbitrary. Regardless of the product that is used by the surgeon, it is critical that each is used properly. Few surgeons are afforded
the opportunity to use these instruments for the first time
in the laboratory setting. Therefore, it is recommended
that the surgeon experiences the mechanism of delivery
of each device before using it in the operating room.
Proper surgical technique is critical for the correct application of these devices without exposing the patient to
untoward consequences.
Conclusion
References
a series of 13 patients in whom he closed the peritoneal

opening of the sac using Michel clips. All but the last
patient in this series were repaired through an open incision. The thirteenth patient was repaired in 1979 under
laparoscopic guidance with a special stapling device. The
three-year follow-up of this patient revealed him to be
free of an identifiable recurrence. Ger and colleagues
continued their efforts to repair these hernias laparoscopically. They reported the closure of the neck of the
hernia sac using a prototypical instrument called the
Herniostat in beagles (Figure 4.1).2 This device was never
produced commercially, but it was certainly ahead of
its time.
Schultz and colleagues published the first patient
series of laparoscopic herniorrhaphy in 1990.3 Rolls
of polypropylene were stuffed into the hernial orifice,
which was then covered by two or three flat sheets of
polypropylene mesh (2.5 ! 5 cm) over the defect. These
rolls of mesh were not secured to either the fascia or
peritoneum. The peritoneum, however, was closed using
clips that were commonly used for hemostasis. Corbitt
EARLY DEVICES
Ger, in 1982, was the first to report the use of the laparoscope in the repair of an abdominal hernia.1 He reported
28
28
Figure 4.1 Ralph Gers Herniostat. (Photograph used with

permission of Ralph Ger, MD.)
26 Overview
Figure 4.2 Ethicon EMS stapler and the staples that it fired.
modified this technique by inverting the hernia sac and

performing a high ligation with sutures or with an endoscopic stapling device used for transection of tissues
similar to that used for open bowel resection.4
A similar concept was applied in the intraperitoneal
onlay patch (IPOM) technique. This repair, originally
investigated by Salerno and coworkers, used a polypropylene patch material in a porcine model.5 They placed rectangular pieces of the prosthesis against the abdominal
wall covering the internal inguinal ring and secured it
with a stapling device. The success of these repairs led
them to apply this method in clinical trials. This early
stapling device was the EMS stapler (Figure 4.2). It was a
reusable instrument that had to be reloaded following the
placement of every staple. This placed a box type of staple
similar to that which is used commonly for skin closure.
This was a 10-mm instrument that greatly improved and
decreased the time required for the inguinal hernia
repair technique.
At about the same time, Toy and Smoot reported on
their first ten patients repaired with the IPOM technique.6 They secured an expanded polytetrafluoroethylene (ePTFE) patch to the inguinal floor with staples that
were introduced by a prototypical stapling device of their
own design, which they called the Nanticoke Hernia
Stapler (Figure 4.3). They used this fixation device successfully without adverse results in 2030 patients. The
device did not become available commercially. A subsequent report of their first 75 patients was published in
1992.7 In this later series, the same prosthetic biomaterial
was attached with the Endopath EMS stapler (Ethicon
Endosurgery, Inc.) (Figure 4.4). After a follow-up of up
to 20 months, the recurrence rate was 2.4 per cent. They
noted a significant decrease in postoperative pain and an
earlier return to normal activity compared with the open
repair of the hernia defect.
These early hernia repairs continued to become modified in many different aspects, including approaches to
the inguinal area, prosthetic biomaterials, and fixation
devices. The devices that followed, such as the EMS,
allowed the placement of multiple staples without the
need to reload after each use. U.S. Surgical Corporation,
Inc. released its stapler, which was similar in concept
(Figure 4.5). This device required a 12-mm trocar rather
than the 10-mm trocar used by the EMS staplers. The
Figure 4.3 Nanticoke Hernia Stapler and staples. These

devices are conformed into a more rounded shape than the
EMS staples.
Figure 4.4 Endopath EMS stapler.
Figure 4.5 Endo-universal stapler of USSG.
Figure 4.6 Endopath EAS stapler.
device, however, allowed the articulation of the end of

the instrument, giving the surgeon the capability to place
the staples more accurately against the abdominal wall
and the ligament of Cooper.
Ethicon responded with the release of the EAS device,
which also has an articulating head (Figure 4.6). Both the
U.S. Surgical Corporation stapler and the Ethicon EAS
allowed 360-degree rotation of the shaft of the device
and articulation of the end of the shaft to place staples. In
most cases, these movements in these two different planes
allowed exact delivery of the staple to the prosthesis and
tissue. At about this time, there was an increasing use of
laparoscopic repair of not only inguinal but also incisional hernias subsequent to the first report in 1993.8 The
Fixation devices for laparoscopic hernioplasty 27
Figure 4.7 Omni-Tack.
delivery of the staples for this operation was not always

ideal because of the lack of further rotation of the end of
the head of the stapler. Because of this limitation, the
staple could not always be placed exactly perpendicular to
the edge of prosthesis, which resulted in fixation that was
not always flat against the abdominal wall. This problem
was solved with the release of the Omni-Tack by Ethicon
Endosurgery (Figure 4.7). Despite its innovative design
and increased ability of accurate staple placement, this
product was never distributed widely.
LATER DEVICES
As laparoscopic surgery expanded into the many areas of
general surgery, there was an unsatisfactory realization
that hernias developed in trocar sites that were larger
than 5 mm. Because of this, the trocar sites of the larger
ports required fascial closure to prevent these hernias. In
an effort to decrease this risk, the use of 5-mm instead
of 10-mm trocars, wherever possible, became more frequent. However, all of the instruments mentioned above
required access with trocars that were at least 10 mm.
Further engineering refinements in all laparoscopic
instruments provided the surgeon with 5-mm instruments and laparoscopes. Origin Medsystems introduced
the first successful 5-mm fixation device (Figure 4.8). The
method of fixation of this new helical coil was a significant departure from the previous staples. Delivery with
the 5-mm size was accepted quickly. The apparent disadvantage of the inability to rotate or articulate the device
did not prove to be important to the vast majority of surgeons. This method of fixation was quite secure.
U.S. Surgical Corporation introduced a similar
product, the ProTack, shortly thereafter (Figure 4.9). The
ProTack is almost identical, conceptually, to the Origin
tacker. Both deliver a 5-mm titanium helical coil that
is screwed through the prosthesis and into the tissues.
The ProTack, however, allows the surgeon to unscrew the
tack after it is introduced if the placement is deemed to
be inadequate or inappropriate. Because the ends of
these devices cannot be manipulated, it is important to
use significant counter-pressure during the implantation
of these tacks. If not, poor placement can result and
Figure 4.8 Origin Tacker.
Figure 4.9 ProTack.
a part of the coil could remain exposed to the intestine.

At least one report has documented the development of
a colocutaneous fistula that is presumed to be due to a
tack.9
LATEST DEVICES
Newer products have recently been introduced into the
hernia repair market. Like their predecessors, these have
unique characteristics. Onux Medical, Inc. has produced
the Salute fixation device (Figure 4.10). Unlike all of the
products discussed above, which used titanium as the
metal for the device, this construct is made of stainless
steel. This is the only reusable fixation device that has
been available commercially. Unlike the other products,
it does not deliver a preformed device into the tissues.
A construct is formed into a keyring shape as the trigger
is fired (Figure 4.11). This motion also cuts the wire at
the same time. While the device does require the use of
counter-pressure for placement, its method of delivery
makes it appealing for use in the upper abdomen, on
the diaphragm or at the esophageal hiatus. Although the
device does not seem to have as deep a penetration
into the tissues as the tack, experimental evidence has
shown that it is an effective method of fixation.10 Two
slightly different heads are available with this instrument. Some surgeons find the use of one or the other
preferable, in that the depth of penetration (depending
upon the particular surgeons technique) is affected by
the shape of the head. Because of the shape of the head,
the thickness of the wire is greater in the newer design.
Therefore, there are two different thicknesses of these
wires. Consequently, the spools of wire that are used
to deliver the coil are not interchangeable between these
devices.
28 Overview
Figure 4.10 Salute instrument.

Figure 4.13 EndoAnchor with the inner needle shaft exposed
by squeezing the trigger of the device.
Figure 4.11 Salute construct.
Figure 4.14 EndoAnchor device.
CONCLUSION
Figure 4.12 EndoAnchor instrument.
The most recently developed product is the EndoAnchor by Ethicon Endosurgery, Inc. (Figure 4.12). This
allows the entire device to be loaded into either a
3-mm or a 5-mm shaft. To place this product into the
tissues, the trigger is fired first. Unlike all of the other
products, this maneuver does not deploy the device. A
large needle-like shaft is moved forward from inside the
end of the outer shaft (Figure 4.13). The anchor is contained within the end of the needle. The anchor is released
into the tissues as the trigger is released. Once this occurs,
the nitinol anchor assumes its shape after that movement
(Figure 4.14). The upper protrusions of the shaft of the
nitinol are the portion of the device that remains in
the tissues. The lower, larger hooks are positioned over
the prosthesis to hold it in place. Currently, there is only
a limited release of this device.
Laparoscopic hernioplasty requires fixation of the biomaterial. The devices described above are almost all in
use today. The effectiveness of the newer products will
become known with the passage of time. Whichever
product is chosen in the laparoscopic repair of hernias, it
is critical to use the device properly. Knowledge of the
mechanism of delivery and the concept that is applied in
the shape of the final delivered device is important.
Emerging technologies will continue to deliver newer
products for this operation.
REFERENCES
1
Ger R. The management of certain abdominal herniae by

intra-abdominal closure of the neck of the sac. Ann R Coll Surg
Engl 1982; 64: 3424.
2 Ger R, Monro K, Duvivier R, et al. Management of inguinal hernias
by laparoscopic closure of the neck of the sac. Am J Surg 1990;
159: 37073.
3 Schultz L, Graber J, Pietrafitta J, et al. Laser laparoscopic
herniorrhaphy: a clinical trial, preliminary results. J Laparoendosc
Surg 1990; 1: 415.
Fixation devices for laparoscopic hernioplasty 29

4
Corbitt J. Laparoscopic herniorrhaphy. Surg Laparosc Endosc 1991;

1: 235.
5 Salerno GM, Fitzgibbons RJ, Filipi C. Laparoscopic inguinal hernia
repair. In: Zucker KA, ed. Surgical Laparoscopy. St Louis: Quality
Medical Publishing, 1991: 28193.
6 Toy FK, Smoot RT. ToySmoot laparoscopic hernioplasty. Surg
7 Toy FK, Smoot RT. Laparoscopic hernioplasty update.
J Laparoendosc Surg 1992; 2: 197205.
8 LeBlanc KA, Booth WV. Laparoscopic repair of incisional
abdominal hernias using expanded polytetrafluoroethylene:
preliminary findings. Surg Laparosc Endosc 1993;

3: 3941.
9 DeMarie EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal
polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral
hernia. Surg Endosc 2000; 14: 3269.
10 LeBlanc KA, Stout RW, Kearney MT, Paulson DB. Comparison of
adhesion formation associated with Pro-Tack (US Surgical) versus
a new mesh fixation device, Salute (ONUX Medical). Surg Endosc
2003; in press.
PART
Laparoscopic inguinal/femoral
hernioplasty
5
6
7
8
9
History
33
41
47
53
65
10 Femoral and pelvic herniorrhaphy

11 Results of laparoscopic inguinal/femoral
hernia repair
12 Complications and their management
75
83
89
5
History
MICHAEL S. KAVIC AND STEPHEN M. KAVIC
Hernia paradigm
Open hernia repair
Genesis of hernias
33
33
36
A hernia has been defined as the protrusion of a loop or

knuckle of an organ or tissue through an abnormal
opening.1 In their earliest state, hernias of the abdomen
and pelvic side wall begin as a protrusion of peritoneum
through a fascial defect. They are rarely symptomatic,
and typically they are undetectable on physical examination. In order to understand the development of laparoscopic hernia repair, it is necessary to review how the
approach to hernias and hernia repair has evolved
throughout history.
HERNIA PARADIGM
Before recorded or written history, humans are thought
to have managed hernia with taxis. From its Greek origin,
meaning the drawing up in rank and file, taxis for hernia
involved the use of finger or hand pressure to reduce the
displaced organ or tissue. Support after reduction, utilizing a belt or girdle to maintain the herniated content,
would have been a logical extension of taxis. Thus the first
paradigm for hernia management is most likely to have
been one of conservative, nonoperative management.
The date of the first operation for hernia and change
in the nonoperative paradigm is unknown. However,
allusion to an operative procedure for hernia was made
in one of the earliest written medical records, an ancient
Egyptian medical text known as the Ebers Papyrus.
George Moritz Ebers (183798), a professor of Egyptology at the University of Berlin, purchased an ancient
papyrus while traveling in Egypt in 1873. The papyrus
contained a collection of older works dating back to
30002500 BC. Ebers prepared a partial translation of
Laparoscopic hernia repair

Conclusion
References
37
39
39
the papyrus in 1875, which was later completed by

Bendix Ebbell, a Norwegian physician. Ebbells study of
the papyrus suggested that the ancient Egyptians had
attained a high level of surgical skill and had developed
procedures for hernia and aneurysm management.2
Interestingly, then, in the first preserved written record of
medical practice, the paradigm for hernia management
included surgical intervention.
Surgical intervention for hernia, and almost any other
disease, was mercifully rare before the modern era.
Without anesthesia, operative pain was real and fearsome.
In addition, infection almost inevitably followed a surgical procedure and frequently was life-ending. Because of
this, the religious proscriptions against human dissection,
and technological immaturity, progress in the surgical
sciences stagnated. The discovery of anesthesia and the
development of antiseptic methods in the mid-nineteenth
century revolutionized the practice of surgery. Operative
intervention without the twin specters of agonizing operative pain and postoperative infection became possible, and
the abdominal cavity no longer remained terra incognita.
Along with that for many other diseases, the paradigm for
hernia changed.
OPEN HERNIA REPAIR

Henry O. Marcy (18371924), a surgeon from the USA
and a disciple of the English surgeon Joseph Lister,
described two cases of incarcerated hernia that he treated
surgically in 1871.3 Marcy, using Listerian antiseptic
techniques, performed the standard operation of the day
on these two patients: he divided the hernia ring in the
34 Laparoscopic inguinal/femoral hernioplasty
usual way with the hernial knife and reduced the incarcerated hernia. However, Marcy went a step further and
expanded the hernia technique then in vogue. Rather
than open the hernia sac, he reduced it and repaired the
defect by closing the constricting ring with carbolized
catgut suture.
Marcy, in his report of these procedures, emphasized
the use of Listers antiseptic technique and a new form of
sterile (carbolized catgut) suture. He stressed that the
two patients healed without infection. Almost as an
afterthought, he noted that both patients were cured of
their hernias. In truth, Marcy may have been the first to
have closed the internal ring for hernia repair and probably helped initiate the modern age of hernia repair.4
Although Marcy made significant contributions to
herniology, it is generally agreed that the Italian surgeon
Eduardo Bassini (18441924) is the progenitor of modern hernia repair (Figure 5.1). Bassini, in 1884, devised a
method of hernia repair that called for a three-layer
reconstruction of the inguinal floor.5 After division of the
posterior wall of the inguinal canal and herniotomy (high
ligation and excision of the sac), Bassini performed a
triple layer repair of the inguinal floor. He approximated
the internal oblique muscle, transversus abdominus
muscle, and transversalis fascia to the inguinal ligament.
According to Bassini, this herniorrhaphy technique (suture
reinforcement of the floor of the inguinal canal) repaired
the inguinal defect(s), re-established the obliquity of the
inguinal canal, and reconstructed the internal and external
inguinal rings, restoring all to competency.
The Bassini repair was logical from an anatomic perspective, and it worked in practice. It was also radical, as
the patient did not have to wear a truss after the procedure as in other repairs popular at the time.
Bassinis operation was a marked improvement over
what had preceded it. Unfortunately, the sound procedure that Bassini devised became corrupted during its
dissemination worldwide. Surgeons, particularly in the
Figure 5.1 Eduardo Bassini.
USA, failed to appreciate the importance of dividing the

transversalis fascia to expose all layers, and a true triplelayer repair was often not accomplished. Bassinis operation was modified and simplified by not dividing the
transversalis fascia, but it was also diminished. Bassini
initially reported a recurrence rate of about three per cent.5
In the USA, experience with the Bassini repair, which was
frequently modified, differed from the Italian master, and
recurrence rates ranged from five to ten per cent in most
hands.6
Although Annandale, in 1876, was the first to enter
the pre-peritoneal space for hernia repair,7 Cheatle, in
1920, is generally credited with being the first to introduce a pre-peritoneal (otherwise known as pro-peritoneal,
extraperitoneal, or posterior) approach.8 Cheatle described his procedure as follows: an incision is made to
one side of the middle line, the rectus abdominus is split
longitudinally and the abdominal wall is retracted to the
side of the operation. The hernia sac was ligated as low
down as possible and the internal ring closed by suturing the muscle fibres and their sheath.
For femoral hernia, Cheatle recommended that a
flap of pubic bone periosteum be secured to Pouparts
ligament to secure the femoral orifice. In 1936, Arnold
Henry described a similar extraperitoneal approach to
hernia repair in which he secured the femoral canal with
a flap of pectineus fascia to Pouparts ligament without
tension.9 The internal ring was repaired from within.
Nyhus and colleagues later adopted and further
refined the open pre-peritoneal repair.10 They recommended that the pre-peritoneum be approached via a
suprainguinal incision and that suture plasty (herniorrhaphy) be performed to secure the defects of indirect,
sliding, and recurrent inguinal hernias.
Because of the significant recurrence rate after
herniorrhaphy, many surgeons recalled a quote attributed to Theodore Billroth (182994): If we could artificially produce tissues of the density and toughness of
fascia and tendon, the secret of the radical cure of hernia
would be discovered.11
The earliest use of synthetic material to substitute for
living tissues in herniorrhaphy occurred in 1894, and
involved the use of silver wire coils placed in the inguinal
canal to induce fibrosis and strengthen the hernia
repair.12 A few years later, German surgeons Goepel13
and Witzel14 independently utilized handmade silver
wire filigrees to serve as a prosthetic mesh for difficult or
recurrent hernias. Silver wire, however, lacked pliability
and caused patient discomfort. It was not inert, and metal
fatigue led to disintegration of the silver wires. Infection
and sinus tract formation with persistent drainage
occurred, and silver wire was eventually abandoned as
prosthesis for hernia repairs.
Despite a genuine need for fascial substitutes, investigation of prosthetics for hernia repair was unfocused
History 35
until the seminal work of Francis Usher (190880).

Usher, in the 1950s, became interested in hernia recurrence and attempted to repair hernias with freeze-dried
homographs and lyophilized dura mater.15 None of these
materials proved satisfactory, so Usher turned his attention to synthetic materials. Various forms of plastic had
been tried before, but because of their rigidity, tendency
to fragment, and susceptibility to infection, none was
found to be satisfactory for hernia repair. Usher persisted
in his investigation of plastic materials and learned of a
new polyolefin plastic (polypropylene, i.e. Marlex) that
could be extruded as a monofilament, did not fragment,
and was inert. Usher worked closely with the company
that produced Marlex (Phillips Petroleum Co.), and had
the material woven into a mesh and tested in animal studies. He found that polypropylene mesh was tolerated well
in sterile and infected fields, and he began to use Marlex
mesh in humans in 1958.16,17 Usher made many original
contributions to the field of hernia repair, which Read
lists elegantly in a scholarly retrospective of Ushers life:15
The development of polypropylene mesh and

suture for repair of abdominal-thoracic defects.
Improved techniques for mesh placement. A
prosthetic bridge was placed deep and under lapped
the hernia defect.
Anterior, pre-peritoneal placement of the prosthesis
for large, primary, direct or recurrent groin herniae
without suture closure of the defect.
Elimination of tension in hernia repair, which
facilitated early ambulation.
Demonstrated that infected prosthesis could remain
in situ and heal after open drainage.
The use of unsplit groin mesh with overlap and
interrupted suture lateral to the internal inguinal
ring to allow extended pre-peritoneal obliquity of
the spermatic cord. This provided a shelf for the cord
to rest on and preserved the normal obliquity of
the internal ring.
The use of bilaminar mesh to bridge a hernia defect
and suture of the two lamina and encompassed
tissue laterally to prevent the suture from tearing
out weakened structures.
These contributions were significant advances in the

field of herniology.1621 However, like so many other pioneers, Usher did not receive the recognition he deserved.
It remained for others to build on his work and advance
the science of hernia repair.
In the 1986 edition of his textbook Hernia Repair
Without Disability, Irving L. Lichtenstein stated that he
was performing a tension-free repair utilizing synthetic
mesh to bridge the hernia defect and that he had discarded
older classical techniques of suture repair (herniorrhaphy).22 Tension, as noted by Lichtenstein, was the bte
noire of the hernia surgeon and could lead to suture or
tissue disruption and hernia recurrence. He reported

that tension-free repair with mesh prosthesis had been
employed in more than 300 consecutive cases of direct
and indirect inguinal hernia without complication or
recurrence.
Lichtensteins genius was not that he introduced
polypropylene mesh for inguinal hernia repair; he did
not. Nor was his concept of a tension-free repair new; it
was not. Usher deserves primacy in both of these matters.
Lichtensteins insight was in understanding the work that
had gone on before and building on it. He helped
popularize the concept of ambulatory hernia surgery and
advocated a tension-free onlay of polypropylene mesh
for all groin hernias, regardless of size or complexity. He
stressed the use of local anesthesia and the importance of
immediate resumption of normal activity. Lichtenstein
and colleagues reported on the technique in 1989.23 They
described over 1000 cases of hernias repaired with a
tension-free hernioplasty technique and followed for
one to five years with no recurrences or mesh infections.
This paper described hernia repair with elegant simplicity
and took the surgical world by storm. Not only were the
results excellent, but the operation was easy to perform
and patients underwent a rapid recovery. In a study of
more than 16 000 tension-free mesh repairs performed by
72 surgeons, the recurrence rate was reported to be less
than 0.5 per cent and the incidence of infection was 0.6
per cent.24 For the last quarter of the twentieth century, a
mantra for hernia repair might have been tension-free,
tension-free, tension-free.
In referring to hernia procedures, Halsted noted that
surgical skeptics at the turn of the nineteenth century
exclaimed: Why take so much trouble, when such good
results, as are published, may be obtained by simpler
methods?25 This at a time when William T. Bull, a
prominent New York surgeon, reported recurrence rates
of 40 per cent in the first year after hernia repair and
almost 100 per cent within four years.26 Indeed, many
surgeons at the turn of the twentieth century held a similar view regarding a change of technique for open hernia
repair: If it aint broke, why fix it?
Groin hernias originate in the abdomen and traverse
a myopectineal orifice between abdomen and thigh to
present in the inguinal region (Figure 5.2). The myopectineal opening, as described by Fruchaud (Figure 5.3), is
bounded by the rectus sheath medially, internal oblique
and transversus abdominus muscles superiorly, the
iliopsoas muscle laterally, and pubis inferiorly.27 It is an
irrefutable anatomic structure whose entire opening must
be addressed before a complete cure of inguinal-femoral
hernia can be anticipated.
The Lichtenstein operation is an excellent procedure.
However, it is not perfect. The Lichtenstein technique
of open anterior repair does not allow for the entire
myopectineal orifice to be addressed easily. There is
prosthesis that would functionally replace the transversalis

fascia.29,30 Stoppa advocated an extensive reinforcement of
transversalis fascia without repair of the hernia defect.
Whereas the goal of surgical therapy had always been to
achieve parietal repair, i.e. closure of the hernia defect,
Stoppas revolutionary concept was to render the peritoneal envelope inextensible without mandatory repair of
the deteriorated abdominal wall and hernia defect. The
operation has become known as the giant prosthetic reinforcement of the visceral sac (GPRVS) or Stoppa procedure, and has worked quite well, with low recurrence rates
reported for even very large, complex, recurrent hernias.
GENESIS OF HERNIAS
Figure 5.2 Myopectineal orifice.
Figure 5.3 Henri Fruchaud.
limited exposure of the inferior aspect of the myopectineal

orifice. Moreover, it should be noted that performance of
an anterior repair requires the spermatic cord and its
structures to be mobilized circumferentially before the
mesh can be positioned. Circumferential cord mobilization
and manipulation can lead to spermatic venous thrombosis, ischemia of the testicle, and testicular atrophy.28
Lichtenstein in 1986 reported his incidence of testicular
atrophy to be one per cent.22
During the latter third of the twentieth century, Ren
Stoppa and colleagues performed much of the innovative
work that ultimately formed the foundation for a successful laparoscopic approach to hernia repair. Stoppas
contribution to herniology was that he suggested managing hernias of the groin with a very large, permanent
For thousands of years, adult groin hernias were thought

to result from a physical rupture or tear of the abdominalwall supporting tissues. In the late 1960s, Read noted that
during a pre-peritoneal approach for hernia repair, the
rectus sheath above the hernia defect appeared thin and
felt greasy, particularly with direct hernia defects.31 He followed up this observation with other studies in which he
biopsied and weighed constant-area rectus sheath samples
of patients operated on for hernia and compared them
with samples from patients operated on for intra-abdominal conditions other than herniation. The weight of the
biopsy specimens, especially of chronic smokers, was less
per unit area in patients with direct hernia than in controls
and did not relate to the patients age or muscle mass.32
Read and others have suggested that there is an
increased number of circulating white blood cells in the
blood and lungs of smokers that discharge free, unbound,
active protease and elastase compounds.33 These proteolytic enzymes disturb the normal protease/anti-protease
balance and contribute to the damage of elastin and collagen in the fascia transversalis and rectus sheath of smokers, which leads to direct inguinal herniation.34 It has been
shown that purified human neutrophil polymorphonuclear leukocyte elastase can induce pulmonary emphysema.35 There are other conditions of systemic illness and
stress (pulmonary emphysema, ruptured abdominal aortic aneurysm, burns) that cause an enhanced leukocyte
count and the discharge of proteases and oxidants from
leukocytes. These conditions may, in part, be responsible
for the biochemical changes that lead to damage of the
collagenous connective tissues in the groin and cause
hernia formation in non-smokers in a manner similar to
smokers. Because of these findings and the work of others,
it was Cannon and Reads opinion that: The surgeons
approach to inguinal herniation should consider more
than the anatomic and technical detail. It must now
embrace biochemistry, because he is dealing with a local
manifestation of a generalized lesion of connective tissue.36
History 37
LAPAROSCOPIC HERNIA REPAIR

With little fanfare and without much notice, Ger
reported the first laparoscopic hernia repair in a paper
published in 1982.37 This study conducted from August
through November 1977 examined the effectiveness of
stainless-steel clips to secure the peritoneal opening of
known abdominal hernias during laparotomy for other
major abdominal procedures. In the thirteenth and final
case of the series, an operating laparoscope was used to
visualize the peritoneal defect of a right indirect inguinal
hernia. The neck of the hernia sac was closed with a
specially devised stapling device passed through a port
placed in the right iliac fossa. The staple was constructed
of tantalum and measured 12.5 mm long in the open
position. Ger reported that the first patient to be treated
by laparoscopic closure of the neck of the sac was under
the care of Dr P. Fletcher of the University of the West
Indies, Jamaica.37
Gynecologists have been responsible for many of the
innovations in laparoscopy, and hernia repair has been
no exception. In 1990, Popp published a report of the
coincidental repair of an inguinal hernia during laparoscopic uterine myomectomy.38 In this paper, Popp
related that the hernia margins were apposed and
secured by endosutures tied extracorporeally. A patch of
dehydrated dura mater was applied to the sutured area to
further cover the repair site.
Early on, several prominent laparoscopic surgeons
advocated repair of inguinal hernia by plugging the
hernia defect. At the annual meeting of the American
Association of Gynecological Laparoscopists (AAGL) in
1989, Bogojavlensky showed a video that demonstrated
repair of an indirect inguinal hernia with a laparoscopic
stuffing technique.39 The hernia canal was filled with a
plug of polypropylene mesh, and the internal ring was
closed with suture placed laparoscopically.
In 1990, Schultz and colleagues reported on a plugand-patch technique for hernia repair that expanded on
the initial work described by gynecologists.40 In their technique, the sac of an indirect inguinal hernia was visualized
with a laparoscope and grasped on its superior margin
with forceps. The peritoneum was incised, and the sac was
removed from the musculofascial defect. The hole in the
muscle was then filled with rolls of polypropylene mesh
tied with dissolvable suture. It was thought that the rolled
polypropylene mesh would expand to completely fill the
canal once the suture tie was absorbed. After the defect was
filled with rolled mesh, one or two pieces of 1 ! 2-inch
mesh were laid over the defect, and the cut edges of peritoneum were brought together (over the mesh patch) and
secured with endoclips. In 1991, Corbitt independently
described a similar technique; however, he further ligated
the inverted hernia sac with an endoscopic linear stapler.41
Both Schultz and Corbitt abandoned the technique of plugand-patch repair because of excessive hernia recurrence
and changed their technique to one that utilized a large
prosthesis of polypropylene mesh in the pre-peritoneal
space that covered the entire myopectineal orifice.
Toy and Smoot42 in 1991, along with Salerno and
colleagues,43 took a somewhat different approach to
laparoscopic hernia repair. Both groups reported on an
intra-abdominal onlay technique subsequently dubbed the
intraperitoneal onlay of mesh (IPOM) procedure.4244
This technique involved a transabdominal examination
of the hernia defect and placement of synthetic mesh
directly on the peritoneal surface about the hernia defect.
Salerno and colleagues, in an animal model, investigated polypropylene as an onlay prosthesis.43 Toy and
Smoot utilized a prosthesis of expanded polytetrafluoroethylene (ePTFE) stapled to the peritoneal surface.42
In the ToySmoot modification, no attempt was made
to shield the graft from intra-abdominal content for
the reason that previous animal studies suggested that
adhesions between ePTFE graft and abdominal viscera
were thin and inconsequential. The IPOM procedure
was satisfactory for small to moderately sized defects.
However, because staple bites were shallow (grasping
principally peritoneum) and because of difficulties in
visualizing substantial pre-peritoneal structures (Coopers
ligament, iliopubic tract, transversalis fascia, transversus
abdominus aponeurosis, etc.), larger hernias repaired
with this technique frequently recurred. With increased
intra-abdominal pressure, such as with coughing, straining or exercise, the mesh (attached principally to peritoneum) would slide into the hernia defect and the repair
would fail.
The early 1990s were a time of great intellectual
ferment in laparoscopic hernia surgery. While the intraabdominal onlay technique was being developed, several
groups, led most notably by Arregui45 and Dion,46
reported on a transabdominal pre-peritoneal patch technique that eventually became adopted widely. In no small
measure, this technique relied on the principles of hernia
repair established by Stoppa and his GPRVS.
After pneumoperitoneum was established, a laparoscope was inserted into the abdominal cavity, typically
via an umbilical port, and both groin areas were examined. Two additional ports, each placed lateral to the
rectus sheath and on a plane level with the umbilicus,
provided access for laparoscopic instrumentation. If an
inguinal hernia was identified, then an incision was made
into the peritoneum several centimeters above the superior margin of the inguinal hernia defect. The indirect or
direct hernia sac was reduced, and wide dissection of the
pre-peritoneal space was performed. No attempt was
made to obliterate the inguinal canal as in the plug-andpatch technique. Rather, a large portion of mesh, commonly 8 ! 13 or 10 ! 15 cm in size, was used to cover
the myopectineal orifice of Fruchaud. The mesh was

fixed to the transverse abdominus aponeurotic arch and
Coopers ligament and lateral to the internal ring with
staples or tacks. The peritoneum was closed over the mesh
with suture or staples.
The transabdominal pre-peritoneal application of
synthetic graft, later dubbed the transabdominal preperitoneal (TAPP) patch procedure, was elegant in concept.
The entire opening between abdomen and thigh through
which all hernias of the groin originate (the myopectineal
orifice of Fruchaud) was bridged in a tension-free manner.
Intra-abdominal content was protected from contact with
the graft by placing the mesh in a pre-peritoneal position.
Several benefits were accrued with this technique, and
were summarized in a 1993 paper:47
Expose and reconstitute the entire myopectineal

orifice.
Examine both groin areas and repair bilateral
inguinal hernias as required.
Perform repair with little disturbance of cord
structures with a likely reduction in the incidence
of ischemic orchitis.
Avoid transgression of the scarred tissue of a
recurrent hernia and the potential for nerve or
spermatic cord injury.
Permit a thorough diagnostic abdominal
laparoscopic examination.
Reduction in the incidence of hernias missed
on external physical examination.
Repair of an inguinal hernia from a transabdominal

approach, however, exposed the patient to theoretical
complications, including postoperative adhesions, postoperative ileus, bowel obstruction, and intra-abdominal organ
injury.48 To reduce the potential for complications associated with a peritoneal incision or the intra-abdominal
application of a synthetic prosthesis, several authors,
including McKernan and Laws,49 Dulucq,50 and Phillips,51
discussed a totally extraperitoneal approach to laparoscopic groin hernia repair. This method, which would
become known as the total extraperitoneal (TEP) patch
procedure, deployed all laparoscopic instrumentation,
cannulae, and camera in a working pre-peritoneal space
outside of the peritoneal cavity.
The entire TEP procedure is performed in an extraperitoneal space, a pneumoextraperitoneum, between the
peritoneum and abdominal wall musculature. An initial
incision is made at the umbilicus, and the anterior rectus
sheath on the side of the hernia defect is incised. A cannula
is inserted and passed caudally along the intact posterior
rectus sheath, and the extraperitoneal space is developed
with blunt dissection or a balloon dissector. Additional
cannulae are placed in this pre-peritoneal space under
direct laparoscopic vision, and extraperitoneal dissection
of the myopectineal orifice is completed. A large piece of
mesh, usually polypropylene, is then positioned to cover

the femoral canal and the indirect and direct inguinal
spaces with a 35 cm overlap. The mesh is secured with
suture, staples or tacks, and the pneumoperitoneum is
deflated. No incision is made into the peritoneum, and the
mesh is completely shielded from intra-abdominal content. Although an additional cost is engendered with the
use of the balloon dissector, its employment has simplified
the technique and encouraged many more surgeons to
perform laparoscopic repair. Additionally, recent longterm outcome studies have suggested that laparoscopic
extraperitoneal hernia repair has outcomes similar to
open hernia repair.52
One of the major frustrations encountered while
performing laparoscopic abdominal wall repair has been
manipulation of the mesh prosthesis. A bitter lesson
learned early on was that there must be adequate overlap
of mesh (usually 35 cm) beyond the perimeter of the
hernia defect. An adequate overlap demands a large portion of mesh, and the larger the mesh the more difficult it
is to manipulate in a laparoscopic environment. Several
pearls have been developed to ease mesh deployment
and assure adequate tension-free repair. Marking the
mesh with a sterile pen has been of help in orienting the
prosthesis. Rolling up the mesh like a cigarette and securing the rolled mesh with suture has simplified initial mesh
placement. Using this technique, an edge of the rolled
mesh is first secured with tacks or staples. The remainder
of the mesh is then unfurled, finessed into position, and
anchored with tacks or staples.
An intriguing use of mesh for groin hernioplasty, first
proposed by Felix and Michas, was that of a doublebuttress repair using two sheets of polypropylene mesh.53
In this variation, the authors suggested using two pieces
of mesh, typically 8 ! 13 cm (in a pre-peritoneal position),
one overlying the other at an oblique angle, thus creating
a double buttress of mesh over the mid-portion of the
myopectineal orifice. While application of two layers of
mesh undoubtedly bolstered the mid-portion of the
orifice, this methodology had the additional benefit of
increasing the diameter of the area repaired far in excess
of 8 ! 13 cm, widely overlapping the entire myopectineal
orifice.
Laparoscopic access has also been proposed for repair
of ventral incisional hernias. In 1993, LeBlanc and Booth
described their experience with repair of incisional hernia
using ePTFE prosthetic graft.54 Franklin and colleagues
reported on the use of open-weave polypropylene mesh
for repair of ventral hernias.55 Notably, no fistula formation or significant adhesive bowel complications were
found in their study. Kavic commented on the use of
dual-mesh ePTFE (Gore-Tex) for abdominal-wall ventral
hernia repair.56 Dual-mesh has a rough side and a smooth
side. The smooth side of the ePTFE graft is intended to
interface with intra-abdominal content and to not excite
History 39
adhesion formation. The rough side is placed in apposition to the abdominal wall, where its rough surface
encourages tissue adhesion. The graft is fixed circumferentially with staples or tacks and anchored with transfascial stay sutures placed at the four cardinal points of
the graft. Carbajo and colleagues prospectively compared
laparoscopic with open prosthetic repair of large incisional hernias.57 Their study suggested that laparoscopic
repair reduces complication rates and hernia recurrence
compared with open methods.
complex pathophysiological, biochemical, molecular, and

perhaps genetic derangements that are, even today, not
well understood. Study of the groin by several generations
of surgeon-scientists has provided an appreciation of the
dynamic mechanisms that protect the myopectineal orifice in the normal state. Current understanding suggests
that the entire myopectineal window must be secured if a
complete cure of groin hernia is to be accomplished.56
Achievement of the perfect operation may be an
unobtainable goal, but pursuit of the perfect operation is
neither unreasonable nor undesirable.
CONCLUSION
The successful repair of groin hernia can be accomplished in many ways. Conventional anterior herniorrhaphy, as described by Bassini and Shouldice, or
anterior hernioplasty, as advocated by Lichtenstein, are
effective procedures. These repairs, however, limit their
focus to the upper aspect of the myopectineal orifice and
neglect the lower aspect. They have been successful in
large measure because of the application of sound surgical principles to secure the hernia defect and because the
large majority of groin hernias pass through the indirect
or direct inguinal ring.
Laparoscopic access has advanced the art of hernia
repair, as the entire myopectineal orifice with its multiple
openings can be approached and exposed. Bilateral groin
hernias can be repaired without a large incision or multiple incisions. Hernias that may have been missed during
anterior repair (contralateral inguinal, femoral, occult
hernias) can be examined and repaired.58 Surgical
trauma to skin, subcutaneous tissue, fascia and muscle is
reduced. Moreover, the spermatic cord is not manipulated circumferentially, offering the possibility that
testicular vein thrombosis and testicular atrophy will be
lessened. Hernias that recur after open procedures can be
repaired laparoscopically without transgressing scarred
tissue of the previous procedure.
Over the past two decades, laparoscopic hernioplasty
has evolved from an experimental procedure to one of
proven efficacy. Groin hernia repair is not a simple exercise, and its practice requires skill and attention to detail.
Differing clinical situations demand different anatomic
approaches. Anterior open repair should probably be
considered for pediatric patients and for patients with
severe cardiopulmonary compromise, when repair may
be performed under local anesthesia. Bilateral inguinal
hernias, recurrent hernias, and unilateral hernias with a
suspected contralateral hernia, however, suggest that a
laparoscopic approach be considered.
The modern herniologist should be proficient in both
laparoscopic and open repair techniques. The myth that
the least skilled surgeon or resident can perform hernia
repair should be laid to rest. Hernia genesis involves
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6
B. PAGE AND PATRICK J. ODWYER
View from the peritoneal cavity

Pre-peritoneal space
Transversalis fascia
Oblique muscles
Inguinal canal
Spermatic cord
41
42
43
44
44
44
A thorough knowledge of the anatomy and function of the

pre-peritoneal space and groin region is required by any
surgeon with a special interest in treating hernias. Lack of
knowledge of the basic pre-peritoneal anatomy has almost
certainly led to injuries to vessels and nerves in this region,
which otherwise could have been avoided. In addition,
failure to recognize the importance of the anatomy by surgical trainees and practicing surgeons has slowed progress
in minimal-access approaches to hernia repair via the
pre-peritoneal space.
Myopectineal orifice
Femoral canal and sheath
Nerves
Pathophysiology and conclusion
References
44
45
45
45
46
VIEW FROM THE PERITONEAL CAVITY

A starting point for any surgeon contemplating laparoscopic hernia repair is to view the normal anatomy of
the pelvis through the laparoscope (Figure 6.1) of a
patient undergoing another laparoscopic procedure, e.g.
cholecystectomy. With a head-down tilt of 1530 degrees,
first observe the natural boundaries between the pelvic
and abdominal cavity. In the midline, one will see the
symphysis pubis, the superior pubic ramii bilaterally, and
the iliopubic tract laterally, traversing out as far as the
Median umbilical ligament

(urachus)
Medial umbilical ligament
Lateral umbilical ligament
Lateral fossa
Medial fossa
Supravesical fossa
Deep inguinal ring

Ileopubic tract
Testicular vessels
Vas deferens
Bladder
Figure 6.1 View of the pelvic anatomy observed through a laparoscope.
anterior superior iliac spines. The iliopubic tract is a condensation of the fascia transversalis and lies deep to the
inguinal ligament. Anterior to this natural division, in the
midline, the median umbilical ligament is observed,
which represents the obliterated remnant of the urachus
and extends from the fundus of the bladder to the umbilicus. On either side and lateral to this are the medial
umbilical ligaments, which represent the peritoneal folds
around the obliterated embryonic umbilical arteries.
Further laterally, one can observe the inferior epigastric
vessels, sometimes referred to as the lateral umbilical ligament. The inferior epigastric vessels are important landmarks for the hernia surgeon, as indirect inguinal hernias
pass lateral to them on their way through the internal ring
to the inguinal canal, while direct hernias pass medially
on their way through the transversalis fascia.
Posterior to the natural division between the abdomen
and pelvis, the bladder is noted in the midline and on either
side the venous pulsation of the external iliac vein and
the arterial pulsation of the external iliac artery. From this
view, it should also be possible, in male patients, to note
the vas deferens on its course through the internal ring
over the external iliac vessels and down the pelvic side well,
where it disappears to join the seminal vesicles on their
way into the prostatic urethra. The testicular artery and
vein should also be noted coursing lateral to the external
iliac artery. If at this stage one is performing laparoscopy
under local anesthesia, then it is worth asking the patient
to cough. It will be noted that the internal inguinal ring is
suddenly pulled upwards and laterally by the fascia transversalis sling, thus shutting the door to the inguinal canal.
PRE-PERITONEAL SPACE
The laparoscopic surgeon enters the pre-peritoneal space
either transperitoneally or totally extraperitoneally. Getting
into the right plane (i.e. immediately posterior to the rectus
muscle) is important (Figure 6.2), otherwise the space
between the pre-peritoneal fat and the deep layer of fascia transversalis is entered (Figure 6.3). This space contains numerous small blood vessels and is associated with
troublesome bleeding, while the space posterior to the
rectus muscle is avascular. The deep layer of fascia transversalis lies between the rectus muscle and the peritoneum,
with pre-peritoneal fat sandwiched between them. The
fascia transversalis extends laterally beyond the inferior
epigastric vessels and can be observed surrounding the
sac of an indirect hernia. It is particularly strong lateral to
the inferior epigastric vessels, and as it is pulled down to
open the space lateral to this it can be seen to interdigitate with the fibers of transversus abdominus muscle.
Inferiorly, in the midline, the fascia transversalis fuses
with the pubis, but it is quite flimsy here and breaks
easily with posterior movement of the laparoscope. In
Figure 6.2 The avascular plane immediately posterior to the

rectus muscle in a patient undergoing open surgery. Note
the transverse fibers pointed out with tissue forceps below
the arcuate line.
Figure 6.3 The vascular plane between the pre-peritoneal fat

and the deep layer of fascia transversalis. This membranous
layer is in continuity with the posterior rectus sheath. The allis
forceps nearest the umbilicus marks the level of the arcuate line.
the midline, it is seen to fuse with the linea alba and can
be difficult to separate from that structure when moving
to the contralateral side in bilateral hernia repair.
The pre-peritoneal space is in direct communication
with the retropubic space of Rietzius.1 Following the pubic
arch around on either side, the pectineal (Coopers) ligament comes into view (Figure 6.4). This is usually crossed
by the anastomotic pubic artery and vein, tributaries from
the inferior epigastric vessels, which course towards the
obturator foramen, where they join with their respective
pubic branch of the obturator vessels. An abnormal obturator artery arising from the inferior epigastric will be
seen in a similar location; observed in about 30 per cent
of cases, this is larger than the aforementioned vessels.
The pectineal ligament itself fans out over a broad area
of the superior pubic ramus, where medially it forms
the lacunar ligament and anteriorly it continues as the
iliopubic tract. The latter structure goes from the pubic
Anatomy and physiology 43

Medial limb of transversalis sling
Aponeurotic arch
Hasselbach's triangle
Internal ring
Femoral branch of
genitofemoral nerve
Inferior epigastric vessels
Rectus muscle
Transversus abdominus muscle
Ileopubic tract
Deep circumflex iliac
artery and vein
Iliacus muscle
Lateral cutaneous
nerve of thigh
Transversalis fascia
Femoral nerve
Lacunar ligament
Genital branch of
genitofemoral nerve
Femoral canal
Anastomotic pubic artery and vein
Testicular vessels
Vas deferens
Psoas mucle
Ileopsoas fascia (cut)
Bladder
Pectineal ligament
Obturator vessels and nerve
Obturator foramen
External iliac artery and vein
Figure 6.4 The pre-peritoneal pelvic anatomy with the iliopsoas fascia partially excised to expose the femoral nerve on the right side.
tubercle to the anterior iliac spine and is a condensation

of the anterior layer of fascia transversalis. The iliopubic
tract thus forms the posterior margin of both direct and
indirect hernias while it is anterior to a femoral hernia.
The femoral canal is bounded by iliopubic tract anteriorly, the pectineal ligament posteriorly, the lacunar ligament medially, and the iliac vein laterally. Likewise, the
triangular area bounded by the deep epigastric vessels
laterally, the lateral margin of the rectus muscle medially,
and the iliopubic tract posteriorly (Hesselbachs triangle)
is the area through which direct hernias are formed.
More precisely, from the pre-peritoneal view, the medial
limb of the fascia transversalis U-sling forms the lateral
margin of a direct hernia, while the medial margin is
formed by the aponeuroses of the transversus abdominus muscle. The former can be seen easily at laparoscopic
surgery with a large direct hernia, where the defect
extends lateral to the deep epigastric vessels. The fascia
transversalis forms a U-shaped sling around the cord,
with the two limbs extending anteriorly and laterally to
fuse with the posterior aspect of the transversus muscle.
This sling is responsible for the shutter mechanism,
which, for practical purposes, closes off the inguinal
canal with sudden increases in intra-abdominal pressure.
The iliopubic tract is an important landmark for the
surgeon, for as well as having the femoral canal posterior
to it, the external iliac vein and artery pass behind the
iliopubic tract and inguinal ligament to become the
femoral vessels. Both run on the medial aspect of the psoas
muscle and can be seen easily during a totally extraperitoneal laparoscopic hernia repair. It goes without
saying for surgeons who continue to use staples or other
fixation methods for laparoscopic hernia repairs that
placement of these devices in this area should be avoided.
As stated already, the vas deferens runs over the iliac
vessels on its course from the prostatic urethra to the
internal ring. The testicular artery and vein course just
lateral to the iliac artery, while the genitofemoral nerve
runs a similar course, having split into its genital and
femoral branches at a variable distance along the psoas

muscle. The femoral nerve lies deep to the iliopsoas fascia and is again lateral to the iliac artery and runs along
the lateral border of the psoas muscle. Further lateral is
the lateral cutaneous nerve of thigh, which can be seen
crossing the iliacus muscle and which passes below the
iliopubic tract just medial to the anterior superior iliac
spine. The deep circumflex iliac artery and vein cross over
the lateral cutaneous nerve on their course parallel and
superior to the iliopubic tract. These vessels can easily
be injured at this site and cause some nuisance bleeding
during laparoscopic hernia repair.
TRANSVERSALIS FASCIA
This fascial layer, which is thought to invest the entire
abdominal cavity, is a source of controversy for surgeons
and anatomists. Some argue that it is a weak layer with no
intrinsic strength, while others regard it as essential both
in the origin and repair of groin hernias. It is likely that
both of these statements are true and almost certainly
represent observations from different groups of patients
or cadavers. Some regard it as a bilamellar structure with
a strong anterior layer and a membranous deep layer.2
There is little doubt from the laparoscopists point of view
that a two-layer fascial structure exists. The anterior layer
of transversalis fascia can be seen easily when reducing a
direct hernia as an attenuated fascial structure that lines
the defect. The deep layer is observed when entering the
pre-peritoneal space subumbilically and immediately
posterior to the rectus muscle (Figure 6.3). Both structures appear strong and difficult to break through in the
young patient with an indirect hernia; in older patients,
both are flimsy, presumably because of a deficiency of collagen.3 Some regard the deep layer as a distinct structure
from the transversalis fascia. However, as it is followed
laterally it appears to interdigitate with the abdominal
muscles, making it likely that it is attenuated posterior
rectus sheath and will thus contain a fascial contribution

from the transversalis fascia.4 It is also likely that the socalled anterior layer of transversalis fascia is merely an
attenuation of the aponeuroses of the internal oblique
and transversus abdominus muscles. Evidence for this
comes from children and young adults, in whom this
layer is mainly muscular or musculotendinous.5
The transversus abdominus muscle is the deepest
of the three abdominal muscle layers and the one seen by
the laparoscopic surgeon. It arises from the costal cartilages of the lower six ribs, the vertebral column and the
iliac crest. Its fibers run transversely, except in the lower
abdomen, where they arch over the inguinal canal as an
aponeurotic arch, which is inserted into the pubic crest
and iliopectineal line. The transverse fibers proceed horizontally to their insertion in the rectus sheath and linea
alba. Below the aponeurotic arch, the posterior wall of
the inguinal canal is closed by transversalis fascia only in
adults and is the site through which direct hernias occur.
When the aponeuroses of the transversus and the internal oblique muscle are fused lateral to the rectus sheath,
the term conjoined tendon is used. This is a variable
structure, however, and does not exist in all patients.6
OBLIQUE MUSCLES
In addition to the transversus abdominus muscle, the
abdominal wall is composed of the internal and external
oblique muscles. The external oblique arises from the lower
eight ribs. From its fleshy origin, the muscle spans widely to
an aponeurotic insertion. Superiorly, the aponeurosis is
very thin and is attached to the xiphoid process. Inferiorly,
it is thick and inserts into the anterior superior iliac spine
and pubic tubercle as the taut inguinal ligament. In the
midline, the aponeurosis forms the anterior rectus sheath
and is inserted into the linea alba. Posteriorly, the external
oblique is not attached and forms part of the lumbar triangle. This, on occasion, may be a site for a lumbar hernia.
The internal oblique muscle arises from the lumbar
fascia, from the anterior two-thirds of the iliac crest, and
from the lateral part of the inguinal ligament. The muscle
fibers run parallel to the costal cartilages until they reach
the ninth rib, where they become aponeurotic. Above the
umbilicus, the tendinous aponeurosis of the internal
oblique splits to encircle the rectus muscle. At a point
2.5 cm below the umbilicus lies the arcuate line, the posterior layer that was once thought to not exist. It is now
recognized that the arcuate line merely marks the point
where the posterior rectus sheath goes from a strong fascial structure to a more attenuated membranous structure (Figure 6.3). The lower fibers of the internal oblique
originate at the inguinal ligament and arch downward
and medially with the fibers of transversus abdominus to
insert into the pubic crest anterior to the rectus muscle.
INGUINAL CANAL
The inguinal canal is an oblique intermuscular slit about
6 cm long, lying above the medial half of the inguinal
ligament. It begins at the deep (internal) ring and ends at
the superficial (external) ring. It transmits the spermatic
cord and the ilio-inguinal nerve in the male, and the round
ligament and the ilio-inguinal nerve in the female. The
anterior wall is formed by the external oblique aponeurosis medially and the internal oblique laterally. Its floor is
made up of the rolled edge of the inguinal ligament. The
lower edges of the internal oblique and the aponeurotic
arch of the transversus muscle form the roof of the canal.
These muscles arch over from in front of the cord laterally
to behind the cord medially. In adults, the posterior wall is
thus strong medially and weak laterally, where it is formed
by the transversalis fascia only. In children, however, the
inguinal canal is short (11.5 cm) and the internal and
external rings are almost superimposed on each other.
SPERMATIC CORD
The spermatic cord leaves the abdominal cavity via the
superficial ring. The coverings of the spermatic cord are
formed by the local muscles and fascia. The internal spermatic fascia is derived from fascia transversalis, cremaster muscle from internal oblique muscle, and external
spermatic fascia from external oblique aponeurosis. The
spermatic cord contains the testicular artery and vein, the
ductus deferens and its accompanying vessels, the cremasteric artery, lymphatics, and the genital branch of the
genitofemoral nerve. Until birth, the processus vaginalis,
the portion of the peritoneum that accompanies the testis
on its descent into the scrotum in embryonic life, remains
opened. In some children, delay in closure may result in
the development of a pediatric hernia. Although patent in
some adults, the role of the processus vaginalis in the
development of an indirect inguinal hernia is not certain.
It is likely that failure of the sphincter mechanism of the
inguinal region, the transversalis U-sling, combined with
contraction and flattening of the transversalis arch and
internal oblique muscle, which essentially closes the
inguinal canal, is more important.
MYOPECTINEAL ORIFICE
Fruchaud emphasized that all groin hernias originate from
a single weak area (Figure 6.5).7 This area is formed by the
abdominal wall muscles above, the arching fibers of the
transversus abdominus, the internal and external oblique
muscles, the bony pelvis below, ilium covered by the pectineal ligament, the rectus muscle medially, and the fascia

Ilio-hypogastric nerve
Ilio-inguinal nerve
Inferior epigastric vessels
Cremasteric vessels
Spermatic cord
Ileopsoas muscle
Inguinal ligament
Femoral vessels
Spermatic cord
Myopectineal orifice
Figure 6.5 The myopectineal orifice.
covering the iliopsoas muscle laterally. The myopectineal

orifice is divided into two levels by the inguinal ligament.
The superior, inguinal level provides a passage for the
spermatic cord or round ligament; the inferior, femoral
level provides a passage for the femoral vessels.
FEMORAL CANAL AND SHEATH

The femoral canal contains fatty tissue, lymph nodes and
lymphatics. The boundaries of the canal include the femoral
vein and connective tissue laterally, the aponeurotic insertion of the transversus abdominus and lacunar ligament
medially, the iliopubic tract and inguinal ligament anteriorly, and the pectineal ligament posteriorly. The entrance to
the canal, the femoral ring, is a little over 1 cm in diameter,
while the canal itself is 12 cm long with its apex at the fossa
ovalis. The femoral sheath is an extension of the transversalis fascia and envelops the femoral artery, vein and canal.
The sheath is divided into three compartments by septa of
connective tissue between each compartment.
NERVES
The nerves of most importance to the laparoscopic surgeon are the genitofemoral nerve, the lateral cutaneous
nerve of the thigh, and the femoral nerve. The genitofemoral nerve comes from the first and second lumbar
nerves and completes the innervation of the groin
Genital nerve
Inguinal ligament
Figure 6.6 Position of the nerves in the right inguinal canal.
region. It passes obliquely through the substance of the

psoas major muscle and emerges from this crossing deep
to the peritoneum and the ureter. It splits behind the
deep inguinal ring into the genital and femoral branches.
The genital branch lies on the floor of the inguinal canal
behind the spermatic cord and supplies the cremasteric
muscle via its motor branches and the scrotal skin via its
sensory branches. The femoral branch contributes to the
sensation of the anterior thigh. The lateral cutaneous
nerve of the thigh crosses the iliacus muscle after emerging from the lateral border of the psoas muscle. It passes
beneath the iliopubic tract just medial to the anterior
superior iliac spine and innervates the skin on the anterior and lateral surface of the thigh. The femoral nerve is
the largest of the three nerves and lies deep to the iliopsoas fascia. It can be seen emerging between the psoas
and iliacus muscle, passing beneath the iliopubic tract,
and innervating the muscles in the anterior compartment of the thigh and the skin of the anteriomedial
aspect of the lower thigh and leg.
Also of importance to the hernia surgeon are the ilioinguinal and ilio-hypogastric nerves (Figure 6.6). The
former is usually smaller than the latter and is sometimes
absent. These are both sensory nerves that arise from
the first lumbar nerve. The ilio-inguinal nerve passes
through the inguinal canal and becomes superficial at the
external ring to innervate the skin of the scrotum and the
medial upper thigh. Damage to the ilio-inguinal nerve in
the inguinal canal causes sensory loss as the motor fibers
are already given off to the conjoint tendon. The iliohypogastric nerve emerges through the external oblique
aponeurosis to innervate the suprapubic skin.
PATHOPHYSIOLOGY AND CONCLUSION

A better understanding of the physiology of the inguinal
region may lead ultimately to novel methods of preventing
and treating inguinal hernias. In children, fusion of the
processus vaginalis is thought to be hormone-related.8

This is supported by the fact that inguinal hernias are
associated with an undescended testis and gonadotropin
administration results in a significantly higher rate of
closure of the processus vaginalis. Since androgen receptors are not present in the processus vaginalis, it has been
postulated that their effect is on the genitofemoral nerve.
This releases calcitonin gene-related peptide (CGRP),
which has been shown to fuse the inner mesothelial layer
of the processus vaginalis.9 Hepatocyte growth factor/
scatter factor (HGF/SF) has also been found to induce
fusion of the processus, suggesting that local administration of these agents may lead to a non-surgical treatment
of an inguinal hernia in neonates.9
While the presence of a patent processus vaginalis is a
key element in the development of pediatric hernias, its
role in adults is less certain. Autopsy studies reveal that
1535 per cent of adults have a patent processus vaginalis
without ever developing a hernia.10 A more likely cause,
given the increasing incidence with age, is a relative
reduction in connective tissue in the inguinal region.11 In
addition, there is evidence that altered collagen synthesis
may weaken the fascia transversalis in patients with an
inguinal hernia. In a study by Klinge and colleagues,
immunohistochemical and Western blot analysis showed
that the ratio of type I to type III collagen was decreased
significantly in the fascia transversalis of patients with an
inguinal hernia.12 The tensile strength of tissues depends
on the proportion of type I and III collagen, and the
authors postulated that the relative increase in type III
collagen, thin, immature fibers might be responsible for a
reduction in mechanical strength of the collagen matrix
of the abdominal wall.
The lack of strength in the supporting structures is
probably only part of the puzzle that leads to failure of the
inguinal region in adults. Anatomically, Hesserts triangle
is a weak area that has the internal ring as its apex, the rectus abdominus as its base, and the inguinal ligament and
aponeurotic arch of the transversus abdominus and internal oblique as its sides.13 This area is normally closed by
the contraction of the transversus and internal oblique
muscular arch, which flattens out this arch and causes it to
approach the inguinal ligament. This essentially occludes
the triangle and is referred to as the inguinal shutter by
Keith.14 Recent evidence indicates that in patients with an
inguinal hernia, this triangle is larger than usual and thus
closure of the shutter may be incomplete.15 The authors of
the latter study concluded that the greater area was a cause
and not a consequence of inguinal herniation because the
reason for the increase in this area was a higher intersection of the internal oblique and transversus abdominus
muscle to its aponeurosis on the rectus sheath. This suggests an inherited anatomical variation that predisposes
certain individuals to the development of an inguinal
hernia and helps explain why one-third of patients will
have or develop a contralateral hernia while a similar
number will have a family history of a hernia.16
Although we have made significant progress in the
understanding of the anatomy and physiology of the
inguinal region, there is still a lot to learn. Advancements
in these areas will undoubtedly lead to the prevention of
some groin hernias and better treatment of existing
symptomatic hernias in the future.
REFERENCES
1
2
3
4
6
7
8
9
10
11
12
13
14
15
16
Bouchet Y, Voilin C, Yver R. The peritoneum and its anatomy. In:

Bengmark S, ed. The Peritoneum and Peritoneal Access. London:
Wright, 1989: 113.
Cooper A. The Anatomy and Surgical Treatment of Abdominal
Hernia. London: Longman, 1804.
Wagh PV, Read RC. Collagen deficiency in rectus sheath of patients
with inguinal herniation. Proc Soc Exp Biol Med 1971; 37: 3824.
Arregui ME. Surgical anatomy of the preperitoneal fascia and
posterior transversalis fascia in the inguinal region. Hernia 1997;
1: 10110.
Bendavid R. The transversalis fascia: new observations in
abdominal wall hernias. In: Bendavid R, Abrahamson J,
Arregui ME, et al., eds. Abdominal Wall Hernias: Principles and
Management. New York: Springer-Verlag, 2001: 97100.
Sorg J, Skandalakis JE, Gray SW. The emperors new clothes or the
myth of the conjoined tendon. Ann Surg 1979; 45: 5889.
Fruchaud H. Anatomie chirurgicale des hernies de laine. Paris:
G Doin, 1956.
Clarnette TD, Hutson JM. The development and closure of the
processus vaginalis. Hernia 1999; 3: 97102.
Sugita Y, Uemura S, Hasthorpe S, Hutson JM. Calcitonin generelated peptide (CGRP) immunoreactive nerve fibre and receptors
in the human processus vaginalis. Hernia 1999; 3: 11316.
Read RC. Historical survey of the treatment of hernia. In:
Nyhus LN, Condon RE, eds. Hernia, 3rd edn. Philadelphia:
JB Lippincott, 1989: 317.
Conner WT, Peacock EE. Some studies on the aetiology of inguinal
hernia. Am J Surg 1973; 126: 7325.
Klinge U, Zheng H, Si Zy, et al. Altered collagen synthesis in fascia
transversalis of patients with an inguinal hernia. Hernia 1999;
4: 1817.
Hessert W. Some observations on the anatomy of the inguinal
region, with special reference to absence of the conjoined tendon.
Keith A. On the origin and nature of a hernia. Br J Surg 1973; 11:
45575.
Abdalla RZ, Mittlestaedt WE. The importance of the size of Hessarts
triangle in the aetiology of inguinal hernia. Hernia 2001; 5: 11023.
Hair A, Paterson C, Wright D, et al. What effect has the duration
of an inguinal hernia on patient symptoms? J Am Coll Surg 2001;
193: 1259.
7
MORRIS FRANKLIN
Patient selection
Operating room set-up
Operative technique
48
48
49
It has been over 100 years since Bassini ushered in a new

era of hernia surgery with the introduction of his triplelayer technique to repair the inguinal floor. Since then,
surgeons have developed a myriad of new methods of hernia repair in an attempt to improve the results. However,
despite a century of advances in hernia surgery, recurrence continues to plague the general surgeon and is the
primary reason why no single technique of herniorrhaphy
has become universally accepted. The repair of inguinal
hernias has probably produced more variety in technique
than any other operation performed by the general surgeon today. Complexity of the anatomy, the variety in size
and location of the defect, and the multiplicity of the
presentations of a hernia have contributed to this
uncertainty regarding the optimal repair.1
After minimally invasive surgery proved to be successful in the treatment of biliary, gastric and colon diseases,
surgeons attempted to find a method of successfully
repairing inguinal hernias laparoscopically. It was felt that
the attendant benefits of decreased postoperative pain and
disability seen in other minimally invasive procedures
could be realized in hernia patients as well. The first report
of a laparoscopic technique of inguinal herniorrhaphy was
by Ger and colleagues in 1990,2 who advocated simple closure of the neck of the hernia sac. This was soon followed
by reports of plugging of the inguinal canal or direct defect
with a prosthetic mesh, as described by Schultz and colleagues3 in 1990 and by Corbitt4 in 1991. After unacceptable early recurrence rates, these methods were abandoned
in favor of newer techniques that combined the advantages of a tension-free repair utilizing a synthetic mesh
with the transabdominal approach of laparoscopy.
Postoperative management
Conclusion
References
51
51
51
The three most popular procedures to emerge were the

transabdominal pre-peritoneal (TAPP) patch, the totally
extraperitoneal (TEP) patch, and the intraperitoneal
onlay mesh (IPOM) repairs. In the TAPP technique,
the peritoneum is incised intra-abdominally and a preperitoneal space is developed. A prosthetic mesh is then
introduced into this space, placed over the abdominal wall
defect, and stapled into place. The peritoneum is then
re-approximated over the mesh so that there is no exposure
of synthetic material to the intra-abdominal contents.
In the TEP approach, the peritoneal space is never
entered. Dissection is carried out in the extraperitoneal
space just below the fascia of the abdominal wall. A
pre-peritoneal space is created using blunt dissection
and carbon dioxide insufflation. Synthetic mesh is then
placed over the defect and fixed into place with staples or
tacks, as in the TAPP procedure.
The potential drawback of both the TAPP and the TEP
procedures is that they require considerable dissection to
create the pre-peritoneal space, which can result in perioperative discomfort and complications, such as hematoma
formation or injury to the vas deferens, vascular structures,
or nerves. The TEP technique in particular is technically
more demanding, and the pre-peritoneal dissection can
be very difficult to perform, particularly in large inguinoscrotal hernias. As a result, a third laparoscopic repair
was developed, which involves placing the mesh on the
intra-abdominal side of the peritoneum, rather than preperitoneally, thus avoiding the radical dissection of the
pre-peritoneal space. This method of repair the IPOM
technique was concurrently investigated in the Laboratory
for Experimental Laparoscopic Surgery at Creighton
PATIENT SELECTION
University and at the Texas Endosurgery Institute, San

Antonio.5 Yorkshire cross-feeder pigs with congenital
indirect inguinal hernias underwent intraperitoneal
herniorrhaphy with placement of Prolene mesh either
laparoscopically or via laparotomy. At six weeks, all pigs
were sacrificed and an intra-abdominal exploration was
carried out to confirm the success or failure of the repair, to
stage the development of any adhesions to the mesh, to
examine the prostheses for infection, and to evaluate the
erosion of the prosthesis into neighboring structures. All
hernia repairs in both groups were successful. In addition, a
significant reduction in adhesion formation was noted
when the mesh was placed laparoscopically rather than by
laparotomy. There was no evidence of intra-abdominal
infection or erosion of the prosthesis into adjacent structures in either group. These findings parallel those of
Franklin6 and Layman and colleagues,7 who found that the
use of intraperitoneal material in swine models resulted
in good in-growth of peritoneum over the mesh with
minimal adhesion formation.
We performed the first IPOM procedure in a human
patient at the Texas Endosurgery Institute in 1990. Since
then, we have repaired over 550 direct, indirect, and recurrent inguinal hernias using the IPOM technique, with
an overall complication rate of 7.5 per cent and a recurrence rate of 0.96 per cent.8 These results are comparable to those of Toy and colleagues,9 who reported 441
IPOM repairs with a complication rate of 8.0 per cent
and a recurrence rate of 3.8 per cent, and Fitzgibbons
and colleagues,10 who detailed 217 IPOM repairs with a
recurrence rate of 5.1 per cent.
Suction
irrigation
All adult patients with inguinal hernias and who are fit
for general anesthesia are considered candidates for a
laparoscopic IPOM procedure. Those patients with an
obliterated pre-peritoneal space secondary to radiation
or previous surgery (radical retropubic prostatectomy,
bladder surgery, vascular procedures, cesarean section,
etc.) are particularly good candidates in that a laparoscopic TAPP or TEP procedure would be technically
difficult or even impossible in this setting. Additionally,
those patients with a failed TAPP or TEP are ideal candidates for this approach, which allows for recurrent hernia
repair in virgin territory.
Relative contraindications include severe intraabdominal adhesions due to prior surgery, ascites, coagulopathy, severe underlying medical illness precluding general
anesthesia, and lack of appropriate laparoscopic skills.
OPERATING ROOM SET-UP

The operating room set-up for the IPOM procedure on a
left-sided inguinal hernia can be seen in Figure 7.1. The
operating surgeon stands on the contralateral side of the
table from the hernia, while the assistant is positioned on
the side ipsilateral to the hernia site. With the patient
under general anesthesia, a catheter is placed in the bladder and a nasogastric tube is introduced into the stomach.
Anesthesia
Cautery
Camera
holder
Laparoscopy
table
Assistant
surgeon
Surgeon
Scrub
nurse
Mayo
stand
Primary
video cart
Secondary
video cart
Hot plate
sequential
compression
devices
Figure 7.1 Operating room set-up

for left-sided hernia repair.
Intraperitoneal onlay mesh approach 49
After insufflating the peritoneal cavity to 14 mmHg using

a Veress needle, a 5-mm trocar is introduced into the
abdomen on the side opposite the hernia, just lateral to the
rectus sheath at the level of the umbilicus. After a generalized inspection of the abdominal cavity and lysis of adhesions if necessary, a 10/12-mm trocar is placed at the
umbilicus and a 5-mm trocar is placed on the ipsilateral
side of the hernia, exactly opposite the initial trocar. Trocar
placement is outlined in Figure 7.2. For bilateral repairs,
the same configuration of trocar placement is utilized.
OPERATIVE TECHNIQUE
After inspection of the entire peritoneal cavity and lysis
of any remaining adhesions, the hernia site and the contralateral inguinal area are evaluated carefully. For proper
orientation, the surgeon should recognize the median,
medial and lateral umbilical ligaments. Just below the
posterior parietal peritoneum, the external iliac vein
and artery, the gonadal vessels, and, in males, the vas
deferens should be identified. The hidden course of the
genitofemoral nerve and the approximate course of the
lateral femoral cutaneous nerve should be recalled and
care taken to avoid rough dissection in this area. The exact
location of the ureter bilaterally should also be noted.
We now routinely remove direct and indirect hernia
sacs, since in our experience leaving the sac may perpetuate a bulge in the groin a bulge that patients and inexperienced surgeons interpret as an operative failure despite
repeated assurances that no bowel can enter the sac or
10/12mm port
5 mm port
5 mm port
Hernia
Figure 7.2 Trocar configuration for IPOM inguinal hernia repair.
space. Division of the sac also gives access to the properitoneal area where a lipoma of the cord, if present, can be
excised. When operating for left-sided hernias, we often
find it necessary to divide the embryonic adhesions that
the sigmoid colon maintains with the parietal peritoneum
adjacent to the hernia defect. We excise the sac using
laparoscopic scissors connected to an electrosurgical unit.
First, the sac is inverted progressively into the peritoneal cavity using gentle traction. Once the inversion is
completed, the sac is incised, starting 1 or 2 cm from its
base at the 12 oclock position and proceeding clockwise to
about the 4 oclock position. The incision is then restarted
at the top and carried in an anticlockwise fashion until
approximately the 8 oclock position. The inversion of an
indirect inguinal hernia sac drags within it the fatty areolar tissue in which the gonadal vessels and the vas may be
embedded. This tissue must be bluntly and carefully swept
away from the sac anteriorly. Once separated fully from
the elements of the cord, the sac can then be safely excised
circumferentially and removed through a 10/12-mm port.
Small or capillary vessel bleeding during this phase of
the operation is controlled easily by pinpoint electrocoagulation. Large inguinoscrotal sacs and sacs in multiple recurrent hernias are ringed at the neck (incision of
the peritoneum circumferentially) and are left in place.
Bleeding and extensive edema may ensue if these sacs are
pursued aggressively.
Once the sac is removed, a piece of Polypropylene
mesh is prepared. The size of the mesh should be such
that it covers the hernia defect and extends 3 cm beyond
its rim in all directions at a minimum. We have found that
a 12 ! 15-cm portion of mesh covers most defects adequately. The folded mesh is introduced into the abdominal cavity. We have found that if the mesh is folded rather
than rolled, it will not have a tendency to curl once opened
and it will be much easier to manipulate and hold in place.
Once the mesh is unfolded, it is placed over the defect and
held there with grasping forceps.
The superior border of the mesh at its mid-portion
is then held tightly against the anterior abdominal wall.
A Keith needle attached to a 2-0 strand of Prolene, Ethicon,
Somerville, NJ is pushed through the abdominal wall and
through the mesh (Figure 7.3). Pressing gently on the
abdominal wall with ones finger and visualizing the indentation laparoscopically can establish the spot where the
1 mm incision is to be made and where the needle is to
pierce the abdominal wall. Through the same incision, a
13-gauge needle is then placed through the abdominal wall
and the mesh, parallel to the Keith needle. Once the Keith
needle is passed through the abdomen and mesh, it is
grasped, turned through 180 degrees, and pushed back
through the lumen of the 13-gauge needle, exiting through
the small skin incision (Figure 7.4). A clamp is applied to
the Prolene suture at skin level, which holds the mesh
tightly against the abdominal wall. The same procedure is
Figure 7.3 Keith needle passing through mesh and abdominal

wall adjacent to 13-gauge spinal needle.
(a)
13G needle
Skin
Mesh
Peritoneum
(b)
Figure 7.4 (a) Keith needle being passed back through abdominal
wall via 13-gauge needle. (b) Diagrammatic representation.
repeated at both upper corners of the mesh. This method

of percutaneous fixation of mesh for inguinal hernia repair
was first described by Rosenthal and Franklin in 1993.11 We
do not rely solely on staples, which grasp only mesh and
peritoneum, to hold the prosthesis in place.
Figure 7.5 Mesh stapled securely to Coopers ligament.
Once placed, these three sutures hold the mesh

securely in place, spreading it out evenly and allowing for
the rest of the mesh to be precisely and easily stapled in
place. The staples are initially placed approximately
11.5 cm apart along the lateral edges of the mesh.
Around the inferolateral aspect of the mesh, care should
be taken to place the staples parallel to the course of the
lateral femoral cutaneous nerve or the femoral branch of
the genitofemoral nerve to minimize the chance of their
entrapment, especially if these are placed lateral to the
internal spermatic vessels and inferior to the iliopubic
tract.12 Along the lower margin of the mesh, staples
should be placed lightly and further apart (2 cm) to avoid
damage to the iliac vessels and the vas deferens. A few
staples are also used to fix the superior and central portion of the mesh to the anterior abdominal wall. Medially, every effort should be made to secure the mesh
to Coopers ligament (Figure 7.5). The anteriorly positioned inferior epigastric vessels, immediately beneath
the peritoneum, should be avoided in the stapling process. Staples should not be used near the inferior or inferolateral aspect of the internal ring because of the risk of
injuring the structures passing through it.
The area is irrigated with saline solution and inspected
for hemostasis. The subcutaneous fat below the skin
incisions through which the Prolene sutures were placed
is spread with a fine-tip hemostat, allowing the sutures
to be tied over the external oblique aponeurosis. In our
opinion, firm anchoring of the mesh by transabdominal
stitches and staples in Coopers ligament prevents displacement of the mesh when the abdomen is deflated and
when the patient assumes the erect position. We firmly
believe that recurrent herniation is the result of early
migration of the mesh away from its intended position.
To repair a contralateral hernia, the same procedure
is performed on the opposite side. Initially, we did not
combine this type of surgery with operations on the bowel
or biliary tree. However, these are no longer contraindications to the simultaneous repair of these hernias with
bowel or biliary surgery subsequent to the development
Intraperitoneal onlay mesh approach 51
of biosynthetic mesh materials such as Surgisis

(Cook Surgical), which have demonstrated high resistance to infection, even in contaminated fields.13 (See
Chapter 4.)
As the trocars are sequentially removed, the trocar
sites are examined to ensure that no bleeding is present.
Finally, the umbilical insertion site is observed by slowly
withdrawing the camera and its cannula in unison. To
prevent potential herniation, all 10-mm trocar sites are
closed by repairing the underlying fascia or aponeurosis with the aid of a Carter-Thomasonsuture passer
(Louisville Laboratories) using 0 Vicryl(Ethicon) or
Polysorb(U.S. Surgical) sutures. The skin edges are then
re-approximated with 3-0 Monocryl(Ethicon) subcuticular sutures or Steri-strips(3M Health Care).
anesthesia, higher costs, the potential problems inherent

to laparoscopy, and the need for technical expertise in
laparoscopic surgery. Potential complications due to the
meshs direct contact with abdominal viscera have yet to
be realized in the laboratory or in clinical practice.
The laparoscopic IPOM technique of hernia repair
is a safe and relatively easy procedure to perform, with
good results and low morbidity. It can be a particularly
effective technique for laparoscopic repair of recurrent
inguinal hernias or for hernia repair in the setting of an
obliterated pre-peritoneal space.
REFERENCES
1
POSTOPERATIVE MANAGEMENT
Patients are generally discharged the evening of surgery
or after a 23-hour observation period, depending on age,
comorbidities, and difficulty of operation. They are
scheduled for follow-up office visits one to two weeks
following discharge and are instructed to be aware of urinary retention, neuralgia (from damage to the lateral
femoral cutaneous nerve), and scrotal swelling in men.
We ask that they avoid heavy lifting ("9 kg) for five
to seven days following surgery. However, after this
brief time period, they are allowed to perform activity as
tolerated.
4
5
CONCLUSION
The transabdominal approach to inguinal hernia repair
is not a new concept. Advocated by Marcy14 in 1887 and
by LaRoque15 in 1932, the transabdominal approach for
inguinal herniorrhaphy allows greater ease in identification of groin anatomy, determination of the type of hernia defect, and separation of incarcerated and adherent
structures to the sac.16,17 However, the morbidity associated with a laparotomy is far too great for repair of
an uncomplicated inguinal hernia. With the advent of
laparoscopic surgery, the benefits of the intra-abdominal
approach to inguinal herniorrhaphy can be enjoyed
without the morbidity of a laparotomy.
The IPOM procedure is relatively simple to perform
and carries with it all the potential advantages of a minimally invasive procedure with respect to the open inguinal
hernia repair, including less postoperative pain, earlier
return to normal activities, ability to clearly visualize
and repair all hernia defects bilaterally, easier repair of
recurrent hernias, and improved cosmesis. Disadvantages
of the IPOM technique include the necessity for general
10
11
12
13
14
15
16
17
Ramshaw R, Shuler FW, Jones HB, et al. Laparoscopic inguinal

hernia repair: lessons learned after 1224 consecutive cases. Surg
Endosc 2001; 15: 5054.
Ger R, Monroe K, Duvivier R, Mishriek A. Management of indirect
inguinal hernia by laparoscopic closure of the neck of the sac.
Am J Surg 1990; 159: 37073.
Schultz L, Graber J, Pietrafitta JJ, Hickok D. Laser laparoscopic
herniorrhaphy: a clinical trial preliminary results. J Laparoendosc
Surg 1990; 1: 415.
Corbitt JD. Laparoscopic herniorrhaphy. Surg Laparosc Endosc
1991; 1: 235.
Fitzgibbons RJ, Salerno GM, Filipi CJ, et al. A laparoscopic
intraperitoneal onlay mesh technique for the repair of an indirect
inguinal hernia. Ann Surg 1994; 219: 14456.
Franklin ME. Animal studies and rationale for intraperitoneal
repair. In: Arregui ME, Nagan RF, eds. Inguinal Hernia: Advances
or Controversies? Oxford: Radcliffe Medical Press Ltd, 1994:
2414.
Layman ST, Burns RP, Chandler KE, et al. Laparoscopic inguinal
herniorrhaphy in a swine model. Am J Surg 1993; 59: 1319.
Franklin ME, Diaz-Elizondo JA. The intraperitoneal onlay mesh
procedure for groin hernias. In: Fitzgibbons RJ, Greenburg AG,
eds. Nyhus and Condons Hernia. Philadelphia: Lippincott Williams
& Wilkins, 2002: 26976.
Toy FK, Moskowitz M, Smoot RT, Jr, et al. Results of a prospective
multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic
inguinal hernioplasty. J Laparoendosc Surg 1996; 6: 37586.
Fitzgibbons RJ, Camps J, Comet DA, et al. Laparoscopic inguinal
herniorrhaphy: results of a multicenter trial. Ann Surg 1995;
221: 313.
Rosenthal D, Franklin ME, Jr. Use of percutaneous stitches in
laparoscopic mesh hernioplasty. Surg Gynecol Obstet 1993; 176:
4912.
Eubanks S, Newman L, Goehring LM, et al. Meralgia paresthetica:
a complication of laparoscopic herniorrhaphy. Surg Laparosc
Endosc 1993; 3: 3815.
Franklin ME, Gonzalez JJ. Preliminary experience with new
bio-active prosthetic material for repair of hernias in infected
fields. Presented at the American Hernia Society meeting,
Tucson, AZ, USA, May 812, 2002.
Marcy HO. The cure of hernia. JAMA 1887; 8: 58992.
LaRoque GP. The intra-abdominal method of removing inguinal
and femoral hernia. Arch Surg 1932; 24: 189203.
Read RC. Preperitoneal herniorrhaphy: a historical review. World J
Surg 1989; 13: 53240.
Nyhus LM, Condon RE, Haskins HN. Clinical experiences with
preperitoneal hernia repair for all types of hernia of the groin.
Am J Surg 1960; 100: 23444.
8
REINHARD BITTNER, CLAUS-GEORG SCHMEDT AND BERNHARD JOSEF LEIBL
Principles
Preoperative management
Instrumentation
Operative room set-up
Operative technique
53
54
55
55
56
The introduction of laparoscopic operating techniques

opened up the possibility of using this method to
implant mesh into the pre-peritoneal space to repair an
inguinal hernia. By sparing the patient a large abdominal
incision in the inguinal region1 or in the midline,2 one
can expect a decrease in the number of wound complications, less postoperative pain, and consequently a faster
recovery of normal physical activity and return to work.
In contrast to pre-peritoneal mesh insertion via a minimized anterior approach,3 the laparoscopic method
provides clear visibility when dissecting the inguinal
region with safe, wrinkle-free placement of a large mesh.4
Laparoscopic hernioplasty with pre-peritoneal placement
of a large mesh (transabdominal pre-peritoneal (TAPP)
repair) represents a synthesis between proven conventional operative techniques and the advantages of a minimally invasive approach.
PRINCIPLES
Indications
The mode of operation of TAPP follows the law of
physics according to Pascal.2 As a result of pre-peritoneal
placement of the prosthesis, i.e. between abdominal
pressure and the weak point in the abdominal wall, the
pressure that initially caused the hernia now acts as a
stabilizer for reconstruction. If the mesh chosen is
Special remarks
Conclusion
References
61
63
63
63
sufficiently large, then laparoscopic pre-peritoneal hernioplasty can be seen as a completely tension-free method of
hernia repair, which dispenses with any and all kinds
of fixation. In contrast to this, the success of an anterior
mesh implant (Lichtenstein) depends on a strong external
oblique aponeurosis and on a row of well-placed fixation
sutures.
Laparoscopic hernioplasty can be used on any type of
hernia, with the exception of huge, non-reducible scrotal
hernia (more than double the size of a mans fist). In our
patient pool of more than 1100 hernia repairs yearly,
TAPP is used in 99 per cent of repairs.5 Conventional hernia repair operations are carried out only in young
patients (#20 years of age), in patients at high cardiopulmonary risk where a general anesthetic is refused, and in
patients who decline to accept implantation of prosthetic
materials.
Preferred indications are hernias recurring after conventional operations (with the advantage of avoiding
anterior scar areas),6 bilateral hernia (both sides can be
treated through the same three trocar incisions), and
hernias with extensive destruction of the rear wall of the
hernial canal (Nyhus type 3 with a defect diameter of
more than 3 cm, pantaloon hernia).7,8 Other accepted
indications are inguinal pain in athletes,9 after eliminating other possible causes, and hernias in patients who
wish to return to normal physical activity as quickly as
possible.
Pain in the inguinal area with no clinically or sonographically proven hernia sac or lipoma of the spermatic
cord is not seen as an indication for laparoscopic hernioplasty. Painstaking neurological (inguinal nerve neuralgia?) and orthopedic investigation is necessary. Strong
selection for operation is the only way to reduce significantly the frequency of postoperative chronic pain for
these patients. However, a clinically proven hernia, even
though a hernia sac may not have been identified laparoscopically, does necessitate complete dissection of the
inguinal region. As a rule, very often one will find a circumscribed lipoma of the inguinal canal or a fatty mass
that has moved into the inguinal canal. The operation is
then identical to a hernia repair.
Advantages of the TAPP technique over the totally
extraperitoneal (TEP) approach include the following:
After insertion of the laparoscope, one can assess

immediately the hernial situation on both sides and
recognize the landmarks that are important for
dissection.
Intestinal adhesions in the hernial sac (sliding hernia)
can be recognized immediately.
Control of any bleeding is possible by appropriately
aimed electrocoagulation, thereby avoiding injury to
the adherent intestinal wall.
It is possible to diagnose accompanying pathological
conditions as well as to carry out additional surgery
in the abdominal space (e.g. cholecystectomy)
without conversion to an open procedure.
Contraindications
The only absolute contraindication is for patients at high
cardiopulmonary risk who cannot be subjected to general
anesthesia or a pneumoperitoneum. A relative contraindication is seen in patients after extensive abdominal surgery,
especially after a lower abdominal laparotomy through a
midline incision as well as after surgery in the space of
Retzius (transabdominal prostate resection, bladder resection), after previous laparoscopic or endoscopic hernioplasty with mesh implant, and in patients with large, old,
irreducible scrotal hernia. Patients who have undergone the
above operations tend to develop extensive adhesions in
the abdominal space as well as substantial scarring between
the retroperitoneal structures. These patients present a risk
not only of increased bleeding but also of injury to the
intestinal organs and the bladder, as well as the large
abdominal vessels.
Laparoscopic versus open repair

According to a meta-analysis of the EU Hernia Trialists
Collaboration covering a total of 58 randomized studies,
recurrence rates can be reduced by about 50 per cent by
implanting prosthetic materials, with no difference noted
between anterior and posterior implant techniques.10 The

same meta-analysis confirmed that in comparison with
anterior mesh implants, laparoscopic/endoscopic techniques provide a clearly higher patient comfort and a
significantly faster resumption of normal physical activity.
It was observed, however, that the risk of severe complications is higher when using the laparoscopic technique
(4.7/1000 v. 1.1/1000). Furthermore, the laparoscopic
technique means longer operating times and significantly
higher costs. There is no doubt that the laparoscopic technique is more difficult to learn. This is, to some extent,
related to the fact that many clinics do not routinely
perform videoendoscopic operations, and therefore there
is no structured training curriculum available. In the
authors hospital, with the experience that comes from
more than 8000 hernia repairs, a median operating time of
40 minutes is sufficient for experienced surgeons, while
trainees need 55 minutes. These times are completely in
the range of those for open repair.5 A decisive factor concerning the costs is whether disposable or non-disposable
instruments are used, and whether, or how, the mesh is
fixed in place. A high potential cost-saving is possible here.
The experience of our clinic is that the costs for the operating theatre alone (personnel and instruments) are only
about $75 higher than those of the Lichtenstein operation,
assuming that an anesthetist is required for the local
anesthesia. Furthermore, the total costs for employees are
lower with the laparoscopic technique when the costs of
lost work days are factored into overall expense.11 All in all,
the literature and our own results show that a well-trained
surgeon can perform a cost-effective laparoscopic hernioplasty in a period of time that is well within the range of
that for conventional open surgery.
PREOPERATIVE MANAGEMENT
Anatomy/pathology
Clinical examination of the patient is indispensable. An
experienced examiner can diagnose correctly inguinal hernia with a total accuracy rate of 0.93. An additional sonographic examination can increase this figure to 0.94.12
Classification of the hernia into medial or lateral, or in
respect to the size of the defect, can be estimated only
approximately, both clinically and sonographically, achieving a total accuracy rate of correct diagnosis of only 0.62
and 0.53, respectively. Exact classification of the hernia is
therefore only possible intraoperatively.
Precise knowledge of anatomy is indispensable for
a successful laparoscopic hernia operation, especially
concerning the course of the epigastric vessels, the large
pelvic vessels, the corona mortis, and the inguinal nerves
(Figure 8.1).
Transabdominal pre-peritoneal approach 55
with a blunt, conical tip and a radially expanding effect.

Endo-Overholt and endo-scissors have a connection for
monopolar electrocoagulation. In the case of large hernia
sac, dissection is carried out using two Endo-Overholts. A
30-degree angled laparoscope is used. We recommend
using ReddickOlsen atraumatic forceps to push an
umbrella-like mesh through the 12-mm trocar. The handles of the instruments mentioned above should not be
lockable; the dissection forceps (Kelly) is the only exception, where a lockable handle is useful. The peritoneum is
closed with a running stitch (Lahodny-Suture, Ethicon,
PDS 3/0) with clip fixation. An endoscopic needle-holder
and a clip-application forceps are necessary for this suture.
Figure 8.1 Complete dissection of the pelvic floor. All
important anatomical structures are visible.
Preoperative testing
In patients who are old ("60 years) or who have an
increased cardiopulmonary risk, an electrocardiogram
(ECG) and thoracic X-ray are essential. Additionally, if
necessary, blood and clotting tests should be run. Patients
should be asked whether they have taken aspirin and, if
necessary, platelet function assay (PFA) values should be
determined.
Some authors recommend evaluation of the colon for
pathology to eliminate a symptomatic hernia, especially
in older patients. If the patients history is uneventful,
however, this is not considered a routine examination.
A preoperative urethral catheter is not necessary. It
is usually sufficient to request that the patient empties
their bladder before being transported to the operating
theater. Should a full bladder be found during laparoscopy, however, a suprapubic urinary catheter can be laid
via percutaneous puncture.
OPERATIVE ROOM SET-UP

The patient is supine and flat on the operating table. After
setting up the pneumoperitoneum, the patient is placed
into the Trendelenburg position and turned at an angle of
about 15 degrees towards the surgeon, so that the surgeon
can approach the inguinal region without being hindered
by intestinal loops. The patients arms are at his or her side,
so that the operator can change sides easily in cases of a
bilateral hernia. The surgeon stands on the side opposite
the hernia; the camera operator is positioned on the ipsilateral side of the hernia. The monitor is placed at the foot of
the patient. The assisting nurse with the instruments is
always to the left of the patient, between the surgeon and
the camera operator. The anesthetist looks after the patient
as usual, from the head of the operating table, so that each
member of the team can follow the progress of the operation on the monitor at any time (Figures 8.28.4).
MCL
MCL
INSTRUMENTATION
The following instruments are needed for a laparoscopic
hernioplasty:
Veress needle for creating a pneumoperitoneum;

10-mm trocar at the navel for insertion of the optics;
5-mm trocar in the left mid-abdomen for insertion
of the Endo-grasper (Overholt);
12-mm trocar in the right mid-abdomen for the hernia
stapler, the mesh and the Metzenbaum endo-scissors.
A dissection swab (forceps according to Kelly) and/or
a gauze for hemostasis can also be inserted.
All the trocars and operating instruments are reusable

instruments. It is important that the trocars do not
cut through the tissues; our preference is to use trocars
Assistant
(camera)
Surgeon
10 mm
5 mm
12 mm
Scrub
nurse
Monitor
Figure 8.2 Localization of ports for TAPP repair of left-sided

inguinal hernia. MCL, medioclavicular line.

MCL
MCL
Assistant
(camera)
Surgeon
12 mm
10 mm
5 mm
Scrub
nurse
Monitor
Figure 8.3 Localization of ports for TAPP repair of right-sided

inguinal hernia. MCL, medioclavicular line.
MCL
MCL
Assistant changes
position for repair
of contralateral side
Surgeon changes
position for repair
of contralateral side
Assistant
(camera)
Surgeon
12 mm
10 mm
5 mm
Scrub
nurse
Monitor
Figure 8.4 Localization of ports for TAPP repair of bilateral

inguinal hernias. MCL, medioclavicular line.
OPERATIVE TECHNIQUE
The operation begins with the creation of the pneumoperitoneum and insertion of the camera trocar. The
pneumoperitoneum can be installed with the help of the
Veress needle or after open insertion of the optical trocar
(Hasson technique). If a patient has had no previous
abdominal surgery, then we prefer the Veress needle technique. Initially, a longitudinal skin incision about 1 cm
long is made along the upper border of the umbilicus.
The abdominal layers are held under maximum tension
(the umbilical area is lifted with two Backhaus clamps in
the corners of the incision), and the Veress needle is
inserted into the abdominal space under careful monitoring, as described by Semm.13 At the beginning of insufflation, the intra-abdominal pressure and the rate of gas flow
must be monitored carefully. Pressure must initially be
0 mmHg and the gas flow must be 23 liters CO2/min. If
the pressure is initially too high or the gas flow too low,
then the position of the needle must be checked and/or an
open approach into the abdominal space should be chosen.
If the patient has an umbilical hernia, we make a
23-cm-long horizontal incision at the upper border of the
umbilicus, dissect the hernial sac, and then use the Veress
needle or the optical trocar to gain entry to the abdominal
space through the hernial gap (fascial closure in these
patients follows at the end of the operation in the same
way as for umbilical hernias). If intra-abdominal pressure
reaches 12 mmHg and the aspiration test is regular, then
the optical trocar is inserted. The abdominal wall should
again be held under maximum tension. The optical trocar
is then inserted into the abdominal cavity in the direction
of the center of the navel with slightly rotating movements, the most effective way to avoid slipping on the
fascia. By using this technique, the danger of inadvertent
injury to the small or large intestines or large vessels is kept
at a negligible minimum.
If intra-abdominal adhesions are expected, especially
after prior median laparotomy, then the open technique
according to Hasson should be chosen to insert the optical trocar. After the somewhat larger skin incision has
been made, the linea alba is dissected and opened up far
enough between two Kocher clamps to allow insertion of
a finger. After opening the peritoneum, the finger is
inserted into the abdominal space to check for and/or
eliminate possible adhesions. The optical trocar can then
be inserted and the pneumoperitoneum created.
Now the further steps of the operation are under direct
view. In cases of a bilateral hernia, both the working trocars, 5 mm left, 12 mm right, are introduced into the midclavicular line at the level of the umbilicus. If the hernia is
unilateral, then we recommend inserting the ipsilateral
working trocar about 12 cm above the navel area and/or
the contralateral working trocar about 13 cm below the
navel region (Figures 8.28.4). In this way, collisions with
the optical trocar can be avoided. In order to dissect the
inguinal region, the surgeon uses the right hand to operate the Metzenbaum Endo-scissors, which are connected
to monopolar electrocautery. The left hand operates the
Endo-Overholt.
The transabdominal technique allows immediate assessment of the hernia situation. The operative procedure is
Figure 8.5 Generous arcuate incision of the peritoneum about

34 cm above the transverse arcade and the inner inguinal ring,
beginning at the anterior superior iliac spine and leading to
the medial umbilical fold.
initially not dependent on the type of hernia because the

aim is to completely dissect the inguinal region and all
possible hernial orifices. Adhesions between the omentum or intestine within the inguinal region or the hernial
sac (e.g. sliding sigmoid hernia) are not detached but
removed en bloc with the peritoneum from the abdominal wall or from the hernial orifices. The operation then
begins by determining the site of the anterior superior
iliac spine using the bimanual method the palpating finger of the left hand on the outside, the tip of the scissors
on the inside. Regardless of the type and size of the hernial orifice, starting at this point a generous curving incision of the peritoneum is performed, well above the
internal inguinal ring and above the rear wall of the
inguinal canal as far as the median umbilical ligament
(Figure 8.5). It is usually not necessary to divide this ligament, even in the case of a prominent ligament, i.e. when
this structure projects far into the abdominal space or has
a large component of adipose tissue, nor if the hernial sac
is found to be located very medially. Division of this ligament can lead to unnecessary bleeding from umbilical
vessels that remain patent. If the peritoneal incision needs
to be extended, then this is carried out parallel to the
ligament in the cranial direction. The peritoneal and/or
subperitoneal small blood vessels are coagulated immediately with monopolar current, so that the site is always
absolutely free of blood and has a yellowish-pink color.
Dissection continues strictly in the mostly avascular,
cobweb-like zone, whereby the procedure is mainly blunt,
and the peritoneum with its surrounding pre-peritoneal
fatty tissue can be pushed away from the fascia transversalis and the rectus muscle (Figure 8.6). The few blood
vessels that may be encountered are coagulated.
Figure 8.6 Partly blunt, partly sharp dissection in the mostly

avascular, cobweb-like tissue layer between the peritoneum and
the abdominal wall.
Figure 8.7 In very obese patients, early preparation of the

anatomical landmarks (e.g. epigastric blood vessels, symphysis)
is very important. Dissection then follows these landmarks
strictly, which have to be prepared absolutely free of fatty tissue.
During this phase, early identification of some anatomical structures (landmarks), including the epigastric vessels, symphysis and Cooper ligament, and iliopubic tract,
is important, especially in obese patients or in unclear
hernia situations (Figure 8.7). Only when these structures
have been identified properly can dissection continue, following the structures in the direction of the hernial orifice/
hernial sac. Special attention must be paid to dissection
underneath the iliopubic tract, in order to avoid injury to
nerves (N. cutaneus femoris lateralis, N. genitofemoralis)
or vessels (Figure 8.8). Clumsy and obscure use of electrocoagulation and placement of clips are strictly prohibited.
Any bleeding that occurs must be controlled immediately to keep the site clearly visible and to avoid increased
light absorption, which would cause insufficient lighting
Figure 8.8 Avoiding rough dissection in the lateral caudal

compartment, below the iliopubic tract and lateral to the
testicular blood vessels, endangering the inguinal nerves, which
may have a very variable course.
Figure 8.9 Dissection of a direct hernia in a case of bilateral

hernias, where the opposite mesh is already in place. In order
to avoid the formation of seroma, generous use of
electrocoagulation in hemostasis is recommended.
of the operative field. Control of any bleeding can be

carried out with the aid of a dissection swab in the right
hand or with a small gauze that is inserted easily via the
12-mm trocar. The electrocoagulator is then connected
to the Endo-Overholt in the left hand, allowing accurate
coagulation.
In most cases of direct herniation, the lipomatous hernial content will be dissected from the extended transversalis fascia and removed from the hernial orifice during
dissection of the Hesselbach triangle, i.e. the level between
epigastric vessels, the transversus arcade, and the ligamentum inguinale/tractus iliopubicus (Figure 8.9). This
dissection is almost completely blunt. Careful hemostasis
is important to ensure that the part of the fascia transversalis that forms the hernial sac is totally free of even the
Figure 8.10 Dissection of the medial compartment has to be

carried beyond the middle of the symphysis so that a suprasymphytic defect, especially in recurrent hernias, is not missed.
slightest points of bleeding. In this way, the formation of

extensive postoperative sero-hematoma can be largely
avoided. Furthermore, two basic principles are to be taken
into account when dissecting the medial compartment:
1 Dissection has to reach past the middle of the
symphysis to the opposite side in order to identify a
suprasymphytic hernial orifice (Figure 8.10), not
uncommon in recurrent hernias, and also to create a
large enough space for wrinkle-free placement of the
mesh. Usually, this preparation is simple and carries
no risk of injury to the bladder wall. Problems may
be expected, however, in cases of previous operations
in this area (e.g. prostate resection). Due to the
significant risk of bladder injury, operations on such
patients should be performed only by very
experienced laparoscopic surgeons, otherwise a
conventional anterior approach should be selected
from the start.
2 In a lateral direction, the medial compartment
should be dissected as far as the iliac vessels, in order
to eliminate the possibility of a femoral hernia.
Preparation should be carried out very carefully to
avoid injury not only to the iliac vessels but also
to the corona mortis, which is found in about
2030 per cent of patients (Figure 8.11).
Dissection of the lateral compartment is significantly
more difficult, especially in patients with a large amount
of adipose tissues with a large indirect hernial sac and in
patients with severe scar contractions between hernial sac
and cremaster muscle. These problems are not uncommon, especially in recurrent hernias after previous conventional operation. A basic consideration in an indirect
hernia is that the hernia sac should be located cranially
and laterally to the spermatic cord, whereas the vas deferens should be most caudal, stretching over the iliac vessels in a medial direction, while the testicular vessels can
Figure 8.11 During medial dissection, the iliac vein has to be

prepared in order to recognize femoral defects. Care: corona
mortis!
Figure 8.12 Tip of the hernia sac clearly visible in front of the
left Endo-Overholt. Strong adhesions to the cremasteric bundle
(in front of the right Endo-Overholt) can be removed after
careful electrocoagulation.
be followed in a lateral direction. Detachment of the hernial sac from the internal inguinal ring in the region of its
upper circumference can therefore be carried out relatively quickly, as there is usually no danger of injury to
the spermatic cord (Figure 8.12). If an accompanying
lipoma of the spermatic cord is present, this can usually
be mobilized out of the inguinal canal relatively easily;
sometimes, only then is it possible to make an approach
to the hernial sac.
Dissection is mainly blunt, adhering strictly to the
hernial sac with careful hemostasis. If there are irremovable adhesions between the hernial sac and the cremaster
tube or spermatic cords, then these are electrodissected
Figure 8.13 In case of a tangled situation around the inner

inguinal ring because of fatty tissue, we first prepare the
testicular blood vessels, caudal and lateral, and then dissect in
a cranial and medial direction.
carefully and pushed aside easily. If the hernial sac is very

long, it may need a strong tug with the left hand holding
the Endo-Overholt to remove the hernial sac from its bed
in the inguinal canal. To prevent the hernial sac from
slipping back into the inguinal canal, e.g. when adjusting
the Endo-Overholt, we recommend dissection with two
Endo-Overholts following the rope-ladder principle. It is
important to identify the testicular vessels as early as
possible during dissection. This is usually done easily
in the region of the base of the hernial sac as far as possible laterally and dorsal-caudally (Figure 8.13). Further
dissection is carried out parallel to the testicular vessels
in a medial-ventral direction to the angle between iliopubic tract and epigastric vessels. It can sometimes be
helpful to create a dorsocaudal window between hernial
sac and spermatic cord, especially in the case of a scrotal
hernia. If complete removal of a hernial sac may seem
too difficult regarding risk of injury to the spermatic
cord, then the hernial sac can be severed. If the hernial
sac stays in situ, however, the risk of postoperative hydrocele may be higher.
Our experience in more than 450 scrotal hernias
shows that the hernial sac can almost always be removed
completely without risk of injury to the testicular vessels
or extensive postoperative hematoma, as long as the following principles are observed:14 early identification of
the testicular vessels laterally and caudally of the hernial
sac, dissecting from caudal-lateral to ventral-medial, careful hemostasis, strict dissection while the hernial sac is
held under tension, and severing stronger adhesions with
the aid of electrocoagulation. Once the point of the top of
Figure 8.14 Partly blunt, partly sharp removal of the hernia sac
towards the abdomen while performing meticulous hemostasis
of the spermatic structures (parietalization).
the hernial sac has been reached, the rest of the procedure
is simple (Figure 8.14). Partly blunt, partly sharp (electrocoagulation) dissection is now carried out in the direction
of the abdominal cavity, and the hernial sac is detached
completely from the spermatic cords. This procedure is
known as parietalization. Parietalization (i.e. detachment
of the hernial/peritoneal sac from the retroperitoneum
and/or from the spermatic fascia covering the retroperitoneum and the spermatic cord) is performed in the direction of the head, as far as the mid-psoas muscle, so that
there is no longer any contact between the peritoneum
and the vas deferens medially and between the testicular
vessels and the peritoneum laterally. Manipulation of the
peritoneum should no longer lead to changes in the position of the spermatic cords. Extensive parietalization is
especially important when an unslitted mesh is to be
inserted. This is the only way to ensure that when the peritoneum is closed, any adhesions that may be left behind
do not displace the mesh into a position that could lead to
a recurrence. If extensive parietalization is not possible,
which does happen very rarely (sometimes in a patient
with a recurrence after TAPP), then a slitted mesh can be
introduced, causing the dorsal portion of the mesh to take
up a position behind the spermatic cords.
After this dissection, the entire myopectineal orifice is
free of peritoneum and fatty tissue, thereby allowing complete identification of the epigastric vessels, the internal
inguinal ring, Hesselbachs triangle, Coopers ligament,
the iliopubic tracts, the testicular vessel bundle, and the
vas deferens (Figure 8.15). A 10 ! 15-cm polypropylene
mesh can now be inserted. The mesh is folded like an
umbrella over the ReddickOlson Endo-forceps and
pushed through the 12-mm working trocar into the
inguinal region, where, due to the memory effect, it can
be spread out easily. The mesh should be positioned with-
Figure 8.15 End of dissection: the peritoneal sac is removed

beyond the middle of the psoas muscle. All anatomic structures
are recognizable and freed of fatty tissue.
Figure 8.16 A 10 !15-cm polypropylene mesh is placed

without folds. All potential hernia openings are overlapped by
at least 3 cm.
out wrinkles, overlapping all possible hernial orifices

by at least 3 cm (Figure 8.16). Using such a large mesh
means that fixation is necessary only to facilitate positioning (e.g. in very shallow curved inguinal areas or to
avoid mesh dislocation in the immediate perioperative
phase). Fixation is carried out with a few clips or staples.
We recommend using two clips in both the areas of the
symphysis and/or Coopers ligament, two clips to fix the
upper border of the mesh to the rectus muscle medial to
the epigastric vessels, and two clips lateral to the epigastric vessels into the fascia transversalis (Figure 8.17).
Before the clips are fixed at the ligament of Cooper, a
possible corona mortis and/or the iliac vessels should be
identified. After the iliopubic tract is identified, the lateral
Clip position in
TAPP technique
! Clip position
! Forbidden area
Figure 8.17 Presentation of clip

positions and the endangered
regions: triangle of pain and triangle
of doom. (a) Medial defect;
(b) lateral defect; (c) femoral defect.
clips are placed, keeping a minimum cranial distance

of about 23 cm. If these basic guidelines are followed
strictly, injury to the large vessels or the inguinal nerves
can be avoided completely.
We almost always use an unslitted mesh for the
following two reasons:
The slit can cause a recurrence because it weakens

the stability of the mesh.
In contrast to the keyhole technique, there is no need
for circular dissection of the spermatic cord with the
risk of damaging some small vessels, and there is also
no close contact between the spermatic cord and the
mesh, thus eliminating the possibility of it becoming
involved in scar tissue.
Before the peritoneum is closed, it is lifted and the

extent of parietalization is checked. The covering peritoneal fold should be at least 12 cm above the upper end
of the mesh (Figure 8.18). Finally, the peritoneal incision is closed carefully with resorbable sutures (PDS,
Lahodny). To facilitate tension-free closure, the intraabdominal pressure should be reduced to 68 mmHg.
When using this technique, a tight and secure seal is possible even with scarred peritoneum, a task that is occasionally difficult when clips are used. The suture closure
is technically more difficult, however, and needs practice.
After carrying out five to ten operations, however, even a
relative beginner should be able to perform it efficiently.
Finally, the working trocars are removed under direct
visualization. Even though blunt trocars are used, bleeding from the epigastric vessels does occur on occasion
and must be recognized and controlled. In such cases,
hemostasis is simple to carry out with electrocoagulation
and can be performed with an Endo-Overholt introduced via the contralateral trocar.
Figure 8.18 The peritoneal fold should be 12 cm proximal to

the caudal edge of the mesh.
Suturing of the lateral fascial openings is not necessary when blunt, radially expanding trocars are used,
because the rectus muscle covers these openings. The
fascial opening for the camera trocar should always
be closed with suture to avoid the occurrence of a late
postoperative trocar hernia.
SPECIAL REMARKS
A drain is generally not necessary, but in the case of large
scrotal hernias, a retroperitoneal closed suction drain
ought to be used, placed between the mesh and the
abdominal wall.
Bilateral hernia
The identical standard technique is used separately
for each side, with implantation of a 10 ! 15-cm polypropylene mesh on each side.15
Recurrent hernia after conventional

operation
An essential advantage of the laparoscopic technique in
recurrent hernias after anterior conventional repair is that
dissection can be shifted into the pre-peritoneal space,
which is mostly free of scar tissue, allowing the use of an
almost standard primary hernia technique. The results
(operating time, morbidity, return-to-work times, recurrence rate) are consequently not significantly different to
those of a primary hernia operation (Table 8.1). The only
exception is the situation after previous hernioplasty
according to Lotheisen. In this case, significant scarring
can be expected at Coopers ligament, and it is difficult to
operate laparoscopically in this area. This situation can be
overcome by choosing a peritoneal incision caudal to
the Cooper ligament. After the usual dissection of the
peritoneum, which has been described above, in an area
somewhat medial to the Cooper ligament a whetstone-like
incision is made around the ligament itself at the peritoneal
level. This method allows renewed access to the scar-free
pre-peritoneal space caudally, where further dissection can
now take place undisturbed. Although this leaves a small,
scarred peritoneal section on the Coopers ligament, the
polypropylene mesh can nevertheless be anchored safely.
In the area of the internal inguinal ring, it is not
uncommon to find scar formation 12 mm thick surrounding both the hernia sac and the spermatic cord.
Once this cuff-like scarred ring of tissue is cut with electrocautery in the neighborhood of the epigastric vessels
(which may involve the cremasteric muscle), standard
dissection can continue.
It must be taken into consideration that the previous
operation may have resulted in an atypical localization of
the spermatic cord. The recurrent hernia can occasionally develop between the vas deferens and the testicular
vessels, so that the former is displaced medially and the

latter are displaced in a very lateral direction. Very rarely,
the testicular vessels may be looped around the spermatic cord in a medial and ventral direction. Whereas
these problems occur mostly in indirect recurrent hernias, operation of a direct recurrent hernia is much easier because, as a rule, there are no structures nearby that
may be injured. It must be taken into account, however,
that the tranversalis fascia should not be perforated during dissection, as one would then enter into the inguinal
canal and possibly damage the testicular vessels.
Recurrent hernia after pre-peritoneal

patch hernioplasty
Laparoscopic operation of a recurrent hernia after
pre-peritoneal hernioplasty is technically possible, but
operation time will be significantly longer, and there will
be a risk of higher morbidity.16 However, the time needed
to regain physical activity is the same as for the standard
technique in primary hernias.
Operation of a recurrent hernia after pre-peritoneal
hernioplasty is extremely difficult and should be carried
out only by very experienced laparoscopic hernia surgeons. As a rule, extensive scarring can be found between
the abdominal layer and mesh, and/or mesh and peritoneum, and can only be dissected sharply. Dissection
begins in the scar-free areas, with early identification of
the landmarks (epigastric vessels, symphysis, Coopers
ligament). Medial dissection should adhere strictly to the
rectus muscle and/or the fascia transversalis in order to
avoid damage to the bladder. In 80 per cent of cases, we
found a dissection layer between abdominal wall and
mesh, and in about 20 per cent of cases between peritoneum and mesh. As noted earlier, reoperation upon a
direct hernia is significantly easier than on an indirect hernia. Operation of an indirect hernia is extremely complicated, but once the scar areas have been overcome and
direct access gained to the hernial sac, the rest of the operation is not too different to that of a primary hernia. The
mesh is usually left in place; parietalization, however, is
possible in only the rarest of cases. As a rule, a slitted mesh
Table 8.1 Operative results in 8050 consecutive laparoscopic hernia repairs
Unilateral primary hernia (n $ 4222)

Bilateral primary hernia repair (n $ 1341)*
Recurrent hernia (n $ 1146)
Scrotal hernia (n $ 440)
*Results related to 2682 repaired hernias.
Median
operation
time (min)
Morbidity
rate (%)
Reoperation
rate (%)
Recurrence
rate (%)
Median
return to
work (days)
47
35
45
65
3.0
2.2
4.5
4.8
0.4
0.5
1.0
1.1
0.8
0.6
1.1
2.7
14
15
21
19
will have to be inserted. In such cases, we do, however,

secure the slit with a second, smaller mesh using the
so-called double-buttress technique. In case of a direct
hernia and stable conditions in the area of the lateral
compartment, lateral dissection is not necessary. It suffices to implant a piece of mesh that is appropriately sized
so that it overlaps the hernial defect by at least 3 cm and
can be anchored to the original mesh, which is located
laterally.
Scrotal hernia
In comparison to the TEP technique, the advantage of
the TAPP technique on scrotal hernia is the immediate
identification of adhesions of the intestinal loops within
the hernial sac, so that trauma to the wall of the bowel
(e.g. by electrocoagulation on the hernia sac) can be
avoided completely. The operation is performed strictly
according to the standard technique, as mentioned above,
almost exclusively using the two Endo-Overholt technique and the rope-ladder principle. Especially important
in this kind of hernia is the fat-free dissection of the
internal inguinal ring, the detachment of all lipomatous
masses from the inguinal canal, the spermatic cord and
the hernial sac, early preparation of testicular vessels, and
carefully controlled hemostasis.14 In the case of a very
large internal inguinal ring, a 10 ! 15-cm standard mesh
may be too small because it is not possible to overlap the
upper border of the hernial ring by the required minimum 3 cm. Therefore, in these patients we prefer to use a
15 ! 15-cm mesh.
Irreducible/incarcerated inguinal hernia

Irreducible and especially acute incarcerated hernias
present a good indication for the laparoscopic technique.17 An exception, however, is the very large, chronically irreducible scrotal hernia, as the relationship
between operative effort and result are out of proportion. Although an open approach is also difficult in such
patients, the few cases that do come into question should
opt for this technique. In contrast, the laparoscopic technique offers advantages in acute incarcerated hernias. It
may be possible to avoid resection of the intestine, as
there is more time available to observe how the damaged
intestinal wall recovers. If a resection does prove necessary, then the required laparotomy can be kept small, or
it may even be possible for the whole operation to be
carried out via laparoscopy.
The operation begins in the standard way, with the
aim of completely exposing the hernial ring in the preperitoneal space. Reduction of the hernial contents via
traction should be avoided. If the exposed hernial ring
is split in a ventral-cranial direction, then reduction is
simple. Sometimes external pressure may be required. The

hernial content can now be reliably assessed for viability.
The further procedure again correlates to the standard
technique. If the intestine shows signs of gangrene, then
a primary mesh implant is not recommended due to the
risk of infection. Thorough rinsing of the inguinal region
and the insertion of a drain is recommended. Defect
reconstruction, however, should not be performed; an
option here is open repair with sutures.
On the evening after the operation, the patient is allowed
to get up and use the toilet. The patient may drink freely
and may have a light meal if desired. A diclofenac 100 mg
suppository is provided as needed. A one-night stay in
the hospital is obligatory for insurance reasons in
Germany, where the authors of this chapter work. On the
following morning, we recommend that the patient
moves around freely and begins light stretching exercises
for the inguinal region. The patient should decide when
to be discharged. As a rule, patients leave the hospital
between the second and fourth postoperative day. Before
discharge, sonography of both inguinal regions and
scrotum is performed routinely. Sutures are removed (as
an outpatient) on the sixth postoperative day. From the
eighth to the tenth postoperative day, we recommend
return to work and resumption of normal physical activity. All patients are included in a follow-up program and
requested to attend a specific hernia consultation four
weeks and one, three and five years postoperatively.
CONCLUSION
Laparoscopic hernia repair is a well-standardized repair
technique, suitable for all types of inguinal and femoral
hernias. The procedure combines highest patient comfort
with low morbidity and recurrence rates. However, fundamental training in laparoscopic surgery is an important
prerequisite for good results. When laparoscopic procedures are established in a surgical department, this technique can be performed on a routine basis, even as a
teaching operation.
REFERENCES
1
Rives J, Nicaise H, Lardennois B. A propos du traitment chirurgical

des hernies de laine. Orientation nouvelle et perspectives
thrapeutiques. Ann Med Reims 1965; 2: 193200.

2
3
6
7
8
9
10
Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron in
repairs of hernias of the groin. Surg Clin N Am 1984; 64: 26985.
Ugahary F, Simmermacher RKJ. Groin hernia repair via a gridiron
incision: an alternative technique for preperitoneal mesh insertion.
Hernia 1998; 2: 1235.
Arregui MD, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair
of inguinal hernia using a preperitoneal approach: a preliminary
report. Surg Laparosc Endosc 1992; 2: 538.
Bittner R, Leibl BJ, Kraft K, et al. Laparoscopic transperitoneal
procedure for routine repair of groin hernia. Br J Surg 2002; 89:
10626.
Felix EL, Michas C, McKnight RL. Laparoscopic repair of recurrent
groin hernia. Surg Laparosc Endosc 1994; 4: 2004.
Nyhus LM. Individualization of hernia repair: a new era. Surgery
1993; 114: 12.
Schumpelick V, Treutner KH, Arlt G. Inguinal hernia repair in
adults. Lancet 1994; 344: 3759.
Ingoldby CJH. Laparoscopic and conventional repair of groin
disruption in sportsmen. Br J Surg 1997; 84: 21315.
EU Hernia Trialists Collaboration. Repair of groin hernia with
synthetic mesh meta-analysis of randomized controlled trials.
Ann Surg 2002; 235: 32232.
11
12
13
14
15
16
17
Heikkinen TJ, Haukipuro K, Hulkko A. A cost and outcome

comparison between laparoscopic and Lichtenstein hernia
operations in day-case unit. A randomized prospective study. Surg
Endosc 1998; 12: 1199203.
Bittner R, Kraft B, Kuckuk B, et al. Ultrasound examination in
laparoscopic/endoscopic hernia surgery. In: Fitzgibbons RJ, Jr,
Greenburg AG, eds. Nyhus and Condons Hernia, 5th edn.
Philadelphia: Lippincott Williams & Wilkins, 2002: 95102.
Semm K. Operative Manual for Endoscopic Abdominal Surgery
Operative Pelviscopy Operative Laparoscopy. Chicago: Year Book
Medical Publishers, 1985.
Leibl BJ, Bittner R, Schmedt CG. Scrotal hernias: a contraindication
for an endoscopic procedure? Surg Endosc 2000; 14: 28992.
Schmedt CG, Dubler P, Leibl BJ, et al. Simultaneous bilateral
laparoscopic inguinal hernia repair: an analysis of 1336
consecutive cases at a single center. Surg Endosc 2002; 16: 2404.
Leibl BJ, Schmedt CG, Kraft K, et al. Recurrence after endoscopic
transperitoneal hernia repair (TAPP): causes, reparative techniques
and results of the reoperation. J Am Coll Surg 2000; 190: 6515.
Leibl BJ, Schmedt CG, Kraft K, Bittner R. Laparoscopic
transperitoneal hernia repair of incarcerated hernias: is it feasible?
Surg Endosc 2001; 15: 117983.
9
ED FELIX
Principles
65
66
The surgical approach to inguinal hernia repair has

undergone a slow evolution since Bassini introduced the
first true anatomical repair over 100 years ago.1 Initially,
surgeons were fixated on tissue to tissue repairs. Then,
Lichtenstein and coworkers2 and Stoppa and colleagues3
demonstrated that tension-free reinforcement of the
abdominal wall with mesh eliminates one of the major
causes of recurrence, the intrinsic or acquired weakness
of the groin; the emphasis of hernia repair then switched
dramatically. Ten years later, laparoscopic surgeons took
the tension-free repair one step further by introducing a
repair that reinforced the groin, avoided missed hernias,
and reduced postoperative recovery.
Many early attempts at a laparoscopic approach, however, fell quite short of this lofty target. There seemed to be
a wide variability in the results reported by surgeons.
Many complications as well as early failures were reported.
It quickly became apparent, however, that success with this
approach was dependent upon the level of laparoscopic
expertise of the surgeon and the ability of the surgeon to
apply proper techniques to appropriate patients.4
At first, the majority of surgeons were limited to a single
laparoscopic approach, the transabdominal pre-peritoneal
(TAPP) approach, but soon the totally extraperitoneal
(TEP) approach became a viable alternative. Arguments
between laparoscopic surgeons on which approach was
better were common, but now most surgeons realize that
each approach works well when applied appropriately in
the hands of an experienced laparoscopic surgeon.5
The purpose of this chapter is to describe an approach
to the laparoscopic TEP repair of inguinal hernias that has
resulted in a recurrence rate of less than one per cent in
over 2000 repairs in our center. The indications and
contraindications to the use of the approach, the operative
References
73
74
method, and the potential complications and their

management will be described.
PRINCIPLES
A surgeon must be experienced in conventional anterior
approaches as well as both laparoscopic approaches
(TAPP and TEP) in order to make a rational decision on
which hernioplasty best fits an individual patient and hernia. The laparoscopic approach that is chosen depends
upon the surgeons level of experience, the type of hernia
present, and the patients past history. For most patients, I
favor the TEP approach because it avoids entering the
peritoneal cavity, it requires less operative time, and it has
less potential for complications than the TAPP approach.
There are, however, a few exceptions. The TAPP approach
is preferred if the patient has an incarcerated hernia,
because this approach allows for an accurate analysis of
what is incarcerated and its viability, as well as safe and
usually easy reduction of the contents of the hernia.
When the hernia is incarcerated, balloon dissection of the
extraperitoneal space may lead to a large tear in the
peritoneum or injury to incarcerated omentum, bowel or
bladder. The extraperitoneal approach and especially the
use of a balloon dissector should be avoided if the hernia
cannot be reduced after the induction of anesthesia.
In female patients with abdominal pain, the etiology
of the pain may be in question. When a surgeon needs to
differentiate between pain secondary to a groin hernia
and other possible causes, such as endometriosis, one
should perform a diagnostic laparoscopy followed by a
TAPP repair when indicated. For female patients where
the diagnosis is certain, a TEP technique is preferred. The

presence of a Pfannenstiel incision is common in many
female patients because of a previous cesarean section or
pelvic surgery, but this should not interfere with the TEP
dissection because a Pfannenstiel incision is really a midline fascial incision.
Some previous operations, abdominal incisions, or
treatments may preclude adequate or safe dissection of
the extraperitoneal space. Previous pelvic irradiation or
radical prostatectomy can prevent separation of the peritoneum from the abdominal wall. Balloon dissection of
the extraperitoneal space may result in injury to the bladder or a large rent in the peritoneum. A lower-abdominal
incision crossing the rectus sheath can obstruct the safe
passage of the dissector. If the dissector is forced through
the obstruction, the peritoneum will tear and an intraabdominal visceral injury may result. A transverse incision
is not a contraindication to the use of the extraperitoneal
approach, but if resistance is experienced when passing the
dissector, then the procedure should be converted to a
TAPP approach. A midline incision is usually not a problem when using the TEP approach. The dissector slides
toward the pubis parallel to the incision. The peritoneum
along the midline will separate from the abdominal wall
when the balloon is inflated, or it can be dissected manually after the trocars are placed. If bilateral repairs are
planned, however, then there is a small chance that a
previous midline incision will prevent dissection of the
opposite side. In this case, the surgeon may initiate the
procedure as a TEP approach and convert to the TAPP
approach when, or if, this becomes necessary.
The laparoscopic approach is ideally suited for recurrent hernias. The surgeons view of the posterior wall is
unobstructed and allows for complete identification of
the site of recurrence and repair of the entire posterior
floor. The decision of whether a TAPP or TEP approach
should be employed is dependent upon the expertise of
the surgeon. The dissection of the recurrent indirect sac
can be difficult using the extraperitoneal technique and
requires more skill than that of a primary repair. With
experience, however, this difference in degree of difficulty disappears, and the surgeon should base the hernioplasty choice on other factors.
The extraperitoneal dissection of large scrotal hernias
is similar to that of recurrent hernias, in that the separation of the indirect sac can be quite difficult.6 To avoid
problems, the surgeon should use the TAPP approach
until he or she has adequate mastery of some of the special maneuvers required to deal with a long scrotal sac.
The age of the patient may influence the type of
hernioplasty chosen. In general, laparoscopic hernioplasty should be reserved for adults. In a few cases, the
patient that is a minor by chronological age may be fully
mature and have an adult-type hernia or even a recurrent
hernia. Only then should the laparoscopic approach be
elected in children. At the other extreme are patients over

70 years of age. Some have suggested that laparoscopic
repair should be limited to working younger adults. It is
our experience, however, that patients of all ages benefit
from the laparoscopic approach, especially regarding the
rapid recovery and return to normal activity.
We recommend that patients who are not candidates
for general anesthesia should have an open hernioplasty
under a local anesthetic. Although several centers have
reported success using local and regional anesthesia for
extraperitoneal repairs,7 it has been our experience that
some patients will become anxious if carbon dioxide
enters the peritoneal cavity, necessitating conversion to a
general anesthetic. We would reserve laparoscopic repair
for patients who are candidates for general anesthesia,
even if the case is to be performed using a local or regional
technique. An absolute contraindication to laparoscopic
hernioplasty is the presence of infection. Neither the
TAPP nor the TEP approach should be used in the face of
local or systemic infection because of the risk of infecting
the mesh.
Anatomy and pathology
Understanding the anatomy of the groin has never been
easy, but it has always been important to the performance
of a successful inguinal hernia repair. Because the posterior anatomy of the groin is being viewed in an unfamiliar way, it can be even more difficult to understand it.
Consequently, without a complete knowledge of the
normal and pathological anatomical structures of the
posterior groin, any laparoscopic posterior repair will
be doomed to failure. (See Chapter 6 for an overview of the
anatomy/physiology of the inguinal region.) The easiest
way to learn the normal anatomy of the posterior wall is to
first view it through a transabdominal route (Figure 9.1).
Once the surgeon understands the normal and pathological aspects of the posterior anatomy via a TAPP approach,
then dissection of the extraperitoneal space and exposing
the anatomy of the posterior space via a TEP approach can
be undertaken. Because the anatomical structures are not
obvious until the dissection is completed, it is key that the
surgeon understands what is being dissected in order to
prevent becoming lost or confused. Serious complications
to major vessels and nerves can occur, especially when
there is a large indirect or femoral hernia.
To proceed without injuring normal structures,
the surgeon must identify certain landmarks. Once the
extraperitoneal space is developed, identification of the
pubis will allow proper orientation of the other structures. The next landmark is the inferior epigastric vessels,
Totally extraperitoneal approach 67
(a)
(a)
(b)
(b)
Figure 9.1 (a) Indirect hernia viewed via the intraperitoneal

approach. (b) Peritoneum opened. IND, indirect hernia;
INF, inferior epigastric vessels; IPT, iliopubic tract; TV, testicular
vessels; VAS, vas deferens.
(c)
Figure 9.3 Femoral hernia.
Figure 9.2 Extraperitoneal view of the groin. C, cord; DIR, direct

hernia; IL, iliac vessels; IND, indirect hernia; INF, inferior
epigastric vessels.
which separate the indirect from the direct hernia and

lead the surgeon to the major vessels of the pelvis (Figure
9.2). Sometimes, a large femoral hernia can obscure the
major vessels, but the surgeon can become reoriented
by locating the inferior epigastric vessels (Figure 9.3).
Additionally, these vertical structures mark the location
of where the lateral dissection of the indirect hernia
begins. The final important landmark is the iliopubic
tract (Figure 9.4). The identification of this is essential to
avoid injury to several cutaneous nerves and dissection
of any cord lipoma that may be present.
Figure 9.5 Balloon dissector and Hasson trocar.

Figure 9.4 Recognizing the iliopubic tract. CL, Coopers
ligament; DIR, direct hernia; INF, inferior epigastric vessels;
IPT, iliopubic tract.
Inguinal hernia repair does not require extensive preoperative testing, but it does require determination of
whether the patient is a candidate for general anesthesia.
If general anesthesia is thought to be safe, then the surgeons next step is to make sure that there are no other
contraindications to laparoscopic hernia repair. If there
are none, then the most appropriate laparoscopic
approach can be selected, as outlined earlier. Before
proceeding to the operating room, however, a complete
examination of both groins by the operating surgeon is
essential. If the surgeon actively looks for a possible
hernia on the contralateral side, then we have shown in a
prospective study that very few contralateral hernias will
be missed.8 It is not necessary to expose the opposite side
to look for a second hernia during a TEP repair if the surgeon has performed a proper preoperative examination.
In addition, the surgeon should determine whether the
hernia is reducible. If it is incarcerated, then a TAPP
approach should be chosen. This avoids complications
caused by the blind dissection of the incarcerated hernia
sac. The TAPP approach also allows the surgeons ability
to evaluate the viability of the incarcerated contents.
Instrumentation
TEP hernioplasty does not require many specialized
instruments. A balloon dissector and balloon Hasson
trocar (Figure 9.5) make the extraperitoneal dissection
easier and simpler for most surgeons, but they are not
mandatory. We use a straight 10-mm endoscope, but
some surgeons prefer an angled scope. Unipolar scissors
for dissection and a bipolar coagulator to control bleeding are useful. At least two atraumatic graspers are
needed to perform the dissection, and endoloop sutures
to ligate an indirect sac or a peritoneal tear are suggested.

Rarely, a suction irrigator will be needed to clear blood
from the extraperitoneal space and decrease groin and
perineal ecchymosis postoperatively.
A full laparotomy set-up is not required, but a Mayo or
68 inch curved clamp is needed to dissect the fat and
muscle at the umbilicus. A number 11 scalpel blade is used
to incise the fascia, and two S retractors facilitate the dissection and retraction of the fascia and muscle. Two 5-mm
trocars are used for the placement of the instruments that
are used in the dissection of the pre-peritoneal space.
Polypropylene mesh is the mainstay of the laparoscopic repair. Usually, a 15 ! 15-cm mesh is used and
trimmed to fit the posterior wall. The mesh is anchored to
the abdominal wall with 5-mm tacks supplied in a multifire gun. Recently, however, we have used a preformed
mesh that does not require fixation of any kind. The recurrence rate remains the same, but the risk of nerve injury is
lowered. In a small number of cases in which we feel fixation is required, such as multi-recurrent hernias or where
the mesh will not lay flat against the wall, we use a regular
mesh and cut it to fit the space.

The room set-up is simple, requiring one surgeon, a
nurse and a video monitor. The patient is positioned
with both arms tucked at his or her side and with a slight
head-down position. The surgeon stands on the side of
the patient opposite the hernia and the scrub nurse/assistant stands on the opposite side. The monitor is placed
at the foot of the operative table and the Mayo stand is
over the legs. The insufflator should also be in plain view
of the surgeon. A single light is positioned directly over
the periumbilical incision to help with the initial exposure of the fascial layers.
Very few instruments are required for extraperitoneal
dissection and hernia repair. They should be set up on the
Mayo stand so that either the surgeon or the nurse can

reach them readily. If a preformed mesh is used, then both
left- and right-sided meshes must be kept in the room.
the procedure should be converted to a TAPP approach.

When the pubis is palpated with the dissector, the balloon
is inflated. The operator views the progress of the dissection directly via the laparoscope in the dissector. After completing the balloon dissection, the balloon is removed and
replaced with a specialized Hasson trocar that seals the
extraperitoneal space. The dissected space is then insufflated with carbon dioxide up to 12 mmHg. We use lower
pressures (810 mmHg) if the patient is thin or elderly.
The anterior and posterior rectus sheaths create a tunnel
that opens into the dissected extraperitoneal space. When
the tunnel is short, it does not interfere with exposure or
placement of the other midline trocars; if it is very long,
the available space will be limited and the exposure will be
poor. In this case, the sheath should be cut back with
laparoscopic scissors. This maneuver will open up the
exposure, greatly facilitating the rest of the repair.
Three trocars are placed in the midline: a 10-mm
Hasson just below the umbilicus for the camera, a 5-mm
trocar just above the pubis, and a second 5-mm trocar
between these two trocars in the midline. The second
trocar is positioned as close as possible to the subumbilical camera trocar in order to leave space between the
lowest trocar and the pubis. The inferior trocar is positioned approximately three fingers below the middle
trocar to prevent sword fighting of the instruments and
still allowing the lowest trocar to be above the level of the
mesh. The surgeon must watch the entry of each trocar
into the extraperitoneal space in order to prevent the laceration of a small branch of the inferior epigastric vessels
or penetration into the peritoneal cavity. We anchor each
trocar to the skin with a specialized adhesive strip to
prevent them from slipping in and out of the abdominal
wall during instrument manipulation.
The exposure of Coopers ligament begins with the
dissection of the posterior aspect of the abdominal wall
by the gentle sweeping off of any tissue remaining on the
pubis. If a direct hernia is present (Figure 9.6), it is completely reduced at this point. This can be accomplished
Operative technique
We begin the procedure with a small transverse skin incision 2.5 cm lateral to and just below the umbilicus on the
side of the hernia (or the dominant hernia if bilateral
hernias are present). By avoiding the midline of the
fascia, we avoid entering the peritoneal cavity where the
anterior and posterior rectus sheaths merge. We choose
the side of the dominant hernia because we use a balloon
dissector that will dissect more completely on the side
that it is placed. This makes the rest of the dissection simpler. We identify the anterior rectus sheath by carefully
spreading the subcutaneous fat with a Mayo clamp. The
small vessels in the fat should not be torn at this point,
because bleeding in the tiny hole will make identification
of the anterior rectus sheath difficult. Two S retractors
are placed in the wound and used to expose the white
fibers of the fascia. An 11 blade is used to incise the fascia
exposing the rectus muscle. One of the S retractors is
placed under the muscle like a shoehorn; the muscle is
elevated, thereby allowing visualization of the posterior
sheath. A finger is used to dilate the space in preparation
for the placement of a balloon dissector.
Because the posterior rectus sheath usually ends at the
line of Douglas, an instrument such as the balloon dissector can be passed on top of the sheath, allowing it to automatically fall into the extraperitoneal space. The dissector is
placed behind the rectus muscle with its tip on the posterior rectus sheath. Aiming it slightly upward, we gently slide
on top of the sheath toward the pubis until the pubic bone
is palpated. If resistance is encountered, then the dissector
must not be forced into the space because it will tear the
peritoneum. A second attempt to pass the instrument can
be tried after dilating the space with a finger, but if that fails
(a)
(b)
Figure 9.6 Reducing the direct hernia. INF, inferior epigastric vessels.
Figure 9.7 Lipoma of the cord.
with gentle traction on the peritoneal attachments to the

defect. The peritoneum usually peels away from the transversalis fascia, allowing it to balloon into the direct defect.
When the direct hernia is not reduced by these maneuvers, we incise the fascial defect on the superior aspect to
release the incarcerated hernia contents. The direct sac
should not be ligated because the bladder may make up
the medial aspect of the sac. In this situation, ligation of
this sac could result in an injury to the bladder.
After dissection of the direct floor, the femoral area
must be examined. The iliac vein will be visible just lateral
to Coopers ligament. If it is not visible, then an incarcerated femoral hernia is probably covering the vein. The
surgeon must reduce the hernia carefully so that the small
vessels in the femoral canal are not avulsed. If the hernia
is stuck in the canal, then an incision in the medial and
superior edge of the femoral ring will release the hernia.
The dissection of the lateral floor is initiated with
identification of the inferior epigastric vessels. The fat
and loose connective tissues are dissected off the posterior abdominal wall just lateral to these vessels until the
peritoneum is identified. If there is a lipoma of the cord,
then it will be lateral to the peritoneal sac and cord
(Figure 9.7). It is pulled out of the internal ring and left
in the retroperitoneum, out of the operative field.
Sometimes, only a slip of fat will be covering the iliopubic tract, but it may lead to a very large lipoma in the
scrotum. The fibers of the iliopubic tract must be identified to prevent leaving behind a lipoma. Cautery should
be avoided in this part of the dissection because the
lateral femoral cutaneous nerve and femoral branch of
the genitofemoral nerve are directly under the lipoma.
Dissection of the cord and possible indirect hernia is
now started. If there is no indirect hernia, then the peritoneal edge will be set back from the internal ring. The
edge of the peritoneum is lifted off the testicular vessels
with atraumatic graspers and dissected cephalad as far
as possible. This maneuver allows the mesh repair to be

covered by the peritoneum and not be lifted by it when the
carbon dioxide is evacuated. To prevent the peritoneum
from lifting the mesh on the medial aspect, the peritoneum must also be dissected off the vas deferens, as originally described by Stoppa in the open posterior repair.
When an indirect hernia is present, the sac will be found
anterior and lateral to the cord structures (Figure 9.8).
If the sac is broad-based, it may extend medially to involve
the vas deferens. We use a hand-over-hand technique to
dissect the sac off the cord structures. The peritoneum
must be dissected cephalad so that it does not contact the
inferior edge of the mesh. If the peritoneum or any of its
filamentous attachments to the canal are left under the
mesh, they will elevate the mesh and lead to an early recurrence. A short or small sac is easily delivered out of the
internal ring, but it may be difficult and traumatic to completely dissect off the cord a very long sac that descends
into the scrotum. In the latter case, the sac should be
transected. The superior lateral edge of the peritoneum is
incised first because the testicular vessels and the vas deferens may be quite adherent to the undersurface of the sac.
The vas deferens will be on the medial side and the testicular vessels on the lateral side. To avoid injury to these cord
structures, they must be identified before the inferior peritoneal surface is cut. A mass ligation of the sac should be
avoided because the spermatic cord could be inadvertently
incorporated into the ligated tissue.
After the proximal sac is completely separated from
the distal sac, it is dissected off the cord structures and
ligated with an endoloop. If the intraperitoneal carbon
dioxide causes the peritoneum to balloon outward into
the operative field, the surgeon can usually dissect the
peritoneum further cephalad in order to hold it out of
the field of vision. Before ligating the indirect sac, it is
probably better to wait until the mesh is in place because
this will allow the peritoneal pressure to be in equilibrium with the extraperitoneal space and exposure will
not be compromised. At the end of the procedure, the
indirect sac and any other tears in the peritoneum are
closed to prevent the development of internal hernias or
adhesions to the mesh. If carbon dioxide is trapped in the
peritoneal cavity, it is vented with a Veress needle to prevent postoperative shoulder discomfort at this point.
At the onset of a TEP repair, one cannot tell whether
there is an indirect component to the hernia until the
lateral dissection is completed. This is in contrast to the
TAPP approach, in which an indirect hernia is almost
always obvious on the initial inspection of the pelvic
floor. Because of this, it is mandatory that the entire
posterior floor be dissected in every TEP repair, even if a
direct or femoral hernia is not immediately apparent.
This is critically important because up to 30 per cent of
patients will have an indirect hernia in addition to the
obvious direct or femoral hernia defect.9 Historically,
(a)
(b)
(c)
(d)
Figure 9.8 Reducing the indirect sac. IND SAC, indirect sac.
14 per cent of recurrent hernias after open repairs are

due to missed hernias, and the laparoscopic approach
potentially eliminates this cause of failure.
The mesh repair is begun after dissection of all potential hernias. A 15 ! 15-cm sheet of polypropylene flat
mesh is cut to fit the pelvic floor and anchored to the
wall. Conversely, a preformed mesh can be used without
anchors. Because the pelvic floor is wider from top to
bottom medial to the iliac vessels, the medial half of the
mesh is wider than the lateral side. The mesh drapes over
Coopers ligament when it is placed into the pelvis. We
place a colored absorbable stitch at the bottom of the
medial side of the mesh as a marker. We do this with both
our flat tailor-cut mesh and our preformed mesh to
make orientation of the mesh much simpler and quicker.
We place the polypropylene mesh into the extraperitoneal space by removing the laparoscope, grasping the
mesh on one end with a 5-mm instrument, and dragging
it into the extraperitoneal space via the 10-mm port. We
do not find it necessary to roll up the mesh tightly before
placing it, as some have described. The laparoscope is
replaced and the mesh pushed gently through the 10-mm
port the rest of the way into the pelvis with the scope.
Once the mesh is fully in the extraperitoneal compartment, it is rotated using two graspers until the tagged
corner is in place below Coopers ligament or pubis. The
Figure 9.9 Mesh placement.
mesh is large enough to cover all three potential hernia

sites in every patient. The total size of the mesh must be
tailored to the size of the patients pelvis. When the mesh
is smoothed out, it overlaps the pubic bone and crosses
the midline (Figure 9.9). Folds or wrinkles in the mesh
should be avoided because they lead to increased scar or
adhesion formation and can be the cause of chronic pain
in the future.
The peritoneum and any lipomas of the cord must be

well behind the inferior edge of the mesh before the mesh is
fixed in place and/or the carbon dioxide is evacuated. As
noted above, if tissue attachments of the sac to the distal
cord remain under the mesh after the mesh is positioned,
then the mesh may be lifted laterally in the postoperative
period. The creation of a window between the vas deferens
and the testicular vessels will allow the surgeon to be certain
that a tail of sac has not been left behind. To accomplish
this, the peritoneum on the vas deferens must be dissected
completely from underneath the mesh. A large sac or
lipoma should be placed on top of the mesh after the mesh
is anchored and before the carbon dioxide is evacuated.
These maneuvers prevent the mesh from being lifted up by
the peritoneal edge when the carbon dioxide is released.
If the testicular vessels do not lie flat against the pelvic
floor, as happens most often in very thin patients and
patients with recurrent hernias, a double-buttress repair, as
originally described for the TAPP hernioplasty, can be utilized.10 In this technique, a polypropylene mesh with a slit
in the lower third is used to secure the indirect defect. The
slit is placed around the cord and loosely re-approximated
over Coopers ligament (Figure 9.10). A second mesh,
like that described for conventional TEP repair, is placed
over the mesh with the slit. Both meshes are cut from
15 ! 15-cm sheets of polypropylene and each measures
approximately 14 ! 10 cm. The second mesh is placed to
prevent a recurrence through the slit and completes the
repair of the direct and femoral areas.
If fixation of the mesh is to be used, this is the next
step. The number of points of fixation has decreased
since our technique was first described.11 It is important
to recognize that the iliopubic tract is essential in the
placement of these anchors. This tract is a white fibrous
band running transversely along the lower edge of the
internal ring. In some patients it is quite prominent and
obvious, while in others it is subtle and barely visible
(Figure 9.11). We confirm the location of the tract by
placing one hand externally on the abdominal wall while
the other hand presses the stapler internally against the
wall. If the tip cannot be felt with the opposite hand, then
it is unsafe to place a staple or tack at that site. The
instrument is below the iliopubic tract and in an area
where the nerves (femoral, genital branch of the genitofemoral, lateral femoral cutaneous) are at high risk
of injury. No anchor should be inserted into the mesh
and the posterior wall unless the anchoring device can
be felt with the opposite hand. It is important not to
press so hard as to force the staples (or other fixation
device) deep into the muscle layers because this can
result in an injury to a more superficial nerve, such as the
ilio-inguinal.
The first tacks or staples are placed through the mesh
into Coopers ligament to stabilize the mesh, which allows
the surgeon to fan out the mesh in a lateral direction so
(a)
(b)
Figure 9.10 TAPP double-buttress mesh approach.
Figure 9.11 Mesh anchored with tacks.
that any wrinkles or folds are removed. If aberrant obturator vessels are present coursing over the pubis, they
must be avoided otherwise serious bleeding can result.
Other anchors are placed into the mesh and transversalis
fascia medial to the inferior epigastric vessels, whereupon
the mesh is smoothed out in a lateral direction, making

Mesh
Mesh placement
Spermatic cord
Iliac vessels
Vas deferens
Figure 9.12 Preformed mesh (3D Max, BARD).
sure that the peritoneum and lipoma of the cord are

well cephalad to the posterior edge of the mesh. Lateral
anchors are inserted using the bimanual technique
described above, so that damage to the neural structures
below the iliopubic tract is prevented. The purpose of the
fixation is not to strengthen the repair but rather to keep
the mesh in place until natural in-growth occurs. The
number of fixation points has therefore decreased as our
understanding of this repair has grown.
More recently we have begun using a preformed mesh
that does not require fixation (Figure 9.12) (see Chapter 3).
The results over the last two years equaled our earlier
results with anchors. In the newer technique, the mesh,
which has a molded contour, fits into the pelvis and is
not fixed with anchors. Care must be taken to use a mesh
that is large enough to be held in place once the carbon
dioxide is removed.
The final phase of the procedure is evacuation of the
carbon dioxide. It is released slowly through one of the
5-mm ports while the lateral inferior corner of the mesh
is held against the wall with a grasper in the other 5-mm
port. This procedure ensures that the peritoneum will
cover the mesh rather than lift the inferior edge. The
peritoneum will rest on top of the mesh, holding it in
place. If the peritoneum lifts the mesh, the mesh must be
manipulated or trimmed until it is covered properly by
peritoneum. If there are bilateral hernias, we release the
gas very slowly while watching both meshes and holding
the corners of each mesh with a grasper as needed. The
small trocars are removed, and the rest of the extraperitoneal gas is evacuated through the umbilical port. If carbon dioxide is trapped within the peritoneal cavity, it is
evacuated from the peritoneal cavity with a Veress
needle. The fascia of the 10-mm port is re-approximated
with absorbable suture. Gas trapped in the scrotum can
also be eliminated with a small needle at the end of the
procedure, if deemed necessary.
Postoperative management for patients undergoing
laparoscopic inguinal hernioplasty is fairly standardized.
The surgery is usually performed under general anesthesia and patients are observed for approximately two to
three hours before discharge. They are allowed to resume
normal activities as soon as they feel that they are
capable. No restrictions are placed upon the patients. We
allow patients to return to work and physical activity as
soon as their pain tolerance allows them to do so. On
average, patients are back to 80 per cent of full activity in
less than a week and are able to perform fairly physical
activity, such as riding a bicycle, by the second week.
Some patients develop a seroma at the site of the hernia.
This, in fact, may mimic a recurrence, but it will reabsorb in
90 per cent of patients by six weeks. If it is not uncomfortable for the patient, it is observed and then aspirated only
if it is present after six weeks and if it appears that it is
not resolving. We have not found it necessary to use
ultrasonography to diagnosis a seroma, but rather have
been able to rely on physical exam alone. On only one occasion did we misinterpret the findings as a recurrent hernia
when it was actually a contained fluid collection.12
Using our extraperitoneal technique with and, more
recently, without anchors, we have maintained a recurrence rate of less than 0.5 per cent over the last ten years.
Short- and long-term morbidity, convalescence and satisfaction of all patients have been excellent. Because the
procedure can be performed rapidly and in an outpatient
setting, the overall cost has remained comparable to
other methods of hernia repair. The keys to a successful
laparoscopic technique are an understanding of the
posterior anatomy, perfection of the laparoscopic skills
required to perform advanced laparoscopic surgery,
and knowledge of the limitations of the laparoscopic
approach to inguinal hernia repair.
REFERENCES
1
2
3
4
5
6
Bassini E. Nuovo me todo cura radicale dellernia inguinale. Arch

Soc Ital Chir 1887; 4: 380.
Lichtenstein IL, Shulman AL, Amid PK, et al. The tension-free
hernioplasty. Am J Surg 1989; 157: 18893.
Stoppa R, Rives JL, Walamount C. The use of Dacron in the repair
of hernias of the groin. Surg Clin N Am 1984; 64: 26985.
Felix E, Scott S, Crafton B, et al. Causes of recurrence after
laparoscopic hernioplasty a multicenter study. Surg Endosc 1998;
12: 22631.
Felix E, Michas C, Gonzalez H. Laparoscopic hernioplasty. Tapp vs.
Tep. Surg Endosc 1995; 9: 9849.
Felix E, Michas C, Gonzalez H. Laparoscopic repair of recurrent
hernia. Am J Surg 1996; 172: 5804.
Ferzli G, Sayad P, Huie F, et al. Endoscopic extraperitoneal

herniorrhaphy. A 5 year experience. Surg Endosc 1998; 12:
131113.
8 Felix E. Laparoscopic approach to bilateral hernias. Sages abstracts
1999.
9 Felix E, Michas C, Gonzalez H. Laparoscopic hernioplasty: why it
works. Surg Endosc 1997; 11: 3641.
10 Felix EL, Michas C. Double-buttress laparoscopic herniorrhaphy.
11 Felix E, Michas C, Mcknight R. Laparoscopic herniorrhaphy.
Transabdominal preperitoneal floor repair. Surg Endosc 1994;
8: 1003.
12 Felix E. A unified approach to recurrent laparoscopic hernia
repairs. Surg Endosc 2001; 15: 96971.
10
Femoral and pelvic herniorrhaphy
CHRISTINE A. ELY AND MAURICE E. ARREGUI
Demographics
History of repair
Techniques
Postoperative care
75
76
76
77
Femoral and pelvic hernias are much less common than

inguinal hernias. If these hernias are diagnosed preoperatively, they are certainly amenable to laparoscopic
repair. However, if they are not diagnosed preoperatively,
these cases are the perfect situation for the application of
diagnostic laparoscopy followed by laparoscopic repair.
Inguinal ligament
Less common
Femoral hernia
(anatomically
less weak)
Most common
Inguinal hernia
(Anatomically
weakest)
Pectineus muscle
Rare
Obturator hernia
(Anatomically least weak)
Figure 10.1 Surgical anatomy of the obturator and inguinal

region. Lateral view of the right side of the pelvis, showing the
sites of inguinal, femoral and obturator hernias. From Carter JE.
Hernias. In: Howard FM, Perry CP, Carter JE, et al., eds. Pelvic
Pain: Diagnosis and Management. Philadelphia: Lippincott
Williams & Wilkins, 2000: 385413, with permission.
Rare and unusual hernias

Conclusion
References
77
81
82
In this chapter, we will focus on our technique of

repair of femoral and obturator hernias, since the obturator hernia is by far the most common of the pelvic
hernias (Figure 10.1). Our technique and postoperative
care will be reviewed. In addition, we will comment on
some other unusual hernias that may be encountered,
such as sciatic, supravesicular and perineal hernias, as
well as prevascular hernias, lipomas of the cord, and low
Spigelian hernias.
DEMOGRAPHICS
Femoral hernias are much less common than inguinal
hernias, with an incidence of two to four per cent of all
groin hernias.1 They are more common in women, with
reported male/female ratios of 1 : 1.6 to 1 : 3.1,2 The incidence and rate of repair increase with age.1 The femoral
hernia is located most frequently on the right.1 Obturator
hernias, although extremely rare, are the most common
of the pelvic hernias. Their incidence is reported to be
0.050.07 per cent of all groin hernias. They typically
occur in an emaciated, dehydrated, multiparous female
patient. The patients may have a positive Howship
Romberg sign or a palpable upper-thigh mass. The
HowshipRomberg sign is positive when medial thigh and
hip pain is created or exacerbated by adduction and
medial rotation of the thigh and relieved by thigh flexion.3
More often, however, symptoms are vague, and patients
frequently present with small-bowel obstruction with
either intermittently incarcerating or strangulated small
bowel. Ones level of suspicion, therefore, needs to be high.
These vague symptoms and small-bowel obstructions can

occur with both femoral and obturator hernias.
d
HISTORY OF REPAIR
Femoral hernias have been repaired anteriorly with and
without mesh, or with a mesh plug, as well as via the
suprainguinal ligament approach or the infrainguinal
approach. They have been repaired posteriorly via open
pre-peritoneal approaches and, most recently, laparoscopically using the transabdominal pre-peritoneal (TAPP) or
totally extraperitoneal (TEP) approach. Reports have
varied with regards to complications, with the rate of
recurrences varying from poor to good.48 Reports are
now emerging regarding the success of the laparoscopic
repair of these hernias.8
A variety of approaches for repair of the obturator
hernia has been used. The abdominal, inguinal (extraperitoneal or retroperitoneal), retropubic, and obturator
approaches have been described, as well as different combinations of these incisions. The abdominal approach has
seemed to be the best approach because it provides simultaneous diagnosis and repair and allows the resection of
compromised bowel if necessary. The obturator defect has
been closed with sutures or mesh, or with tissue, such as a
flap of adductor longus, the round ligament, or a portion
of the bladder wall.9,10 Most recently, the laparoscopic
approach has been applied to these hernias (Figures 10.2
and 10.3). The reports are few but the results are favorable,
and this approach also affords the above-mentioned
benefits of the open abdominal approach.
a
c
Figure 10.2 Transperitoneal view of (a) indirect inguinal hernia,

(b) direct inguinal hernia, (c) femoral hernia, (d) inferior
epigastric vessels, and (e) median umbilical ligament.
b
a
c
d
TECHNIQUES
If the hernia is discovered preoperatively, our approach
of choice is the extraperitoneal approach. If the hernia is
discovered during diagnostic laparoscopy, either it may
be repaired via the TAPP approach or the pre-peritoneal
space may be insufflated and an extraperitoneal approach
may be used, as described below.
We perform extraperitoneal repair of indirect and
direct inguinal hernias. Femoral hernias and obturator
hernias are repaired in a similar fashion. As we will point
out, the most important concept is wide coverage of all
hernia orifices with mesh to prevent recurrence.
General endotracheal anesthesia is used. After infiltrating with 0.5 per cent bupivacaine with epinephrine
(adrenaline), a 5-mm incision is made in a skin fold in
the inferior portion of the umbilicus. A Veress needle
is introduced for insufflation of carbon dioxide to a
pressure of 15 mmHg. A 5-mm trocar is then inserted,
followed by a general inspection of the peritoneal cavity
Figure 10.3 Intraoperative view of obturator foramen. (a) Plug

of fat in obturator foramen, (b) Coopers ligament, (c) obturator
nerve, and (d) obturator artery.
with a 5-mm, 30-degree viewing laparoscope. Using the

transperitoneal view, an additional 5-mm trocar is
placed on the ipsilateral side about one fingers breadth
below the level of the umbilicus over the lateral aspect of
the rectus muscle just above the arcuate line of the posterior rectus sheath. The trocar is introduced carefully into
the posterior rectus space to avoid perforation of the
peritoneum. Dissection of this space is then carried out
with a long, blunt grasper inserted through the trocar.
For unilateral repair, a second 5-mm trocar is inserted in
the midline at the midpoint between the symphysis pubis
and umbilicus. For bilateral repair, the second trocar is
placed on the opposite side, in the lateral rectus space,
again just above the arcuate line.
Femoral and pelvic herniorrhaphy 77
After dissection with the blunt grasper, an additional

5-mm incision is made below the umbilicus, through
which a 5-mm trocar is placed. The 5-mm, zero- or 30degree viewing laparoscopes are then used. The dissection
of the pre-peritoneal space is carried beyond Coopers ligament into the space of Retzius below the obturator foramen. Once dissection is complete, the symphysis pubis,
the rectus muscle medially, the anatomic landmarks
surrounding Hesselbachs triangle (including Coopers
ligament and the medial iliopubic tract), the transversus
abdominus musculo-aponeurotic arch, and the inferior
epigastric vessels will be identified. Laterally, the dissection will have exposed the cord structures, the underlying
femoral vessels, and the lateral iliopubic tract. The direct,
indirect and femoral hernial orifices should be identified
easily. The obturator orifice should be seen inferior to
Coopers ligament.
Subsequent to the reduction of the herniated contents
and sac, the femoral hernia defect and the entire
myopectineal orifice of Fruchaud will be covered with
Mersilene mesh. A 15 ! 15-cm mesh is trimmed to
13 ! 15 cm. It is introduced by rolling it, grabbing one
end with grasping forceps, and pushing it through the
5-mm trocar. The mesh is unrolled and positioned over
the entire area, thereby covering the hernia defect and
all other potential sites of herniation. The mesh is not
sutured or tacked into place. In the case of an obturator
hernia, the mesh can be smaller and limited to a wide
coverage of the obturator foramen with or without fixation. We would choose to fashion the size of the mesh so
that it overlaps the defect by 34 cm. Others have fixated
the mesh, which can be done with either sutures or tacks.
Based on the above principles, however, we would not
fixate the mesh. After making sure that the prosthesis is
lying flat and in the correct space, the pre-peritoneal trocars are removed and the pre-peritoneal space is desufflated. The laparoscope is then placed in the peritoneal
cavity and the mesh is observed as the peritoneum lies on
top of it, making sure that there is no buckling of the
mesh. Then, while still under direct vision, the peritoneal
cavity is desufflated and the final trocar is removed. The
positive intra-abdominal pressure that took part in
creating the hernia itself is now used to secure the mesh
in place, obviating the need for fixation of the prosthetic
biomaterial. The subcutaneous tissue at all trocar sites is
closed with 3-0 Vicryl (Ethicon). Collodian is applied to
the skin for dressing.11
POSTOPERATIVE CARE
The patient is observed in the recovery room for one to
two hours. The majority of electively repaired patients
are then discharged home on the same day. Most patients
are given a prescription for propoxyphene for pain control. The patient is restricted only from driving for two to
three days, or until they are pain-free and not requiring
narcotic analgesics. Patients may bathe the same day and
may return to work or full activity without restrictions
when they feel ready.11
RARE AND UNUSUAL HERNIAS

In this section, we will mention some unusual hernias
that may be encountered and the principles and techniques for their management and repair.
Sciatic hernia
Sciatic hernias are very rare. A literature search on
Medline from 1966 to 1996 generated only 57 reported
cases of sciatic hernias.12 A sciatic hernia is a protrusion
of a peritoneal sac and its contents through the greater or
lesser sciatic foramen. They may be congenital or, more
commonly, acquired. The defect usually results from
weakness of the piriformis muscle from a chronic
increase in the intra-abdominal pressure, such as in pregnancy, severe constipation, surgery or trauma. It can also
occur because of atrophy of the muscle caused by neuromuscular or hip disease.13 The hernia sac can protrude
through one of three openings: the greater sciatic foramen above the piriformis muscle, the greater sciatic foramen below the piriformis muscle, or the lesser sciatic
foramen (Figure 10.4). Typical symptoms include intermittent pain radiating to the buttocks and/or posterior
thigh, with or without a palpable mass deep to the gluteus maximus muscle. The most common contents of a
sciatic hernia are small bowel, ovary (with or without the
adjacent fallopian tube), and ureter.13
The sciatic hernia has traditionally been approached
transabdominally, with reduction of the hernia, excision
of the sac, and either suture closure or mesh coverage of
the defect. Alternatively, if it is diagnosed preoperatively
and it is easily reducible, the hernia could be repaired
from a transgluteal approach.
The largest series of patients who underwent laparoscopic repair of a sciatic hernia consisted of 20 women
who underwent diagnostic laparoscopy for pelvic pain
and were found to have a sciatic hernia, which was then
repaired via laparoscopic approach.14 When a sciatic hernia was identified, the contents were reduced. The peritoneum was elevated and transected transversely with
endoscopic scissors. The obturator internus and coccygeus muscles were identified with the use of blunt dissection. A 6.0 ! 12.5-cm piece of Surgipro mesh (U.S.
Surgical) was then folded and placed into the space that
had been created by the atrophic piriformis muscle.
The authors do not describe it exactly as a plug; this is

the only description that they gave. A second, smaller
piece of mesh, trimmed to the size of the peritoneal defect,
was placed over the folded mesh. The second piece of mesh
was secured to the obturator internus fascia laterally and
the coccygeus medially with a stapler. The peritoneum
was then closed over the mesh.12 If the peritoneum is
not closed, then an inert mesh, such as DualMesh
(W. L. Gore & Associates) could be used to prevent morbidity due to adhesions.15 The repair was very successful,
with 14 patients reporting complete pain relief, and the
other six individuals noting continuing improvement
over a median follow-up of 13 months.
Laparoscopy is a great adjunct in the diagnosis of this
hernia because of the excellent view of the pelvis that
it affords. In this series of patients, all of the hernias
contained an ovary and/or the fallopian tube, which left

little room for the distention of the peritoneum contained within the hernia sac by the intra-abdominal carbon dioxide. However, the authors felt that in other cases
the increased intra-abdominal pressure could be helpful
in the detection of sciatic hernias because of the actual
stretching of the peritoneum to its limit of support, such
as the bone or muscle.12
Supravesical hernia
Supravesical hernias are rare hernias that herniate
through the supravesical fossa of the anterior abdominal
wall. They are classified as either external (those that pass
downward through the supravesical fossa to become
Anterior sacroiliac ligament
Piriformis muscle
a
Sacrospinous ligament
b
Sacrotuberous ligament
Ischial tuberosity and spine
(a)
Posterior sacroiliac
ligament
Posterior inferior
iliac spine
Greater sciatic foramen
Piriformis muscle
Sacrospinous ligament
Capsule of hip joint
Sacrotuberous ligament
Greater trochanter
Lesser sciatic foramen
Ischial tuberosity
Sciatic nerve
(b)
Quadratus femoris
muscle
Figure 10.4 Sites of potential hernias

through the sciatic foramina:
(a) suprapiriformis sciatic hernia,
(b) infrapiriformis sciatic hernia, and
(c) subspinous sciatic hernia through the
lesser sciatic foramen. From Carter JE.
Hernias. In: Howard FM, Perry CP, Carter JE,
et al., eds. Pelvic Pain: Diagnosis and
Management. Philadelphia: Lippincott
Williams & Wilkins, 2000: 385413, with
permission.
direct inguinal or femoral hernias) or internal (those

that pass downward to enter the space of Retzius)
(Figure 10.5). While the external hernias may be much
easier to diagnose, an internal hernia may present with
non-specific clinical findings, such as pelvic pain or bladder symptoms, or, as in other hernias, it may present as
small-bowel obstruction with its attendant symptoms.
Open repair has been described for these hernias, either
with or without mesh, particularly for the external hernias. Laparoscopic repair, however, is again applicable
to such hernias, using the same technique as described
above for sciatic hernias. The internal supravesical hernia
e
d
a
c
b
Figure 10.5 External supravesical hernia: (a) external

supravesical hernia orifice, (b) Hesselbachs triangle,
(c) transversus abdominus aponeurotic arch, (d) rectus muscle,
and (e) inferior epigastric vessels.
may be especially well suited for the laparoscopic approach

because of the better visualization of the entire pelvis.16
Perineal hernia
Perineal hernias are very rare true hernias, which are usually found in women. These defects are characterized by a
peritoneal sac that has herniated between the muscles and
fascia of the perineal floor.16 They can be categorized as
either anterior or posterior to the superficial transverse
perineus muscle. Anterior perineal hernias pass through
the pelvic and urogenital diaphragms, lateral to the
urinary bladder and vagina and anterior to the urethra
(Figure 10.6). They have also been referred to as pudendal,
labial, lateral and vaginal-labial hernias. These hernias are
unique to women and may contain intestine or bladder.
Posterior perineal hernias pass directly through the
components of the pelvic diaphragm. Their content is
usually omentum or small bowel, which lie between the
rectum and uterus. The hernia usually remains lateral to
the uterosacral ligament and posterior to the broad ligament. There are two possible locations, an upper posterior hernia between the pubococcygeus and iliococcygeus
muscles, and a lower posterior hernia between the iliococcygeus and coccygeus muscles, below the lower
margin of the gluteus maximus muscle. Posterior perineal
hernias may occur in men or women, but they are more
common in men.13,17
Laparoscopic repair of these hernias has been
described as an approach for maximum visualization of
Ischiocavernous muscle
Bulbocavernosus muscle
Superficial transverse
perineal muscle
External anal sphincter
Levator ani muscle
Coccygeus muscle
Gluteus maximus muscle
Figure 10.6 The female perineum, showing possible sites of perineal hernias. A primary perineal hernia may occur anterior or
posterior to the superficial transversus perineal muscle. An anterior hernia protrudes through the urogenital diaphragm, lateral to the
urinary bladder and vagina (a, b). Anterior hernias occur only in women. A posterior perineal hernia may merge between bundles of
levator ani muscle (c), or between that muscle and the coccygeus muscle, midway between the rectum and the ischial tuberosity (d).
From Carter JE. Hernias. In: Howard FM, Perry CP, Carter JE, et al., eds. Pelvic Pain: Diagnosis and Management. Philadelphia: Lippincott
Williams & Wilkins, 2000: 385413, with permission.
the pelvic cavity. The hernia is identified, the hernia

contents are reduced, and a pre-peritoneal dissection is
performed to define the boundaries of the hernia ring.
Permanent prosthetic mesh is used to cover and overlap
the defect. The mesh is tacked or stapled in place, and
reperitonealization is performed.16
Prevascular hernia
Prevascular hernias are a variation of the femoral hernia
in which the sac is situated in the femoral sheath, but
anterior to the femoral vessels rather than medial to
them as in the usual fashion.18 This hernia was originally described by Teale in 1846. Other related hernias
have been described that protrude through the femoral
sheath in strict continuity with the femoral vessels but in
various locations and are separated from the vessels only
by adventitia (Figure 10.7). There is one report of a
patient who simultaneously had two bilateral femoral
hernias (total of four femoral hernias).18
This group of hernias is rare, with a reported incidence
of 1.72.5 per cent of all femoral hernias.19 However,
recent reports suggest that these hernias may be more
common than originally recognized. In a retrospective
study in which 105 femoral hernias were identified in an
eight-year period, ten (9.5 per cent) of the hernias were of

the prevascular type.20 Repair of these hernias can be difficult because, if repaired anteriorly, the iliopubic tract
must be sutured to the vascular adventitia, which obviously holds inherent danger. The pre-peritoneal approach
has therefore been recommended as the safest and preferred approach.20 In the previously mentioned study,
all ten of the prevascular hernias were repaired using
the TEP laparoscopic technique, with good results, no
complications, and no recurrences to date.
Lipoma of the cord

A lipoma of the spermatic cord or the round ligament is an
isolated discrete collection of fatty tissue arising from the
retroperitoneal tissue, which protrudes through the internal ring and is easily separated from the cord structures
(Figure 10.8). These tissues can cause symptoms similar to
a true hernia. Lipomas can occur with or without a coexisting peritoneal defect. In a retrospective review of 280
hernia repairs, the incidence of lipoma of the cord was
found to be 22.5 per cent (63/280).21 Eighteen of these
lipomas were found in groins without hernias. Fourteen
of the patients with lipomas presented with groin pain,
and four were asymptomatic. The authors believe that
a lipoma can be the cause of a patients groin pain, and
also can be a predisposing factor to formation or recurrence of a hernia, possibly by insinuating itself into the
internal ring and dilating it over time. They recommend
removal of all lipomas, with or without a hernia, in symptomatic patients and documenting in detail those found
incidentally in asymptomatic patients because of the possibility of future symptoms.21
Hesselbach
(lateral femoral)
Teale
(prevascular)
Serafini
(retrovascular)
Femoral
Callisen-- Cloquet
Laugier
Figure 10.7 The various paravascular hernias. From Bocchi P.

Paravascular hernias. In: Bendavid R, ed. Prostheses and
Abdominal Wall Hernias. Austin, TX: RG Landes Co., 1994:
41516, with permission.
Figure 10.8 Laparoscopic view of lipoma of the cord. Cord

structures can be seen medially.
Contrary to the advantage that laparoscopy adds in all

of the above-mentioned hernia surgeries, lipomas of the
cord or round ligament are more difficult to visualize
with the laparoscope. A maneuver that is useful to help
visualize the lipoma is external compression with the
hand at the inguinal canal, thus pushing back the lipoma
through the internal ring. This should be done in any
patient who is undergoing laparoscopic evaluation for
groin pain when a hernia is not found.21 Herniated preperitoneal fat can also be found in the femoral canal,
Hasselbachs triangle, or obturator foramen, or alongside
the pre-peritoneal nerves. We have seen small herniations
along the lateral femoral cutaneous nerve, which, when
reduced, relieved the patient of the preoperative pain over
the distribution of that nerve.
When a lipoma is discovered and requires removal, it is
not always easy to pull it through a 5-mm or 10-mm trocar.
The available options are piecemeal removal of the lipoma
(which can be tedious), allowing it to remain attached at
the base and placing it between the mesh and the peritoneum, or separation of the lipoma from the cord, leaving
the lipoma in situ. The latter option is not recommended
as the lipoma may re-herniate into the inguinal canal.21
aponeurosis. This aponeurosis, or fascia, is defined as the

region between the semilunar or Spigelian line (the transition from muscle to aponeurosis in the transversus
abdominus muscle) and the lateral border of the rectus
muscle. The usual Spigelian hernia refers to a hernia
located above the inferior epigastric vessels. Hernias that
penetrate the Spigelian fascia inferior to the inferior epigastric vessels are called low Spigelian hernias (Figure
10.9). These hernias are actually traversing through
Hesselbachs triangle, which includes part of the
Spigelian aponeurosis caudal and medial to the inferior
epigastric vessels. One can easily appreciate that these
hernias are very easily confused with direct inguinal hernias and most likely are underreported because of misrepresentation as direct inguinal hernias. Low Spigelian
hernias, if diagnosed properly, are usually diagnosed
intraoperatively. The hernial orifice is usually small and
has rigid, sharply defined edges. These hernias may also
be repaired laparoscopically, which can be done in a preperitoneal fashion, as described for repair of a direct
inguinal hernia.22,23
CONCLUSION
Low Spigelian hernia

A Spigelian hernia is a rare hernia that protrudes
through a congenital or acquired defect in the Spigelian
(c)
(a)
(d)
(f)
We have described in detail our approach for laparoscopic

repair of femoral and obturator hernias. The repair is no
different in principle to that of direct or indirect inguinal
hernias. The most important step to remember is that
wide coverage of all of the possible hernia orifices is necessary to prevent recurrence. In addition, we have stressed
the usefulness of the laparoscopic approach because it
gives a better total visualization of the entire inguinal and
pelvic regions than the open technique. This is especially
helpful when one encounters some of the more unusual
hernias that have been mentioned in this chapter. Finally,
we have described some of the unusual inguinal and
pelvic hernias that may be encountered and the basic
principles of management of them.
REFERENCES
(b)
(e)
Figure 10.9 Anatomy of the low Spigelian hernia. Shaded area:

Spigelian aponeurosis. (a) Region of Spigelian hernia; (b) region
of low Spigelian hernia; (c) Spigelian line; (d) lateral border of
rectus abdominus muscle; (e) inferior epigastric vessels; and
(f) transversus abdominus muscle. Modified from Bennett D.
Spigelian hernias. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus
& Condons Hernia, 5th edn. Philadelphia: Lippincott Williams &
Wilkins, 2002: 40513, with permission.
3
4
5
6
7
Rutkow I. Epidemiologic, economic, and sociologic aspects of

hernia surgery in the United States in the 1990s. Surg Clin N Am
1998; 78: 94151.
Sandblom G, Haapaniemi S, Nilsson E. Femoral hernias: a register
analysis of 588 repairs. Hernia 1999; 3: 1314.
Haith LR, Simeone MR, Reilly KJ, et al. Obturator hernia:
laparoscopic diagnosis and repair. JSLS 1998; 2: 1913.
Koontz AR. Femoral hernia. Arch Surg 1952; 64: 298308.
Glassow F. Femoral hernia: review of 2,105 repairs in a 17 year
period. Am J Surg 1985; 150: 3536.
Bendavid R. A femoral umbrella for femoral hernia repair. Surg
Lichtenstein IL, Shore JM. Simplified repair of femoral and inguinal
hernia by a plug technique. Am J Surg 1974; 128: 43944.

8
9
10
11
12
13
14
15
Hernandez-Richter T, Schardey HM, Rau HG, et al. The femoral

hernia: an ideal approach for the transabdominal preperitoneal
technique (TAPP). Surg Endosc 2000; 14: 73640.
Marchal F, Parent S, Tortuyaux JM, et al. Obturator hernias
report of seven cases. Hernia 1997; 1: 236.
Skandalakis LJ, Skandalakis PN, Colborn GL, Skandalakis JE.
Obturator hernia: embryology, anatomy, surgery. Hernia 2000; 4:
1218.
Arregui ME, Navarrete J, Davis CJ, et al. Laparoscopic inguinal
herniorrhaphy techniques and controversies. Surg Clin N A 1993;
73: 51327.
Miklos JR, OReilly MJ, Saye WB. Sciatic hernia as a cause of
chronic pelvic pain in women. Obstet Gynecol 1998; 91: 9981001.
Carter JE. Sciatic, obturator, and perineal hernias: a view from the
gynecologist. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and
Condons Hernia, 5th edn. Philadelphia: Lippincott Williams &
Wilkins, 2002: 53949.
Kavic MS. Chronic pelvic pain in females and obscure hernias.
Hernia 2000; 4: 2504.
Chaudhuri A, Chye KK, March SK. Sciatic hernias: choice of
optimal prosthetic repair material in preventing long-term
morbidity. Hernia 1999; 4: 22931.
16
17
18
19
20
21
22
23
Kavic MS. Chronic pelvic pain in women. In: Bendavid R,

Abrahamson J, Arregui ME, et al., eds. Abdominal Wall Hernias
Principle and Management. New York: Springer-Verlag, 2001:
6368.
Skandalakis JE. Perineal hernia. In: Skandalakis JE, Gray SW,
Mansberger AR, et al., eds. Hernia Surgical Anatomy and
Technique. New York: McGraw-Hill, 1989: 185206.
Harkins HN. In: Nyhus LM, Condon RE, eds. Hernia, 3rd edn.
Philadelphia: JB Lippincott, 1989: 3023.
Bocci P. Paravascular hernias. In: Bendavid R, ed. Prostheses
and Abdominal Wall Hernias. Austin, TX: RG Landes Co., 1994:
41516.
Spurbeck WW, Voeller GR. Prevascular and retropsoas hernias:
incidence of rare abdominal wall hernias. Abstract presented at
American Hernia Society Hernia Conference, Tucson, AZ, May
2002.
Lilly MC, Arregui ME. Lipomas of the cord and round ligament.
Ann Surg 2002; 235: 58690.
Spangen L. Spigelian hernia. Surg Clin North Am 1984; 64: 35166.
Bennett D. Spigelian hernia. In: Fitzgibbons RJ, Greenburg AG, eds.
Nyhus and Condons Hernia, 5th edn. Philadelphia: Lippincott
Williams & Wilkins, 2002: 40513.
11
Results of laparoscopic inguinal/femoral
hernia repair
KETAN M. DESAI AND NATHANIEL J. SOPER
TEP versus TAPP repair

Laparoscopic versus open tissue repair
Laparoscopic versus open mesh repair
Summary
83
84
85
86
Over 750 000 inguinal hernia repairs are performed in the

USA annually. Historically, many techniques for the tissue
repair of groin hernias have been used, including the
Bassini, McVay, Cooper and Shouldice repairs. Currently,
the tension-free repair of Lichtenstein and the mesh-plug
procedure dominate the majority of surgical practices.
Since the introduction of laparoscopic cholecystectomy
in the late 1980s, advancements in minimally invasive surgery have led surgeons to investigate laparoscopic techniques for treating inguinal hernia while still providing a
durable repair. Accepted indications for laparoscopic hernia repair are recurrent and bilateral inguinal hernias in a
patient at low anesthetic risk. However, considerable debate
over laparoscopic inguinal hernia repair, not seen with
other laparoscopic procedures, has diminished the enthusiasm for adopting this technique for unilateral, primary
inguinal hernias.
The emergence of laparoscopic groin hernia surgery is
multifactorial. Following open repair, high rates of postoperative patient discomfort, pain, and increased time
away from work, coupled with recurrence rates that
ranged from one to ten per cent, influenced surgeons to
explore alternative repair methods. Early attempts at
laparoscopic inguinal hernia repair included intraperitoneal onlay mesh (IPOM) techniques, simple inguinal
ring closure, and plug-and-patch repair. However, these
early laparoscopic approaches were abandoned secondary
to an unacceptable rate of recurrence and the formation
of intra-abdominal adhesions, except at a few centers (see
Chapter 7). Today, the two predominant laparoscopic
Laparoscopic femoral hernia repair

References
Further reading
86
86
87
approaches for the repair of inguinal hernia include the

transabdominal pre-peritoneal (TAPP) and the totally
extraperitoneal (TEP) approaches. These two laparoscopic procedures, based upon the open Stoppa repair,
provide pre-peritoneal mesh reinforcement of the iliopubic tract.
TEP VERSUS TAPP REPAIR

TAPP repair requires entry into the peritoneal cavity.
Following placement of trocars, the peritoneum is divided
transversely anterior to the internal ring, wide peritoneal
flaps are raised, and the hernia sac is reduced. A large
prosthetic mesh is stapled into place, widely overlapping
the defect and buttressing the iliopubic tract. Similarly,
TEP repair requires advanced knowledge of the anatomy
of the inguinal floor. However, access to the pre-peritoneal
space is achieved without incision of the peritoneal membrane. Following balloon or blunt dissection of the preperitoneal space, the cord structures are dissected, and
indirect or direct hernias are reduced. The inguinal floor
is covered with a large prosthetic mesh and secured with
staples or another fixation device. Potential early postoperative complications include bowel injury from trocar
insertion (TAPP), bowel obstruction from adhesion formation (TAPP), nerve entrapment from staple placement
(TAPP and TEP), and mesh infection (TAPP and TEP).
The extraperitoneal approach avoids a number of these

Table 11.1 Recurrence rates of laparoscopic repairs
Study
Procedure
Number
Follow-up
(months)
Recurrence
rate (%)
Aeberhard et al. (1999)3

Katkhouda et al. (1999)4
Farinas and Griffen (2000)5
Knook et al. (1999)6
Ferzli et al. (1999)7
Frankum et al. (1999)8
Halkic et al. (1999)9
Lucas and Arregui (1999)10
ORiordain et al. (1999)11
Juul et al. (1999)1
Knook et al. (1999)12
Smith et al. (1999)13
Johansson et al. (1999)14
TEP
TEP
TEP
TEP
TEP
TEP
TEP
TEP
TEP
TAPP
TAPP
TAPP
TAPP
1605
99
96
256
100
779
118
199
71
138
34
536
204
12
24
12
40
8
30
22
36
12
12
35
17
12
1.3
0
0
5
0
0.2
0
0
0
2.9
0
0.6
2
pitfalls that are unique to entry into the peritoneal cavity.

However, early problems with nerve entrapment and
hernia recurrence secondary to inadequate mesh size
following either procedure have resulted in significant
morbidity.
Outcome measures following groin hernia repair
include postoperative pain, complications, return to work,
patient satisfaction, and cost, as well as long-term hernia
recurrence rates. Comparisons of laparoscopic approaches
have revealed lower rates of postoperative pain following
TEP repair; however, operating times and return to normal activity were generally similar. Recurrence rates following either laparoscopic repair were variable (Table 11.1).
Non-randomized (usually sequential) trials comparing
TEP versus TAPP approaches have reported lower recurrence rates following the TEP technique. However, in a
number of these trials the differences were not statistically
significant, with subsequent randomized studies reporting similar recurrence rates irrespective of laparoscopic
procedure.
Evaluations of these two laparoscopic techniques have
demonstrated a slightly lower complication rate following
TEP repair. Reports of bowel injury and small-bowel
obstruction secondary to intra-abdominal adhesions were
more common following the TAPP approach than the TEP
approach. The difference in complication rates between the
two accepted laparoscopic approaches may result from
remaining completely extraperitoneal during TEP dissection and repair. However, initial experience with TAPP may
have provided surgeons with the additional skills and
knowledge to perform a superior TEP repair.
In general, due to the small number of comparative
studies, firm conclusions on the relative merits of the different techniques are difficult to obtain. However, TEP
repair may have some advantages regarding complications and postoperative pain. Despite these potential differences, surgeons should be skilled in both minimally
invasive repairs, due to conversions and recurrences

requiring the alternative procedure.
LAPAROSCOPIC VERSUS OPEN

TISSUE REPAIR
Although we currently use the Lichtenstein (tension-free)
repair for open inguinal herniorrhaphy, the Shouldice
technique appears to have similar advantages in terms of
short recovery time and low recurrence rates. Laparoscopic repair has been compared with a number of open
repair methods, with varying results. A number of early,
small trials failed to demonstrate a clear benefit following
laparoscopic repair. More recent randomized trials comparing laparoscopic and open suture repair have reported
superior outcomes following the laparoscopic approach
in terms of less postoperative pain and a faster return to
normal activity. Although operative times of the laparoscopic approaches have been reported to be significantly
longer than with open suture methods in a number of
studies, wound complications and overall recurrence
rates were similar (Table 11.2). In addition, general anesthesia was used in the vast majority of laparoscopic cases
as opposed to local, epidural or spinal anesthesia in the
open group. Despite this, several trials have shown earlier
hospital discharge and less postoperative pain (early
and late) in patients undergoing laparoscopic repair. A
randomized comparison of extraperitoneal laparoscopic
repair with various open approaches by Liem and colleagues revealed longer procedure times for the laparoscopic repair.13 However, the laparoscopy group had
lower analgesia requirements, less postoperative pain, and
an earlier return to work. The recurrence rate was slightly
lower in the laparoscopy group, as were wound infections
and chronic postoperative pain.
Results of laparoscopic inguinal/femoral hernia repair 85

Table 11.2 Comparison of open versus laparoscopic repair
Recurrence (%)
Study
No.
randomized
Open
Laparoscopic
Open
Laparoscopic
Liem et al. (1997)15

Juul and Christensen (1999)1
Fleming et al. (2001)2
Paganini et al. (1998)16
Zieren et al. (1998)17
Koninger et al. (1998)18
Payne et al. (1994)19
Heikkinen et al. (1997)20
Beets et al. (1999)21
Filipi et al. (1996)22
Johansson et al. (1999)14
Aitola et al. (1998)23
Wellwood et al. (1998)24
Champault et al. (1997)25
Khoury (1998)26
994
268
200
108
240
280
100
38
79
53
613
60
403
100
292
Various
Shouldice
Shouldice
Mesh
Mesh
Mesh
Mesh
Mesh
Mesh
Mesh
Mesh
Mesh
Mesh
Mesh
Mesh
TEP
TAPP
TEP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TEP
TEP
6
2
5
0
0
1
0
0
3
7
5
8
0
2
3
3
3
2
4
0
1
0
0
14
0
2
13
0
6
2
Laparoscopic repair of groin hernias is generally

reserved for bilateral and recurrent hernias. However, the
benefits of laparoscopic repair for primary, unilateral hernias have been demonstrated. Patients with primary, unilateral hernias may recover more rapidly after TAPP repair
than after an open approach, as assessed by analgesia
requirement and functional status. In a randomized clinical
trial by Juul and coworkers of laparoscopic (TAPP) versus
open (Shouldice) inguinal hernia repair, complication rates
were similar, whereas the laparoscopic repair resulted in
less postoperative pain, shorter analgesia requirement,
and an earlier return to work.1 At postoperative followup, there were similar rates of recurrences. Comparison
of Shouldice and TEP repairs by Fleming and colleagues
also demonstrated the potential benefits of the laparoscopic approach. TEP repair led to a more rapid return to
work, with fewer complications at one-year follow-up,
when compared with the open group.2
LAPAROSCOPIC VERSUS OPEN MESH REPAIR

The practice of tension-free groin hernia repair using
prosthetic mesh materials has become increasingly popular over the last decade. Laparoscopic inguinal hernia surgery should be comparable to the standard Lichtenstein
repair, which has a reported recurrence rate of 0.11 per
cent. Multiple small studies with relatively short-term
follow-up have reported that laparoscopic repair can be
performed safely with results that equal or surpass open
hernia repair. Although the laparoscopic approach may
offer shorter recovery time owing to less pain, only a few
large studies have investigated overall differences in
complication and recurrence rates.
A number of prospective non-randomized studies

have compared laparoscopic and open mesh repair.
Objective pain scoring, analgesia use, and complication
rates were similar. Laparoscopic repair was shown to be
superior to open mesh repairs in terms of faster return to
normal activity and return to work. Although recurrence
rates did not differ significantly, a short duration of
follow-up and small cohort numbers were potential limiting factors to a number of these studies. Laparoscopic
repair required longer operating times and, in general,
was more expensive; however, more rapid return to work
may result in lower overall societal costs following the
laparoscopic approach.
Randomized clinical trials of open versus laparoscopic repair of primary, unilateral inguinal hernias have
shown comparable results with respect to overall complications and recurrences (Table 11.2). Major intraoperative and postoperative complications were uncommon
in both groups. However, severe visceral and vascular
injuries were more frequent following the laparoscopic
approach. Postoperative pain was shown to be less
among the laparoscopic groups, possibly contributing to
the earlier return to regular activity in patients undergoing laparoscopic hernia repair. However, length of hospital stay was similar in patients undergoing open mesh
and laparoscopic repair, with no difference in recurrence
rates between open mesh and laparoscopic repair at
short- to medium-term follow-up (Table 11.2).
Outcomes of randomized trials comparing laparoscopic and open herniorrhaphies have shown less pain
and faster recovery following laparoscopic approaches,
but at increased cost and slightly greater risk. However,
prospective, randomized data comparing laparoscopic
versus open bilateral hernia repair are lacking. It would
be expected that bilateral open repairs would result in a
doubling of operative time and postoperative pain when

compared with laparoscopic repair. The laparoscopic
approach for repair of unilateral or bilateral hernias
utilizes the same ports, thereby limiting additional time
requirements for bilateral herniorrhaphy. In addition,
pre-peritoneal repair (TEP/TAPP) avoids the scarring of
the anterior groin that follows failed open repair, and it
should be expected to be less time-consuming and fraught
with fewer complications than open herniorrhaphy for
recurrent hernias.
SUMMARY
Recurrence rates following various open hernia repair
techniques have ranged from less than one per cent to more
than ten per cent at long-term follow-up. Laparoscopic
techniques that were introduced in the early 1990s show
promise in treating unilateral, bilateral and recurrent hernias with respect to less postoperative pain, earlier recovery,
and improved cosmesis (Table 11.3). Recurrences that do
occur following laparoscopic repair are usually the result of
inadequate lateral pre-peritoneal dissection or an inadequate size of the prosthesis. In addition, the skill and experience of the operating surgeon greatly affect the rate of
recurrence, such that results during the initial learning
curve are worse than later in a surgeons operative series. In
addition, the lack of an inguinal incision, avoidance of
extensive dissection, creation of a tension-free repair, and
low complication rates all contribute to more rapid return
to normal activity following laparoscopic inguinal hernia
repair.
Comparing laparoscopic and open inguinal herniorrhaphy, differences in outcomes regarding postoperative
pain, return to work, and analgesia requirements have
generally favored the laparoscopic approach. However,
potential limitations to the laparoscopic approach include
increased cost, the requirement for general anesthesia,
and a steep learning curve. Disadvantages to laparoscopic hernia repair include the widespread use of general anesthesia and the potential for visceral and vascular
complications, unique to the laparoscopic approach
(Table 11.4).
Table 11.3 Potential advantages of laparoscopic inguinal
hernia repair
Less difficulty in repairing a recurrent hernia
Ability to treat bilateral hernia via same incisions
Performance of simultaneous diagnostic laparoscopy (TAPP)
Less postoperative pain
Reduced recovery time
Improved cosmesis
Table 11.4 Perceived disadvantages of laparoscopic

inguinal hernia repair
Requirement for general anesthesia
Complications unique to laparoscopic approach
Steep learning curve
Increased cost
LAPAROSCOPIC FEMORAL HERNIA REPAIR

The published literature on femoral hernia repair is
inadequate to make firm conclusions regarding the relative safety and efficacy of different surgical approaches.
Although a few prospective studies comparing different
methods of open femoral hernia repair exist, small study
sizes hinder definitive conclusions regarding differences
in outcomes. Laparoscopic femoral hernia repair is performed in the same fashion as that for inguinal herniorrhaphy. Reports of laparoscopic femoral hernia repair
are, in general, limited to case reports, with no randomized trials comparing open and laparoscopic repair.
REFERENCES
1
2
10
11
Juul P, Christensen K. Randomized clinical trial of laparoscopic

versus open inguinal hernia repair. Br J Surg 1999; 86: 31619.
Fleming WR, Elliott TB, Jones RM, Hardy KJ. Randomized clinical
trial comparing totally extraperitoneal inguinal hernia repair with
the Shouldice technique. Br J Surg 2001; 88: 11838.
Aeberhard P, Klaiber C, Meyenberg A, et al. Prospective audit of
laparoscopic totally extraperitoneal inguinal hernia repair: a
multicenter study of the Swiss Association for Laparoscopic and
Thoracoscopic Surgery (SALTC). Surg Endosc 1999; 13: 111520.
Katkhouda N, Campos GM, Mavor E, et al. Laparoscopic
extraperitoneal inguinal hernia repair. A safe approach based on
the understanding of rectus sheath anatomy. Surg Endosc 1999;
13: 12436.
Farinas LP, Griffen FD. Cost containment and totally extraperitoneal laparoscopic herniorrhaphy. Surg Endosc 2000;
14: 3740.
Knook MT, Weidema WF, Stassen LP, van Steensel CJ. Endoscopic
total extraperitoneal repair of primary and recurrent inguinal
hernias. Surg Endosc 1999; 13: 50711.
Ferzli GS, Frezza EE, Pecoraro AM, Jr, Ahern KD. Prospective
randomized study of stapled versus unstapled mesh in a
laparoscopic preperitoneal inguinal hernia repair. J Am Coll Surg
1999; 188: 4615.
Frankum CE, Ramshaw BJ, White J, et al. Laparoscopic repair of
bilateral and recurrent hernias. Am Surg 1999; 65: 83942,
8423.
Halkic N, Ksontini R, Corpataux JM, Bekavac-Beslin M.
Laparoscopic inguinal hernia repair with extraperitoneal doublemesh technique. J Laparoendosc Adv Surg Tech A 1999; 9: 4914.
Lucas SW, Arregui ME. Minimally invasive surgery for inguinal
hernia. World J Surg 1999; 23: 3505.
ORiordain DS, Kelly P, Horgan PG, et al. Laparoscopic
extraperitoneal inguinal hernia repair in the day-care setting. Surg
Endosc 1999; 13: 91417.
Results of laparoscopic inguinal/femoral hernia repair 87

12
13
14
15
16
17
18
19
20
21
22
23
24
Knook MT, Weidema WF, Stassen LP, van Steensel CJ. Laparoscopic
repair of recurrent inguinal hernias after endoscopic
herniorrhaphy. Surg Endosc 1999; 13: 11457.
Smith AI, Royston CM, Sedman PC. Stapled and nonstapled
laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia
repair. A prospective randomized trial. Surg Endosc 1999; 13:
8046.
Johansson B, Hallerbck Glise H, Anesten B, et al. Laparoscopic
mesh versus open preperitoneal mesh versus conventional
technique for inguinal hernia repair: a randomized multicenter
trial (SCUR Hernia Repair Study). Ann Surg 1999; 230: 22531.
Liem MSL, van der Graaf Y, van Steensel CJ, et al. Comparison of
conventional anterior surgery and laparoscopic surgery for
inguinal-hernia repair. N Engl J Med 1997; 336: 15417.
Paganini AM, Lezoche E, Carle F, et al. A randomized, controlled,
clinical study of laparoscopic vs open tension-free hernia repair.
Surg Endosc 1998; 12: 97986.
Zieren J, Zieren HU, Jacobi CA, et al. Prospective randomized study
comparing laparoscopic and open tension-free inguinal hernia
repair with Shouldices operation. Am J Surg 1998; 175: 3303.
Koninger JS, Oster M, Butters M. Management of inguinal hernia:
a comparison of current methods. Chirurg 1998; 69: 13404.
Payne JH, Jr, Grininger LM, Izawa MT, et al. Laparoscopic or open
inguinal herniorrhaphy? A randomized prospective trial. Arch Surg
1994; 129: 9739, 97981.
Heikkinen T, Haukipuro K, Leppala J, Hulkko A. Total costs of
laparoscopic and Lichtenstein inguinal hernia repairs: a
randomized prospective study. Surg Laparosc Endosc 1997; 7: 15.
Beets GL, Dirksen CD, Go PM, et al. Open or laparoscopic
preperitoneal mesh repair for recurrent inguinal hernia? A
randomized controlled trial. Surg Endosc 1999; 13: 3237.
Filipi CJ, Gaston-Johansson F, McBride PJ, et al. An assessment of
pain and return to normal activity. Laparoscopic herniorrhaphy vs
open tension-free Lichtenstein repair. Surg Endosc 1996; 10: 9836.
Aitola P, Airo I, Matikainen M. Laparoscopic versus open
preperitoneal inguinal hernia repair: a prospective randomised
trial. Ann Chir Gynaecol 1998; 87: 225.
Wellwood J, Sculpher MJ, Stoker D, et al. Randomised controlled
trial of laparoscopic versus open mesh repair for inguinal hernia:
outcome and cost. Br Med J 1998; 317: 10310.
25
26
Champault GG, Rizk N, Catheline J-M, et al. Inguinal hernia repair;

totally preperitoneal laparoscopic approach versus Stoppa
operation: randomized trial of 100 cases. Surg Laparosc Endosc
1997; 7: 44550.
Khoury N. A randomized prospective controlled trial of laparoscopic
extraperitoneal hernia repair and mesh-plug hernioplasty: a study
of 315 cases. J Laparoendosc Adv Surg Tech A 1998; 8: 36772.
FURTHER READING
Barkun JS, Wexler MJ, Hinchey EJ, et al. Laparoscopic versus open
inguinal herniorrhaphy: preliminary results of a randomized
controlled trial. Surgery 1995; 118: 70310.
Champault G, Benoit J, Lauroy J, et al. Inguinal hernia in adults.
Laparoscopic surgery versus the Shouldice method. Controlled
randomized study in 181 patients. Preliminary results. Ann Chir
1994; 48: 10038.
Cheek CM, Black NA, Devlin HB, et al. Groin hernia surgery: a
systematic review. Ann R Coll Surg Engl 1998; 80 (suppl 1): S180.
Collaboration EH. Laparoscopic compared with open methods of groin
hernia repair: systematic review of randomized controlled trials.
Br J Surg 2000; 87: 86067.
EU Hernia Trialists Collaboration. Mesh compared with non-mesh
methods of open groin hernia repair: systematic review of
randomized controlled trials. Br J Surg 2000; 87: 8549.
Kozol R, Lange PM, Kosir M, et al. A prospective, randomized study of
open vs laparoscopic inguinal hernia repair. An assessment of
postoperative pain. Arch Surg 1997; 132: 2925.
Maddern GJ, Rudkin G, Bessell JR, et al. A comparison of laparoscopic
and open hernia repair as a day surgical procedure. Surg Endosc
1994; 8:14048.
Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus
open inguinal hernia repair: randomised prospective trial. Lancet
1994; 343: 12435.
Vogt DM, Curet MJ, Pitcher DE, et al. Preliminary results of a
prospective randomized trial of laparoscopic onlay versus
conventional inguinal herniorrhaphy. Am J Surg 1995; 169: 8490.
12
RICARDO V. COHEN, CARLOS A. SCHIAVON, SRGIO ROLL AND JOS C.P. FILHO
Anesthesia
Events related to laparoscopic access
Organ involvement
Hydrocele
Seroma
Vascular injury
89
89
90
90
90
91
The modern era of the treatment of inguinal/femoral

hernias has evolved over the past 155 years. From truss
support to elective outpatient procedures, the surgical
techniques to treat these patients have progressed, such
that now surgeons are able to employ the use of laparoscopy
to approach these hernias. Laparoscopic approaches allow
the inspection of the inguinal and femoral areas bilaterally,
thereby avoiding unexpected non-diagnosed contralateral
hernias. This method of hernioplasty has been shown to
reduce postoperative pain and disability and allows the
treatment of bilateral defects in one sitting. But, as in
all operative procedures, complications exist. Nothing is
more effective in the prevention of the occurrence of
complications as ones awareness and fear of them.
In this chapter, complications and their management
will be focused on the two most commonly performed
laparoscopic inguinal hernia repairs, the transabdominal
pre-peritoneal (TAPP) approach and the totally extraperitoneal (TEP) technique.
ANESTHESIA
It has been suggested that the general anesthesia needed
for laparoscopic herniorrhaphy is a major drawback, and
open procedures are preferred because they can be
performed under local anesthesia. However, numerous
reports have revealed the relative absence of anesthesiarelated complications, probably associated with proper
patient selection.4,5 If a medical contraindication, other
Neuropathy
Visceral complications
Mesh-related problems
Recurrence
Conclusion
References
91
92
93
93
94
94
than age, to general anesthesia exists, then hernias must be

repaired through an anterior approach under local anesthesia. No controlled trial has been published that has
shown definitely that a local anesthetic is truly superior
to carefully administered general anesthesia. Consequently,
this does not represent a strong reason to avoid TAPP
or TEP.
EVENTS RELATED TO LAPAROSCOPIC

ACCESS
Inherent to laparoscopy are the insufflation of carbon
dioxide and the possibility of systemic alterations following pneumoperitoneum, documented very well in the
literature. Additionally, trocar access may carry some
intra-abdominal complications, such as major vascular
or visceral injuries.3 Blind insertion of the Veress needle
or trocars may cause intra-abdominal and abdominal
wall complications. In a retrospective study of 103 852
laparoscopic operations (nine per cent inguinal hernias),
which involved the insertion of 390 000 trocars, the incidence of serious complications was 3.2/1000 interventions (0.032 per cent).4 Bleeding from the trocar site
was the most common complication, accounting for
two-thirds of the accidents; this resulted in conversion to
an open procedure in 11.3 per cent. Visceral injuries
occurred in 0.6/1000 interventions, and the conversion
rate was 65 per cent. The incidence of vascular injuries
was 0.5/1000, and resulted in six deaths (17 per cent); the
90
Laparoscopic inguinal/femoral hernioplasty
conversion rate to laparotomy was 85 per cent. The two

most important risk factors were inexperienced surgeons
and the introduction of the first trocar, which was responsible for 83 per cent of vascular injuries, 75 per cent of
bowel injuries, and 50 per cent of local hemorrhage.
Complications are theoretically different depending
upon the laparoscopic technique (TAPP or TEP). In TEP,
because there is no invasion of the abdominal cavity, major
intracavity injuries are very rare. However, there have
been reports of enterotomies resulting from the tearing of
adhesions during extraperitoneal balloon dissection.5
Another complication related to the laparoscopic
approach is trocar site incisional hernia. Although quite
uncommon, this is associated particularly with TAPP
repair. Because the incidence varies from five to 15 per
cent, it is recommended that all port sites over 5 mm
should be closed in order to avoid this postoperative
complication.
ORGAN INVOLVEMENT
Almost all organ complications that follow the laparoscopic treatment of inguinal/femoral hernias are similar
to those that follow open techniques. The morbidity rate
in open operations is approximately ten per cent.6 Tetik
and colleagues in 1994,7 Phillips and colleagues in 1995,8
and Crawford and Phillips in 19989 reported complication rates in the order of 11 per cent. Roll and coworkers,
in a large Brazilian multicenter trial of 4000 operated
patients, found that the rate of complications was seven
per cent.10 Felix and colleagues in 1999 reported an incidence of complications of 6.1 per cent.11 All authors
demonstrated that the incidence of the complications
were significantly higher in the period of the learning
curve and could be reduced to less than one per cent with
greater experience.
Testicular complications
The two pertinent complications concerning the testicle
are ischemic orchitis and testicular atrophy. Postoperative
inflammation of the testicle occurs within 2472 hours following the procedure. The associated pain is severe, usually requiring aggressive and effective analgesia. Ischemic
orchitis may progress, resulting in testicular atrophy, a
process that may be observed over several months. The
mechanism of this complication originates from an intense
venous congestion within the testicle, secondary to thrombosis of the veins within the spermatic cord. The initiating
trauma is seen during dissection of the spermatic cord
from the hernia sac, whether for direct, indirect or femoral
hernias, or the TAPP or TEP procedure. The incidence of
testicular complications is lower with laparoscopy than
with the conventional techniques, ranging from 0.3 to

5 per cent.12
Vas deferens complications

The incidence of vas deferens injuries is about the same
(about 0.04 per cent) regardless of whether the hernia
repair is performed open or laparoscopically. Trauma to
the vas deferens can be one of immediate transection or
ultimate obstruction. Transection is a very rare mishap
following TAPP or TEP repair. If this does occur, then
repair must be attempted unless fertility is not a consideration. Obstruction can result from the vigorous
handling of the vas deferens with instruments/graspers,
yielding a fibrosis of variable intensity through the muscular wall of the vas deferens. Sometimes, the vas deferens may become adherent to the posterior inguinal floor
following the operation and form kinks that may represent an outflow obstruction and hence account for
dysejaculation.
HYDROCELE
This is an uncommon complication following either
laparoscopic approach. It may be secondary to overzealous
skeletonization of the spermatic cord or tissue dissection
from the sac and at the internal ring. Some authors, in
retrospective studies, found a low incidence of hydrocele.
When a TEP repair was employed, the incidence reported
varied from 0.5 to 1.5 per cent.13,14 Felix and coworkers, in
a paper devoted to significant complications following
laparoscopic hernia repair, pointed out that the incidence
of hydrocele was higher in patients with the use of a mesh
that was modified to place a keyhole to accommodate
the spermatic cord.11 Earlier, in a large, multicenter trial,
Phillips and colleagues reported an incidence of 0.2 per
cent, regardless of the method of laparoscopic technique.8
In a study of open repairs by Obney and Chan, the incidence of hydrocele formation was 0.9 per cent.15
SEROMA
Seromas represent an exudate, normally resulting from the
trauma of electrocautery, balloon dissection of the preperitoneal space in the TEP approach, scissors dissection,
or foreign bodies, such as sutures and mesh. They are
infrequently clinically evident and usually they can be
allowed to reabsorb spontaneously. Size may vary, and
ultrasound follow-up may be important to determine
whether needle aspiration and/or drainage is necessary.
Several publications have discussed whether the incidence
Complications and their management 91
of seromas is more common in the TEP or the TAPP

approach. Studies by Felix and colleagues,11 Ramshaw and
colleagues,16 DAllemagne and colleagues,17 Kald and colleagues,18 and Cohen and colleagues19 revealed different
results regarding the higher incidence of seroma in the
TEP approach. It seems plausible that the use of balloon
dissection in TEP repair can be more aggressive to the preperitoneal space than the TAPP technique. Consequently,
it appears that seromas following TAPP are often smaller
and easier to manage than those that follow TEP.
Additionally, it is quite rare for a seroma to become encapsulated with such a strong fibrotic capsule that resection is
required.
The aggressiveness of the dissection and complete parietalization of the cord structures is the probable cause. Injuries
of the aorta were described during TAPP, either secondary
to the first blind trocar or during dissection in the inappropriate location and resultant injury to the terminal aorta.20
The introduction of prosthetic materials originally
raised some concerns with regard to their proximity to
arteries and veins. Flat sheets of prosthetic materials
have not been associated with vascular erosions and
thrombosis.21
VASCULAR INJURY
Residual neuralgia following laparoscopic hernia repair

represents the most vexing complication of the inguinal
region. The absence of convincing objective tests and the
subjective nature of the complaints do not favor an easy
resolution of the problem.
The femoral branch of the genitofemoral nerve, the
lateral cutaneous nerve of the thigh, and the intermediate
cutaneous branch of the femoral nerve are at risk of damage during laparoscopic inguinal hernioplasty because of:
Bleeding from arteries or veins can occur at all anatomic

levels during an inguinal hernia repair. Superficially, subcutaneous hematomas or severe ecchymoses can result
from injuries to superficial vessels, such as the epigastric
artery or vein. The dissection in the space of Bogros during TAPP, if careless, may incur bleeding that is usually
insidious and may result in large hematomas that can
extend from the anterior abdominal wall to the scrotum.
During TEP, it is recommended after balloon insertion
and insufflation to keep the balloon full of air for five to
seven minutes to allow for better hemostasis.
Injuries below the iliopubic tract to the major vessels,
such as the iliac and femoral artery and vein, can occur
and obviously must be controlled swiftly. All control of
bleeding must be done under direct vision. Blind clamping and the use of deep suture ligatures must be avoided.
Careful postoperative observation must be instituted, and
early detection of vascular complications is important.
Injury to the inferior epigastric vessels is not infrequent during the learning curve. As this injury is diagnosed, the vessels should be clamped; posterior clip
ligation is the desirable treatment. No adverse sequelae
have been reported when the inferior epigastric vessels
have been ligated.
The presence of an aberrant obturator artery originating from the deep inferior epigastric artery can be
the source of bleeding when tacks or staples are anchored
to the ligament of Cooper. Care must be taken, and
acknowledgment of its existence underneath the mesh is
very important. If this bleeding is managed poorly, the
result can be a bloody operative field that can be an
obstacle to the completion of the procedure. This dangerous injury must be avoided. This complication has
earned the artery the unenviable designation of the
artery of death.
Injuries to the spermatic vessels are more common during the learning curve for both TAPP and TEP procedures.
NEUROPATHY
a failure to appreciate the anatomy from the

posterior aspect;
difficulty in visualizing the nerves pre-peritoneally;
the variable course of the nerves in this region;
improper staple placement;
extensive pre-peritoneal dissection.
The incidence of neurological complications varies

with the technique (TAPP, 1.22.2 per cent; TEP, 00.5
per cent).22,23
The main clinical features of genitofemoral nerve
injury consist of intermittent or constant pain and burning sensations in the inguinal region, with radiation of
pain to the genitalia and upper medial thigh. As the
mechanism of injury is defined poorly, its diagnosis may
be imprecise and available treatment options are varied.
The best way to minimize this kind of complication is to
avoid any extensive dissection of the posterior pelvis and
to avoid placement of staples or tacks below the iliopubic
tract, thereby keeping far away from the triangle of doom
and the trapezoid of disaster (Figure 12.1).24 A study in 50
cadaveric inguinal regions by Rosen and Halevy demonstrated that the mean safe distance to avoid any possible
contact with the genitofemoral nerve or the lateral
femorocutaneous nerve during fixation is 3.95 cm lateral
to the internal inguinal ring.25 To take all anatomic variations into account, Rosen and Halevy recommended
placement of staples no further than 1.5 cm lateral to the
lateral border of the internal inguinal ring. This location
of fixation, in addition to the non-extensive dissections
and the avoidance of manipulation or stapling below the
92
(a)
of the pain. Electromyography may also be helpful.

The management is controversial and multimodal.
Initial efforts at clinical control with non-steroidal antiinflammatory drugs, rest, and eventually infiltration with
local anesthetics are frequently helpful. If inguinodynia
persists, and sensory/motor deficit is present on examination, then immediate exploration and staple removal
should be considered. If there is mild pain relief, then
local infiltration may be a good step, but if local-ized tenderness persists with positive Tinels sign, then removal of
the staple/tack or mesh or neurectomy may be required.
If re-exploration is undertaken, care must be exercised during the removal of the staples/tacks and/or
mesh. The removal of the mesh or staples may disrupt
the structural integrity of the hernia repair. It should also
be realized that removal of the prosthesis could be a very
difficult procedure that could pose a threat of injury to
contiguous structural injuries, such as the iliac vessels.
VISCERAL COMPLICATIONS
Urinary bladder complications
(b)
Laparoscopic hernia repair is associated with urinary

complications with an incidence of 1.55 per cent,
including retention, infection and hematuria.26 Bladder
injury with closed peritoneal access is rare but possible. It
may be adherent or it may slide into a direct or femoral
hernia. The most common offender is the Veress needle,
followed by the first blind trocar. There is an increased
risk in patients with previous dissection in the preperitoneal space or space of Retzius, such as a prior
laparoscopic hernia repair or prostatectomy.
Intestinal complications
(c)
Figure 12.1 (a) TAPP anatomical view: (1) Coopers ligament;

(2) vas deferens; (3) spermatic cord; (4) nerve area below the
iliopubic tract; (5) iliopubic tract; (6) internal ring. (b) Black
area, triangle of doom; red area, trapezoid of disaster.
(c) Recurrence Mesh invagination in the defect.
iliopubic tract, are the most effective tools to avoid

neuralgia paresthetica that may follow the laparoscopic
approach to groin hernias.
The ilio-inguinal nerve and the ilio-hypogastric nerve
are more superficial structures, making them easier to
injure in open repair than in the laparoscopic method.
Diagnosis can be made after careful anatomical localization
Bowel obstruction is almost unheard of with conventional

repair, but it can be associated with the laparoscopic
approach, particularly TAPP. However, its incidence in
the literature is low, ranging from 0.06 to 0.2 per cent.27
The complication was frequent in the developmental
stages secondary to inadequate peritoneal closure over
the prosthesis, allowing bowel to migrate into the preperitoneal space, which could result in intestinal obstruction. The major advantage of the TEP procedure is the
theoretical avoidance of this problem, as the peritoneal
sheath is kept untouched.
Another situation, related almost solely to TAPP
repair, is the lack of appreciation of the need to close
trocar sites. If one considers any hernia as a part of a
systemic abdominal wall disease, then it is mandatory to
close all fascial defects, avoiding potential port site hernias. The incidence of delayed bowel obstruction related
to adhesions because of the intra-abdominal nature of

TAPP has yet to be determined but would appear to be
extremely low.
Intraoperative laceration of incarcerated or sliding
(large bowel) hernias must be avoided and currently are
reported rarely. Following general principles of gentle
surgical technique, this kind of problem should seldom
be found.
Bone complications
Bone-related complications were very rare before the
laparoscopic era. Today, osteitis pubis after the learning
curve is an avoidable complication. The usual mechanism of injury is tacking/stapling the mesh while anchoring it over the periosteum. Oral analgesia and eventually
local infiltration may be a good way to initiate treatment
of this complication. If unsuccessful, re-exploration with
tack/staple removal is the best alternative to treat such a
painful complication. It is a personal observation that
pubic pain is more frequent when employing tacks rather
than the regular hernia staples, probably due to their
penetration into the bone.
Skin complications
In major series, ecchymoses and subcutaneous emphysema were reported, but these are self-limiting and without major consequences. Skin infections are very rare
following laparoscopic repair, and there are no situations
that impose a higher risk in either TAPP or TEP.
MESH-RELATED PROBLEMS
The introduction of prosthetic mesh in an inguinal
hernioplasty is a standard procedure today. Mesh placement allows tension-free repair, leading to significantly
lower recurrence rates, but its main complication infection poses a series of special management problems.
The use of monofilament biomaterials carries a theoretic
advantage over the braided biomaterials. Pores in braided
yarns and expanded polytetrafluoroethylene (ePTFE) are
smaller than macrophages, which implies that an infection associated with these types of mesh affects its management. The presence of infection does not necessarily
mandate removal of a polypropylene or polyester mesh,
unless the mesh is sequestered or is bathing in a purulent exudate. The infection is predominantly in the surrounding tissue, and abscess drainage and aggressive
clinical management with broad-spectrum antibiotics
are required. However, when a braided mesh or ePTFE
prosthesis is employed, their removal is almost always
required, due to their pore diameter, the inability of

drainage through them, and impaired macrophage
migration and activity.
When systemic conditions are unstable and sepsis is
present, an aggressive surgical approach is the rule. One
should never forget, however, that removal of an infected
mesh could be perilous, as firm adhesions to local structures such as major vessels may be found. Fortunately,
the incidence of infections in the laparoscopic era varies
from 0 to 0.6 per cent.6,28
Rarely, delayed infections may be seen months or years
later. The mechanism in this delay is not understood.
Conservative management is the choice, and mesh
removal is required rarely, subject to the above discussion.
Mesh and infertility

Although infertility is not usually reported after hernia
repair, a few reports from fertility clinics have shown an
association of infertility and previous hernia repair,
without accounting for vas deferens injuries or overmanipulation. The placement of large meshes in the preperitoneal space in TAPP or TEP repair may lead to
fibrosis in the proximity of the vas deferens and may predispose to an unknown effect on its function, without any
clear vas luminal obstruction. Further studies are needed.
It should be noted that it is important to avoid extensive
manipulation of the cord structures and vas deferens in
men of reproductive age to avoid affecting fertility.
RECURRENCE
As stated by Rutkow in 1995, recurrences are not a parameter of success in the surgical repair of groin hernias;29
rates higher than three per cent are unacceptable, and
if any technique reports recurrences higher than that
number, then it should be abandoned. However, despite
Rutkows reasonable ideas on recurrence, and the increasing popularity of the comparison of outcomes by measurement of postoperative pain, return to work, patient
satisfaction, and cost, the standard by which any repair is
measured is its recurrence rate. That rate in laparoscopic
techniques has fallen gradually as experience and knowledge of the anatomy and mesh sizes have improved.
Recurrence may be due to a variety of mechanisms,
including:
incomplete dissection, with missed hernias,

inadequate identification of anatomical landmarks,
and the prosthesis being allowed to roll up instead
of lying flat;
mesh being too small, therefore not covering all
potential defects;
94
REFERENCES
Table 12.1 Recurrences in large multicenter trials

No.
hernias
Recurrence
(%)
Mean
follow-up
(months)
Reference
Repair
Tetik et al.
(1994)7
TAPP
TEP
553
457
0.7
0.4
13
Fitzgibbons
et al. (1995)27
TAPP
TEP
562
87
5
0
23
Phillips et al.
(1995)8
TAPP
TEP
1944
578
1
0
22
migration of the mesh;

mesh slit (the slit is the site of the recurrence);
folding or invagination of the mesh into the defect;
displacement of the mesh by hematoma.
The first reports with the abandoned laparoscopic

plug or plug-and-patch reported recurrence rates of
25 per cent.30 As experience and knowledge of the anatomy
and mesh size have grown, so recurrence rates have
decreased. Evaluation of large multicenter trial results
reveals the low recurrence rates for TEP (Table 12.1).
Tetik and coworkers reported a 0.4 per cent incidence of
recurrence in TEP,7 whereas no recurrences were reported
in 578 patients by Phillips and colleagues8 or in 87 repairs
by Fitzgibbons and colleagues.27 It is important to stress
that the vast majority of surgeons throughout the world
began their experience and learned the TAPP procedure
first; TEP came later, bringing more comfort with the
anatomy and handling the mesh better. Adoption of the
TEP technique by many of these surgeons occurred later,
thereby providing a higher level of comfort with the
anatomy, and better handling and sizing of the mesh
for the laparoscopic procedure. This may explain the
relatively lower recurrence rates with TEP than with
TAPP in these large trials.
CONCLUSION
Over the past 15 years, laparoscopic hernioplasty has
made the transition from an experimental to a proven
procedure. With increasing laparoscopic skills, many
surgeons are now faced with the question of when to
recommend a laparoscopic approach to their patients.
Complication and recurrence rates, although initially
higher than traditional repairs, have now fallen to equal
or lower levels at centers experienced in laparoscopic
techniques. Prospective randomized trials prove that when
patients are selected properly and surgeons are trained,
TAPP or TEP repairs may be performed with reasonable
rates of complications and recurrence.
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Arvidsson D, Smedberg S. Laparoscopic compared with open

hernia surgery: complications, recurrences and current trends. Eur
J Surg 2000; 585: 4047.
Moreno-Egea A, Aguayo JL, Canteras M. Intraoperative and
postoperative complications of totally extraperitoneal
laparoscopic inguinal hernioplasty. Surg Laparosc Endosc 2000;
10: 3033.
Baadsgard SE, Egelblad K. Major vascular injury during
gynecologic laparoscopy: report of a case and review of published
cases. Acta Obstet Gynecol Scand 1989; 68: 2835.
Champault G, Cazacu F, Taffinder N. Serious trocar accidents in
laparoscopic surgery: a French survey of 103,852 operations. Surg
Topal B, Hourlay P. Totally preperitoneal endoscopic inguinal
hernia repair. Br J Surg 1997; 84: 613.
Bendavid R. Complications of groin hernia surgery. Surg Clin N Am
1998; 78: 10892000.
Tetik C, Arregui M, Castro D. Complications and recurrences
associated with laparoscopic repair of groin hernias: a multiinstitutional retrospective analysis. In: Arregui M, Nagan RF, eds.
Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe
Medical Press, 1994: 494500.
Phillips EH, Arregui M, Caroll BJ, et al. Incidence of complications
following laparoscopic hernioplasty. Surg Endosc 1995; 9: 1621.
Crawford DL, Phillips EH. Laparoscopic repair and groin hernia
surgery. Surg Clin N Am 1998; 78: 104762.
Roll S, Cohen R, Miguel P, et al. Laparoscopic transabdominal
inguinal hernia repair with preperitoneal mesh. Surg Endosc 1994;
8: 485.
Felix EL, Harbetson N, Vartanian S. Laparoscopic hernioplasty.
Significant complications. Surg Endosc 1999; 13: 32831.
Cohen RV. Laparoscopic transabdominal preperitoneal hernia
repair. Doctoral thesis presented to the Department of Surgery,
University of Sao Paulo, Brazil. Sao Paulo, Brazil: University of Sao
Paulo Press, 1996: 4357.
Ferzli G, Massad A, Albert P. Extraperitoneal endoscopic inguinal
hernia repair. J Laparoendosc Surg 1992; 2: 2815.
McKernan B, Laws HL. Laparoscopic repair of inguinal hernias
using a totally extraperitoneal prosthetic approach. Surg Endosc
1993; 7: 268.
Obney N, Chan CK. Hydrocoeles of the testicle complicating
inguinal hernias. Can Med Assoc J 1956; 75:7336.
Ramshaw B, Tucker JG, Conner T, et al. A comparison of the
approaches to laparoscopic herniorrhaphy. Surg Endosc 1996;
10:2932.
DAllemagne B, Markiewicz S, Iehaes C. Extraperitoneal
laparoscopic inguinal hernia repair: technique and results. Surg
Endosc 1996; 10: 22834.
Kald A, Anderberg B, Smedh K. Transperitoneal or totally
extraperitoneal approach in laparoscopic hernia repair. Surg
Cohen RV, Alvarez G, Roll S, et al. Transabdominal or totally
extraperitoneal hernia repair? Surg Laparosc Endosc 1998; 8: 2648.
Oshinsky GS, Smith AD. Laparoscopic needles and trocars: an
overview of designs and complications. J Laparoendosc Surg 1992;
2: 11725.
Kathkouda N. Avoiding complications of laparoscopic hernia
repair. In: Arregui M, Fitzgibbons R, Kathkouda N, eds. Principles of
Laparoscopic Surgery: Basic and Advanced Techniques. New York:
Springer-Verlag, 1995: 4358.
Starling JM. Genitofemoral neuralgia. In: Arregui M, Nagan RF,
eds. Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe
Medical Press, 1994: 21317.

23
Eubanks S, Newman L, Goehring L, et al. Meralgia paresthetica: a

complication of laparoscopic herniorrhaphy. Surg Laparosc Endosc
1993; 3: 3815.
24 Seid AS, Amos E. Entrapment neuropathy in laparoscopic
herniorrhaphy. Surg Endosc 1994; 8: 105053.
25 Rosen A, Halevy A. Anatomical basis for nerve injury during
laparoscopic hernia repair. Surg Laparosc Endosc 1997; 7: 46971.
26 Payne JH. Complications of laparoscopic herniorrhaphy. Semin
Laparosc Surg 1997; 4: 16681.
27 Fitzgibbons RJ, Camps J, Cornet DA, Annibali R. Laparoscopic
inguinal herniorrhaphy: results of a multicenter trial. Ann Surg
1995; 221: 313.
28
29
30
MacFadyen BV. Laparoscopic inguinal herniorrhaphy:

Complications. In: Arregui M, Nagan RF, eds. Inguinal Hernia:
Advances or Controversies? Oxford: Radcliffe Medical Press, 1994:
28496.
Rutkow I. The recurrence rate in hernia surgery. How important is
it? Arch Surg 1995; 130: 5758.
Schultz L, Graber J, Pietrafitta J. Laparoscopic laser herniorrhaphy:
a clinical trial preliminary study. J Laparoendosc Surg 1990; 1:
415.
PART
Laparoscopic incisional and

ventral hernioplasty
13
14
15
16
17
18
History
Herniorrhaphy with the use of transfascial sutures
99
103
111
115
125
133
19 Parastomal hernia repair

20 Lumbar hernia and denervation hernia repair
21 Results of laparoscopic incisional and ventral
hernia repair
143
151
155
161
13
History
KRISTI L. HAROLD, BRENT D. MATTHEWS AND B. TODD HENIFORD
Laparoscopic ventral herniorrhaphy
Adoption of procedure
99
100
Ventral hernias present a challenging surgical problem.

Approximately 311 per cent of all laparotomy incisions
develop a fascial defect, resulting in 90 000 ventral hernias
repairs each year.1 Due to the high rate of recurrence with
simple suture closure, the techniques of hernia repair
have evolved from primary repair to those employing
biomaterials. More recently, surgeons options have
expanded to include repairs using minimally invasive
approaches.
Primary repairs involve suturing of the aponeurotic
layers of the abdominal wall to close defects, along with
unique variations such as the vest-over-pants technique
developed by William J. Mayo in 1895. To repair large
defects, in the 1920s Gibson introduced the concept of
relaxing incisions, which allowed closure of the abdominal wall in the midline with reduced tension.2 Despite the
various and inventive techniques for primary repair, the
recurrence rate after primary repair remained unacceptably high, spurring the development of biomaterials
to repair abdominal wall defects in the first half of the
twentieth century.
The first biomaterials employed for hernia repair were
metallic. Silver wire mesh, tantalum mesh, and stainlesssteel mesh were all used in an attempt to create stronger
hernia repairs. The metallic prostheses, however, led to
problems such as erosion, fragmentation, fistulas, and
patient intolerability. Hence, a variety of synthetic polymeric meshes were developed, leading to a revolution in
hernia repair. Francis Usher introduced monofilament
polypropylene mesh in 1958, and today this is the most
commonly used mesh. Polyester mesh, which is very
popular in Europe, was also introduced in the 1950s.
Expanded polytetrafluoroethylene (ePTFE) was added
Conclusion
References
100
100
to the armamentarium of biomaterials in the 1970s and

has become a popular prosthetic for ventral/incisional
hernia repair.3
The introduction of tension-free repair with biomaterials has drastically reduced the recurrence rate of
abdominal wall hernias. In several studies, the addition
of prosthetic mesh has reduced hernia repair failure
by more than 50 per cent.4 Nevertheless, the techniques
developed by Stoppa and others to employ meshes
for repair involve large areas of tissue-flap dissection
and create significant patient morbidity, including
wound complications, infection, a need for drains, and
pain.5
Advances in minimally invasive surgery prompted the
first attempts at laparoscopic ventral hernia repair in the
early 1990s.6 These techniques eliminated the need for
wide soft-tissue dissection and large incisions, and it was
hoped that there would be a corresponding decrease
in morbidity, such as was seen in the transition from
conventional to laparoscopic cholecystectomy.
LAPAROSCOPIC VENTRAL
HERNIORRHAPHY
Initial laparoscopic ventral hernia repairs were usually
performed by placing a large intraperitoneal prosthesis
and securing it to the anterior abdominal wall with hernia staples or spiral tacks.68 Recurrences secondary to
the mesh pulling free from the abdominal wall or migration with the peritoneum into the hernia prompted most
surgeons to adopt a fixation technique that employs
100 Laparoscopic incisional and ventral hernioplasty
transfascial non-absorbable sutures in addition to staples

or tacks to secure the mesh.7,9 Surgeons also recognized
that the lack of overlap of the defect by the prosthesis
contributed to recurrent hernia formation.10 This has
led to the recommendation that at least a 3-cm overlap
be provided circumferentially. Many surgeons advocate a
46-cm circumferential overlap if the mesh can be placed
without undue technical difficulty. We and others often
underlay the entire previous incision, even if it is not
involved with the hernia, to prevent the development of
another hernia above or below the repaired defect.
The choice of prosthetic material for laparoscopic ventral hernia repair is varied and often debated. By far, however, the most frequently used mesh has been expanded
polytetrafluoroethylene (ePTFE). While some authors
have reported the use of polypropylene or polyester materials for laparoscopic ventral herniorrhaphy without
complication,8 these biomaterials lead to adhesion formation and have been associated with intestinal erosion
and fistula formation in up to five per cent of patients
when placed intraperitoneally.11 Accordingly, the trend
has been toward the use of PTFE in most hospitals.
ADOPTION OF PROCEDURE
While laparoscopic inguinal herniorrhaphy enjoyed a
rather quick acceptance after its introduction, the popularity of laparoscopic ventral hernia repair has arrived
somewhat more slowly. This can probably be attributed
to the inherent difficulty of the adhesiolysis in the previously operated abdomen and the need for surgeons with
limited laparoscopic experience to apply large pieces of
mesh. A search of Medline and Embase demonstrated
only three articles concerning the procedure published
in 1992, the year that laparoscopic ventral herniorrhaphy was introduced. However, interest in the technique
increased, and by 1994, 13 publications were posted.
There has been a steady or increasing number since that
time, and now more than 100 peer-reviewed articles
concerning laparoscopic ventral hernia have been published (Table 13.1). Additionally, the number of patients
included in single and multi-institutional studies has
continued to grow. Currently, well over 1000 patient outcomes have been reported in peer-reviewed articles, and
one manuscript details the outcomes of more than 400
patients.9
Use of the technique for laparoscopic ventral herniorrhaphy has also been reported in cases of unusual defects,
such as lumbar hernias, parastomal hernias, and diaphragmatic hernias.1214 While the number of patients in these
series is small, the outcomes have been positive, and the
laparoscopic approach seems uniquely suited for defects
located in challenging anatomical locations.
Table 13.1 Number of articles published

concerning laparoscopic ventral hernia
repair by year (Medline and Embase search)
Publication
year
Number of
articles published
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
18
19
11
13
9
12
8
13
3
3
CONCLUSION
The future of laparoscopic ventral and incisional hernia
repair is promising. Many studies now document a low
recurrence rate with this technique, as well as minimal
patient morbidity afforded by the laparoscopic approach.
While advances in biomaterials and mesh-fixation devices
may lead to future modifications in this technique,
the ability to perform tension-free repair by a minimally
invasive approach is a positive milestone in the history of
hernia surgery.
REFERENCES
1
2
3
4
8
9
Mudge M, Hughes LE. Incisional hernias: a 10-year prospective

study of incidence and attitudes. Br J Surg 1985; 72: 7071.
Flament JB, Palot J, Burde A, et al. Treatment of major incisional
hernias. In: Bendavid R, Abrahamson J, Arregui M, et al., eds.
Abdominal Wall Hernias: Principles and Management. New York:
Springer-Verlag, 2001: 50816.
DeBord JR. The historical development of prosthetics in hernia
surgery. Surg Clin North Am 1998; 78: 9731006.
Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of
suture repair with mesh repair for incisional hernia. N Engl J Med
2000; 343: 3928.
White TJ, Santos MC, Thompson JS. Factors affecting wound
complications associated with prosthetic repair of ventral hernias.
Am Surg 1998; 64: 27680.
LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal
hernias using expanded polytetrafluoroethylene: preliminary
findings. Surg Laparosc Endosc 1993; 3: 3941.
LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
incisional and ventral herniorrhaphy: our initial 100 patients.
Hernia 2001; 5: 415.
Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and
incisional hernioplasty. Surg Endosc 1997; 11: 325.
Heniford BT, Park A, Ramshaw B, Voeller G. Laparoscopic ventral
190: 64550.
History 101
10
11
LeBlanc KA. The critical technical aspects of laparoscopic

repair of ventral and incisional hernias. Am Surg 2001; 67:
80912.
Leber GE, Garb JL, Alexander AI, Reed WP. Long-term
complications associated with prosthetic repair of incisional
hernias. Arch Surg 1998; 133: 37882.
12
Arca MJ, Heniford BT, Pokorny R, et al. Laparoscopic repair of

lumbar hernias. J Am Coll Surg 1998; 187: 14752.
13 LeBlanc KA, Bellanger DE. Laparoscopic repair of paraostomy
hernias: early results. J Am Coll Surg 2002; 194: 2329.
14 Matthews BD, Bui H, Harold KL, et al. Laparoscopic repair of
traumatic diaphragmatic hernias. Surg Endosc 2003; in press.
14
KARL A. LEBLANC
Anatomy and function
Anatomy of a hernia
Anatomical considerations in the repair of
abdominal wall defects
Effects of biomaterial placement in laparoscopic
herniorrhaphy
103
105
106
Maturation of the hernia repair

Cosmetic result
Functional result
Conclusion
References
108
109
109
110
110
107
The abdominal wall is a complex structure with a multitude of components, including skin, muscles, aponeuroses, fat and mesothelium. This musculo-aponeurotic
structure is attached to the vertebral column posteriorly,
the pelvic bones inferiorly, and the ribs superiorly. The
integrity of the abdominal wall is essential for protecting
the underlying organs, allowing for movement of the
trunk of the body, providing assistance in respiration,
and preventing herniation of the intra-abdominal contents. Breaches in this integrity can occur with incisions,
drainage tubes, and postoperative complications. Furthermore, the closure of the incisions is affected by the method
of closure, the type of suture used, and the development of
wound sepsis. Recent studies have even identified that
the suture technique, the suture length to wound length
ratio, and the suture tension have an effect on the ultrastructural composition of the regenerating tissue and
collagen composition.1
Despite the importance of this portion of the body,
many surgeons have little knowledge of the anatomical
details as they relate to the function of the structure. All
physicians know of the need for the disruption of its
structural integrity during the course of an operation
that requires access to the abdomen and sometimes the
retroperitoneum. The factors that influence both the
prevention and development of hernias are frequently
overlooked during the closure of wounds. The result can
be predisposition to a fascial defect that will allow extraabdominal migration of the contents of the abdomen.
This hernia, in turn, can result in complications such as

incarceration, strangulation, loss of domain, and significant cosmetic deformities. Therefore, the approximation
of the abdominal wall as the final act of laparotomy
should be considered to be as important as the intraabdominal procedure that necessitated the incision. This
represents the optimum opportunity to avert the development of herniation in the future.
Once a hernia has developed and a surgeon is to repair
the fascial defect, many considerations influence the
herniorrhaphy or hernioplasty chosen, whether open or
laparoscopic. The aim of this chapter is to familiarize the
laparoscopic hernia surgeon with a working knowledge of
the anterior abdominal wall. This understanding is
important because the anatomical basis of the repair of
incisional and ventral hernias is necessary to assure an
optimal result, structurally, functionally and cosmetically.
ANATOMY AND FUNCTION

The functional anatomy of the abdominal wall centers
upon the flat muscles that provide protection and retention of the abdominal viscera. These muscles also provide assistance in respiration and allow movement of the
mid-portion of the body. These components include the
rectus abdominus, external oblique, internal oblique,
and transversus abdominus muscles.
Rectus abdominus muscle

This muscle extends from the xiphoid process and
the lower rib margins to the pubis. The entire length
of this muscle inserts into the linea alba in the midline of
the abdomen. Because the linea alba is the site of the
most frequent point of entry into the abdomen for open
surgical procedures, this is the site that most commonly
becomes the site of herniation. We have found that
approximately 80 per cent of the incisional hernias that
we repair laparoscopically are located in the midline of
the abdomen.2 The rectus muscle, when contracted, will
bring the xiphoid and ribs closer to the pubis. It also acts
to contain the viscera in concert with the other flat muscles of the abdominal wall. The function of the rectus will
be compromised after the development of a hernia at the
site of the linea alba. The laparoscopic repair of midline
hernias does not re-approximate the linea alba. A few
centers make an effort to close this defect when possible,
but the vast majority of surgeons make no effort to do so.
Therefore, in most cases the normal function of the rectus is not restored to its native state. The placement of the
prosthetic biomaterial will reconstruct the containment
function of the muscle, but it will improve its motor
functions only minimally, if at all. However, the contraction of the scar of the hernia itself will result in a mild to
moderate reduction in the size of the gap of the linea alba
in many patients.
Some laparoscopic surgeons use the posterior rectus
sheath of the rectus within which to perform the operative procedure and to place the prosthetic material. This
posterior rectus sheath is entered, the hernia is reduced,
and the repair is performed within that space. This
provides for an extraperitoneal operation similar to that
of the laparoscopic inguinal herniorrhaphy and the
RivesStoppa repair. The space limitations of this operative field make the approach impractical for very large
and/or incarcerated hernias that do not reside within
the rectus sheath, such as Spigelian or lumbar hernias. It
has also not been proven that this method of repair
improves the functionality of the muscles to a greater
extent than that provided by intraperitoneal placement
of prosthetic biomaterial. The extraperitoneal repair that
is described in Chapter 17 does not afford any differences
as to the function of the linea alba because it is not
re-approximated in this repair.
External oblique muscle

This outermost layer of the flat muscles of the wall of the
abdomen arises from the lowest seven or eight ribs and
courses obliquely downward and towards the midline.
There, it interdigitates with the fibers of the contralateral
external oblique. The fleshy muscle fibers insert on the
anterior iliac spine and the iliac crest. This muscle, in

concert with the internal oblique and the transversus
abdominus muscles, functions to contain the abdominal
viscera. Bilateral contraction of the external oblique
lowers the ribs, thereby bringing the thorax closer to the
pelvic brim. In this manner, it functions as an accessory
muscle of expiration. Unilateral contraction of this muscle causes the opposite hemithorax to depress and rotate
toward the side of muscle contraction.
The function of this muscle can be compromised by
the development of the hernias that are located away from
the midline of the abdomen. Such hernias include subcostal incisional, post-appendectomy, post-colostomy and
Spigelian hernias. Because of the lack of re-approximation
of the edges of the fascial defect during laparoscopic repair,
expiratory function will not resume the efficiency that
was present before the herniation. The extent of this effect
will be dependent upon the size of the fascial defect and
the tone of the other muscles of the abdomen.
Internal oblique muscle

These fibers course beneath those of the external oblique
muscle in an opposite direction. The muscle runs from
the pelvic brim upward and medially to the thoracic cage
and the linea alba. The function of the internal oblique
muscle is similar to that of the external oblique muscle,
but its unilateral contraction results in rotation and lowering of the thorax on the ipsilateral side of the contraction. Consequently, laparoscopic hernioplasty has an
effect on the internal oblique muscle that is similar to
that seen in the external oblique muscle.
Transversus abdominus muscle

This innermost muscle layer of the abdominal wall
inserts posteriorly on to the lower six ribs, the lumbodorsal fascia, the iliac crest, and the iliopsoas fascia. It
also inserts on the medial surface of the costal portion of
the lower seven or eight ribs and interdigitates with the
insertions of the diaphragm. It is a very important component of respiration as it is the main antagonist of the
diaphragm. As such, it could be considered a key muscle
of expiratory function. It acts in this role by displacing
the visceral contents under the diaphragm at the end of
the initial stage of diaphragmatic inspiration.
Because of its position within the layers of the
abdominal wall, the transversus abdominus muscle is
also the major component of the containment function
of these muscles. Because of its structure, it has a powerful action that results in traction on the abdominal wall.
It is this action that results in the tendency of the margins
of the laparotomy incision to separate. This act, of rapid
retraction, explains the dehiscence that can occur acutely
with a vertical midline laparotomy incision. It also

accounts for the difficulty encountered during attempts
to provide closure of the midline following dehiscence or
after development of midline incisional hernias. One of
the advantages of laparoscopic hernioplasty and the use
of a prosthetic biomaterial is that the forces of traction
by this muscle are diminished. Therefore, the function of
the transversus abdominus that would weaken or destroy
a tissue re-approximating type of repair is averted. Conversely, the use of prosthetic material to bridge the gap
that is created by the hernia does little to correct the respiratory function that is lost after such an occurrence.
Much is known about the function of the muscles of
the abdominal wall before the occurrence of a hernia, but
few studies have examined the effects of the muscle function after incisions through them or after the development and subsequent repair of the hernias. These studies
are needed to assess the ability of these operations to
restore the function of these muscles other than that of
the retention of the viscera within the abdomen (see
below).
ANATOMY OF A HERNIA
Approximately 90 per cent of non-inguinal hernias of
the abdominal wall result from an incision through the
aponeurotic layer. The loss of integrity of the transversalis fascia predates its development. Additionally, poor
nutritional status, infection, pulmonary disease, steroid
usage, and morbid obesity can potentiate the weakening
effects of such an incision. Initially, one may not recognize that a hernia has developed as it could take several
months for this to become apparent. Sometimes, however, a postoperative incisional infection will be of such
severity so as to delineate the fascial defect before discharge of the patient from hospital. There is a five-fold
increase in the occurrence of incisional hernias following
an infection in the wound.
The edges of the fascial defect may be difficult to
demarcate preoperatively by the surgeon because of
obesity and/or incarceration. The muscle layers will be
forced aside from the herniation of the pre-peritoneal
tissues or intra-abdominal contents. The herniated structures can be pre-peritoneal fat, omental fat, or small or
large intestine. Rarely, other organs can herniate. Frequently, these organs will be fixed to one another due to
adhesions that have developed after the initial operation.
Generally, as the number of the intra-abdominal operations increases, so does the probability of encountering
more numerous and denser adhesions. Each additional
operative procedure increases these odds, especially if the
patient has had a previous hernia repair using a polypropylene mesh.
Most incisional and ventral hernias will be single

defects within the fascia. The layers of muscle and
fascia will be displaced from the normal position into
all directions from the hernia. This results from the
traction effects of the flat muscles of the abdomen.
Approximately 22 per cent will be of the multiple defect
(Swiss-cheese) variety.1 In these cases, the muscle will
be displaced laterally from the defect, but the fascia will
be intact between the hernias. This will create one or
many fascial bridges separating the various hernias. In
either of these hernia anatomic variations, the peritoneal
surface of the hernia will then be covered with preperitoneal fat (if any exists), subcutaneous fat, and the
skin of the abdominal wall. In some patients, there may
be a lack of any tissue between the hernia sac and the
skin. If this is encountered, good judgment will dictate
that no energy source, such as electrocautery or ultrasonic dissection, should be utilized in that area during
the dissection of adhesions. This will avoid the application of heat in the area, which might otherwise cause
necrosis of the compromised skin surface and exposure
of the underlying prosthetic biomaterial.
Numerous types of incisions are used to enter the
abdomen, obviously influenced by the intra-abdominal
procedure to be performed. Because of this, some
patients may have separate and distinct hernias in more
than one location. This is not infrequent in patients who
have temporary colostomies placed after diverticular
perforation of the colon. These are particularly well
suited for the laparoscopic approach as both hernias can
be repaired simultaneously without the requirement of
two separate incisions. A similar situation is seen in
patients who present with both incisional and inguinal
hernias.
The tissue disruption that can be seen following the
flank incisions for anterior lumbar interbody fusions and
nephrectomies are not usually hernias. This problem is
not a true defect in the fascia but is the result of denervation of the musculature caused by the incision itself. The
flat layer of muscles becomes paralytic. This loss of tissue
support results in a broad area of weakness that is
unsightly and frequently symptomatic. While there is no
true fascial defect in the usual case, occasionally one will
note intestinal contents in a fascial defect within the area
of muscle paralysis (see Chapter 20).
Finally, hernias that occur without a premorbid event
are known as primary hernias. These include epigastric
and umbilical hernias. These can represent 1020 per
cent of abdominal-wall hernias in most series (excluding
inguinal hernias). These patients, however, will incur a
weakness in the transversalis fascia that results in herniation of pre-peritoneal fat and/or the intra-abdominal
contents (Figure 14.1). Predisposing factors include low
birth weight, steroid usage, pulmonary disease, urological disorders, trauma and obesity. Despite the origin, the
Figure 14.1 Attenuated epigastric fascia (arrows) in a patient

with an umbilical hernia.
concepts of the laparoscopic repair of these hernias are

not changed.
There is only limited information regarding the function of the abdominal wall once herniation develops. Of
course, the development of a hernia mandates a loss of
the retention function of the muscles of the abdominal
wall. It is felt that there is also a decrease in the respiratory function of the flat muscles as they have now been
compromised. With chronic incisional herniation, the
affected muscles are no longer inserted into the midline
and are initially hypertonic. Over time, these muscles
undergo ultrastructural changes that result in hypotonicity. The resultant musculofascial changes increase
the risk of recurrence with the sutured repair. For this
reason, the use of a prosthesis is preferred.
Large hernias can result in a paradoxical motion of the
abdominal wall with respiration. As the diaphragm is
moved inferiorly to inspire, this action increases the intraabdominal pressure, which then forces the hernia outward. In this case, the respirations are shallower than
normal, which can be revealed as exertional dyspnea. This
will worsen as the hernia enlarges, but compensatory
mechanisms will normalize the respiratory exchanges at
the expense of increased respiratory work.3
ANATOMICAL CONSIDERATIONS IN THE

REPAIR OF ABDOMINAL WALL DEFECTS
The goal of abdominal-wall hernioplasty is the restoration of the integrity of the covering of the abdominal
contents. The oldest method by which to do this is the
sutured technique of herniorrhaphy. This method will
approximate the linea alba and attempt to restore the
normal architecture of the abdominal wall. It is felt that
this will provide the best long-term functional and
cosmetic results for the patient. Unfortunately, this

method of repair is fraught with a recurrence rate of
2551 per cent in most centers.4,5 In many patients, reapproximation of the midline is impossible due to the
distraction of the abdominal wall musculature. In such
cases, some form of prosthesis is absolutely required if
the hernia is to be repaired.
The use of a prosthetic biomaterial in the open
repair of incisional hernias has reduced the rate of recurrence to 1025 per cent.2,6 The manner of placement of
this biomaterial can vary widely, however.7 The biomaterial can be placed intraperitoneally, extraperitoneally,
below the rectus muscle, above the rectus muscle, or
above the fascia. Additionally, there are several methods
by which to handle the fascial defect itself during the
insertion of the prosthesis. Some surgeons will place
the mesh at the edge of the fascial defect; others will
close the fascial defect before or after the insertion of
the mesh.8
Additionally, methods of fixation of biomaterial vary
greatly across the world. Indeed, it is very common for
the method of fixation to vary between staff of a single
institution. Thus, a comparison of the method of prosthetic repair of open incisional hernias can be difficult
and inaccurate.
Proponents of the laparoscopic repair of incisional
and ventral hernias share the common belief that an
effective repair of the defect requires the insertion of a
prosthetic biomaterial. Only the very smallest of hernias
(#11.5 cm) are closed with sutures alone, although
most series have not mentioned this.9 The method of
fixation and the location of the prosthetic can vary, as with
open repair. The biomaterial can be placed intraperitoneally, extraperitoneally, or behind the rectus muscle
but within the rectus sheath. Most commonly, however,
it is placed in the intraperitoneal position. The method
of fixation is usually with tacks alone or with tacks and
transfascial sutures. Other fixation devices are also available (see Chapter 4). It appears that in only one published series has there been a concerted effort to close the
fascial defect;10 it has not been the practice in other published reports to close this defect. In fact, little attention
has been paid to the necessity of the closure of the linea
alba in the laparoscopic hernioplasty of incisional and
ventral hernias. It is believed that the repair of the fascial
defect will place tension on the repair and offer no
improvement in outcome.
The anatomical considerations of the closure of the
fascial defect and, in most cases, the linea alba will be the
reconstitution of the normal anatomy and function of
the anterior abdominal wall. It has not been proven that
any long-term benefits will be seen if this is done. Many
proponents of open repair will insist on the approximation of the linea alba, as it is felt that this will
restore the respiratory function of the abdominal wall.
This can be done in many but certainly not all cases of

herniation within the abdominal wall (other than
inguinal and femoral defects). Hernia defects that are
larger than 5 cm2 are unlikely to be repaired, primarily
because re-approximation of the fascial edges is usually
not possible. Should one accomplish this closure, then the
repair of most of these hernias will result in a considerable amount of tension. The success of both open and
laparoscopic hernia repair depends on the elimination of
tension on the tissues. This can be accomplished, in the
majority of patients, only with the use of a prosthetic biomaterial. The question of the anatomical modification of
the laparoscopic approach becomes moot if acknowledgment of the concept of tension-free hernioplasty is applied
to every hernia repair.
EFFECTS OF BIOMATERIAL PLACEMENT IN

LAPAROSCOPIC HERNIORRHAPHY
During the repair of incisional and ventral hernias, the
prosthesis will usually be placed in the intraperitoneal
position. In some areas and in some patients this may not
be the case, but in the majority of published series the
location is within the abdomen. While there is a theoretical risk of patch migration, such as has been seen in open
repair, to date none have been reported with laparoscopic
repair. In only one series has the defect within the fascia
been closed.10 The usual operation will simply place the
prosthesis under the defect with a minimum fascial overlap of 3 cm. The biomaterial is then fixed into position
and the operation terminates without regard to the reapproximation of the linea alba. Certainly, in hernias that
are located in sites not in the midline, the linea alba is not
involved in the repair of the hernia. These typically are
not large and are not considered to be significant in the
overall function of the wall of the abdomen. Laparoscopic
repair does not provide for the resection of the peritoneal
sac. Because this sac is not resected, seromas occur very
frequently. Some authors have used electrocauterization
of the peritoneal surface of the sac to diminish the occurrence of seromas.11 Others have used argon-beam coagulation for the same purpose.12 When seromas do occur,
some may require additional procedures to treat them;
fortunately, this is infrequent.
The prosthesis acts as a barrier to the protrusion of
the intra-abdominal contents. It does not assume any
functional role in the abdominal wall. The muscles of the
abdomen will not have any significant change in their
own function after the operation. Repair of the hernia,
especially larger ones, will probably improve the function
of the flat muscles of the abdomen. There are no supportive data to prove this, but one would assume that
elimination of the hernia eliminates the paradoxical
motion of the hernia and its contents in relation to the

normal movements of the abdominal wall. This may be
enhanced over time as the healing process results in
the contraction of the original fascial defect.
The method of fixation could potentially impact the
function of the abdominal-wall musculature, although
this has never been studied. The use of tacks, coils or
other fixation devices alone in the fixation of biomaterial
may not allow the prosthesis to act in tandem with the
muscles, as would the use of transfascial sutures. These
devices will penetrate only 34 mm, thereby attaching
the biomaterial to the posterior layers of the transversus
abdominus and possibly the internal oblique muscles. It
could be postulated that only the movement of the transversus abdominus muscle will affect the patch attached
in this manner. Similarly, one could postulate that the use
of transfascial sutures increases the likelihood that the
flat muscles that are attached to the prosthesis in that
manner will function more normally.
Fixation of the biomaterial with transfascial sutures
will more likely ensure that the movement of each of the
three layers of muscle of the abdominal wall will impact
the prosthesis in some manner. The prosthesis becomes a
significant portion of the abdominal-wall function once
it has been fixed in this manner. I believe that the patch
will respond to movement of these muscles and have a
greater impact in the function of the wall of the abdomen.
However, the sutures will also transfix all of the layers
of the flat muscles together. This could diminish the
independence of each of their functions at those points
of fixation. If the biomaterial is placed in the retrorectal position, then the effects of this will also be felt.
Usually, however, hernias are smaller and only in the midline if this method is utilized. The same functional result
should be seen. More experimental data are needed to
evaluate the impact of these issues.
During adhesiolysis and particularly at the time of
fixation of the biomaterial, there is a risk of injury to the
vessels of the abdominal wall. The significant vessels of
the abdominal wall are the inferior epigastric arteries
and veins. These are usually out of harms way during
more traditional repairs of hernias of the abdomen.
Generally, any injury to these vessels will be recognized
and controlled on the operating table. The most common method of control is the transfascial placement of
sutures, similar to the manner used to fix the patch. This
will easily and effectively control the hemorrhage. Late
hematomas have been described in several series in the
literature. One could assume that these represented late
development of hemorrhage from these vessels, due to
either partial tamponade or delayed necrosis of the vessel
wall secondary to electrocautery or other smaller vessels
that experience the same process.
The sutures may also impinge the small nerves of the
subcutaneous space. This is unavoidable, but it has
MATURATION OF THE HERNIA REPAIR
Figure 14.2 CT appearance of the repaired midline incisional

hernia with DualMesh six months postoperatively.
not proven to be a significant complaint following the

operation. Most of the pain is probably related to neuroma formation, but there are patients who seem to have
prolonged pain (one to two per cent) that may be due to
suture constriction. I have had two patients who were
relieved of symptoms after laparoscopic incisional hernia
repair by the incision of the offending sutures. Local
anesthetic injection can also be used.
The type of biomaterial that is used in laparoscopic
incisional and ventral hernioplasty (LIVH) will also
impact the functionality of the abdomen. The polypropylene meshes (PPM) are usually quite stiff and result in a
significant amount of cicatrization during the healing
process. The contraction of the scar that occurs will result
in a firm area of the abdomen at the site of the previous
hernia sac and defect. This site will not be pliable in the
manner of the normal anatomy. It is not an area that acts
in unison with the muscles of the abdomen but instead
it is an independent site in which the muscles of the
abdomen act around rather than with the biomaterial.
The thicker, two-layered Composixmesh has an even
greater effect of solidifying the site of implantation than
does the single layer of PPM. In the few patients I have
seen who have had this implanted, the abdominal wall
was more board-like than flexible.
Expanded polytetrafluoroethylene (ePTFE) products
result in an organized healing process that resembles
more closely that of the normal progression. As a result,
the abdominal wall is more likely to act with rather than
against the patch in the function of the muscles. While
this prosthesis is not stretchable, the softness of the product and the characteristics of the collagen infiltration
into the biomaterial allow it to conform more naturally
to the abdominal wall. Follow-up computerized tomography (CT) of the abdomen after this procedure will verify the conformability of the prosthetic biomaterial
(Figure 14.2).
Once LIVH is completed, the healing processes will begin

immediately. Scar contraction, which has the effect of
shrinking the biomaterials, will generally be completed
within 90 days. Following this time period, the effects of
the biomaterial choice will become apparent. PPM products can contract as much as 2060 per cent, although
this process may take place over the ensuing one or two
years. In so doing, the original defect will correspondingly contract, which results in a closer re-approximation
of the abdominal wall muscles. This could improve the
function of these muscles, but the dense scar may actually be more of a detriment to this fact; no studies are
available to verify this statement.
ePTFE biomaterials will contract 2050 per cent but
with more flexibility than polypropylene biomaterials.
There is rapid infiltration of cellular elements into the
interstices of the product. This may effect more rapid
healing and result in the function of the abdominal wall
being more matured at the completion of the LIVH if
ePTFE rather than other materials is used in the repair.
This is especially true with the newest products that have
a corduroy surface.13
During the healing phase following the operation,
many clinical changes will be seen that may be new to
surgeons who have just started using this technique.
Initially, many patients will not have any noticeable protrusion at the site of the original hernia, particularly if
a pressure dressing or abdominal binder is used following the procedure. Many, if not all, patients, however,
will develop a seroma at the site of the hernia sac.14 The
size and significance of this varies greatly. This can be
worrisome and unsightly, but it usually resolves without
intervention.
Following its resolution, the patient will generally have
an abdominal wall that is very similar in appearance to the
premorbid condition before the development of the hernia. The cosmetic result in the vast majority of patients
will be acceptable to both the surgeon and the patient
because of the resumption of a normal contour as perceived by the patient. Most patients, particularly obese
individuals, will have a lax abdomen due to lack of tone in
the muscles of the abdominal wall. In these individuals,
the larger patches will actually result in a flattened appearance compared with other areas of the abdomen. This is
probably related to the improved support of the abdominal wall by the prosthetic. In some patients, the lateral
aspects of the abdomen (outside the prosthetic biomaterial) will seem to protrude disproportionately compared
with the mid-portion where the repair was done. These
effects are more pronounced with PPM biomaterials than
with ePTFE products. A few patients will need reassurance
of this phenomenon. In patients that have a particularly
lax abdomen, I prefer to make a note of this to the patient

preoperatively so that this can be anticipated.
COSMETIC RESULT
Many surgeons are concerned with the skin that overlies
the hernia protrusion. In many cases, this represents a fairly
sizable amount of tissue that is much larger than the defect
of the fascia itself. Patients with a large amount of redundant skin after the hernia repair may need to wear the
binder for a longer period of time. This will help to eliminate the dead space that is created by the repair of the hernia. Despite this effort, however, many patients will have
changes that will take a few months to resolve. Initially, this
area will be soft owing to the presence of a seroma in many
cases. After a few weeks or months, this will become firmer
as a result of the healing process. The seroma fluid will be
absorbed, and scar tissue will replace this fluid. The scar
will then contract within several weeks or months. The
timeframe of these events will be dictated by the size of the
hernia at the original operation. The larger eventrations
will, of course, take a longer period of time to complete the
healing process. Generally, however, this will be completed
within 90120 days (Figures 14.3 and 14.4).
The redundant skin will contract as these events are
taking place. Once this is complete, the skin will almost
always resume the appearance that it had before the
development of the hernia. The pre-peritoneal fat that
was scarce preoperatively overlying the hernia sac will
sometimes be replaced by new fat. The patch will not be
felt underneath the skin, and a more normal curve of the
abdomen will be seen, regardless of the size of the hernia
that was repaired. In essence, the cosmetic result will be
excellent. In no patient, in either my personal work or
any known published series, has any mention been made
of the need for reconstruction or revision of the skin and
subcutaneous tissues overlying the hernia defect after
this period of time has transpired.
However, some surgeons believe that the cosmetic
result is unacceptable to themselves and their patients.
For this reason, open repair may be preferred so that a
paniculectomy can be performed at the same time. This
is particularly apparent with large hernias, such as those
that have loss of domain. One may be advised to proceed
with the open repair from the outset.
FUNCTIONAL RESULT
There is a paucity of information regarding the functional
result following LIVH. The compliance of the abdominal
wall has been noted to change after the repair of incisional
Figure 14.3 Preoperative photograph of a patient with a

post-appendectomy hernia.
Figure 14.4 Postoperative photograph of the patient shown in

Figure 14.3 after five months. Note the resumption of the
contour of the abdomen. The cosmetic result was symmetrical
bilaterally.
and ventral hernias. This seems to be dependent on the

type of biomaterial that has been used in the repair of
the fascial defect. The elasticity (tensile strength) of the
abdominal wall has been evaluated in the laboratory.
The mean distention of the abdominal wall at 16 N
ranged from 11 to 32 per cent. The textile analysis of
PPM, polyester and other meshes revealed the range of
elasticity from four to 16 per cent.15 This would indicate
that the flexibility might be affected by the implantation
of these meshes. These measurements, however, were
taken in cadavers, which may have affected the results.
Nevertheless, there has been a move to decrease the
amount of PPM material that is used in the open repair of

incisional hernias when repaired with PPM. The effect of
this can be shown in the laboratory, but the actual clinical
significance has not been shown conclusively. There are
even fewer data relating to ePTFE products, and no data
are available regarding the laparoscopic approach to this
implantation.
It can certainly be said that there is no re-approximation
of the fascia or the muscles of the abdominal wall with
LIVH. The long-term effects of this remaining defect in
the fascia of these muscles have not been studied. The
follow-up of our patients over a period of time that exceeds
ten years has not revealed a single problem related to this
remaining functional defect. I believe that these patients
have lost the benefit of a normal anatomical functioning
abdominal wall because of lax musculature and/or the
hernia itself. The repair of the single defect does not impact
the innate laxity of the normal muscles. Additionally, the
development of the hernia itself signifies that the patient
has weakened fascia.
10
CONCLUSION
11
Laparoscopic repair of incisional and ventral hernias

requires the use of a prosthetic biomaterial. In all but the
smallest of hernias, no tension is placed on the repair. This
may explain the decrease in the length of hospitalization of
patients because of diminished levels of pain and ileus.
This does not provide for the reconstitution of the normal
anatomy of the abdominal wall. In so doing, expiratory
function may be compromised. In no cases, however, has
this been proven to be a clinical problem. More experimental and clinical studies are needed to assess accurately
the functionality of the wall of the abdomen following
laparoscopic ventral and incisional hernioplasty.
REFERENCES
1
Her JJ, Junge K, Schachtrupp A, et al. Influence of laparotomy

closure technique on collagen synthesis in the incisional region.
Hernia 2002; 6: 938.
12
13
14
15
LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes VK. Laparoscopic

incisional and ventral hernioplasty: lessons learned from 200
patients. Hernia 2003; in press.
Trivellini G, Danelli P. Respiratory pathophysiology and giant
incisional hernias. In: Bendavid R, ed. Abdominal Wall Hernias.
New York: Springer-Verlag, 2001: 16672.
Hesselink VJ, Luijendijk RW, deWilt JHW, et al. An evaluation of
risk factors in incisional hernia recurrence. Surg Gynecol Obstet
1993; 176: 22834.
Luijendijk RW, Hop WCJ, Tol van den P, et al. A comparison of
2000; 343: 3928.
Flament JB, Avisse C, Palot JP, Delattre JF. Biomaterials. Principles
of implantation. In: Schumpelick V, Kingsnorth AN, eds. Incisional
Hernia. Berlin: Springer-Verlag, 1999: 21730.
Flament JP, Palot JP, et al. Treatment of major incisional hernias.
In: Bendavid R, ed. Abdominal Wall Hernias. Berlin: SpringerVerlag, 2000: 50816.
incisional and ventral herniorrhaphy in 100 patients. Am J Surg
2000; 180: 1937.
Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral
and incisional hernia repair. Surg Laparosc Endosc 1998;
8: 2949.
Tsimoyiannis EC, Siakas P, Glantzounis K, et al. Seroma in
laparoscopic ventral hernioplasty. Surg Laparosc Endosc Percutan
Tech 2001; 11: 31721.
Lehr SC, Schuricht AL. A minimally invasive approach for treating
postoperative seromas after incisional hernia repair. J Soc
Laparoendosc Surg 2001; 5: 26771.
LeBlanc KA, Bellanger DE, Rhynes VK, et al. Tissue attachment
strength of prosthetic meshes used in ventral and incisional hernia
Susmallian S, Gerwurtz G, Ezri T, Charuzi. Seroma after
laparoscopic repair of hernia with ePTFE patch: is it really a
complication? Hernia 2001; 5: 13941.
Junge K, Klinge U, Prescher A, et al. Elasticity of the anterior
abdominal wall and impact for reparation of incisional hernias
using mesh implants. Hernia 2001; 5: 11318.
15
GUY R. VOELLER
References
113
Laparoscopic repair of ventral/incisional hernias is

usually an elective surgical procedure. While these hernias
may incarcerate, it is usually over a long period of time
and they become what should be called chronically incarcerated. The bowel comes to reside in the subcutaneous
tissues and can cause cosmetic problems and/or discomfort, but only infrequently does it acutely obstruct. When
discussing laparoscopic repair of ventral/incisional hernias in the truly emergent setting, we are talking about the
few cases where the bowel is acutely obstructed and/or
strangulated. While not common, there is a role for the
laparoscopic approach in select cases.
Basic preoperative preparation is fairly standard and
well known to most surgeons. Fluid and electrolyte correction is most important, along with nasogastric decompression and Foley catheter placement to monitor fluid
replacement. Appropriate antibiotic therapy should be
administered before making the first incision. If there
is evidence of a septic situation, then pulmonary artery
catheters, arterial lines and ventilators must be available.
A review of our technique is published elsewhere,1 but
important points will be described here. The abdominal
wall is shaved and prepped in its entirety. The one wellestablished advantage of the laparoscopic repair of ventral/
incisional hernias when compared with open techniques
is fewer wound problems. In addition, the mesh becomes
infected less frequently. We treat the mesh like a vascular
graft and avoid any contact with the skin, etc. An Ioban
(3M Healthcare) protective drape is used to cover all the
skin. Using this approach, we have never encountered a
patient who has developed a postoperative infection of
the prosthesis when placed laparoscopically.
Safe access to the peritoneal cavity is of utmost importance, especially when dealing with distended loops of
bowel. As we first described, our procedure of choice is the
use of a balloon-tipped Hasson-type trocar lateral at the
Figure 15.1 Hasson cannula at left costal margin.
costal margin (Figure 15.1). This is carried out through a

10-mm incision using the S-shaped Hasson retractors.
Each layer is incised under direct vision and the muscle
layers are spread with a tonsil-type clamp. The retractors
hold the muscle aside while a number 11 blade is used to
incise each layer of fascia. Again, in several hundred repairs
we have never injured any viscera with this method and we
have never been unable to gain access. An angled laparoscope (30 or 45 degrees) is very beneficial since it allows
viewing of almost any area, depending upon how the angle
is directed. A good 5-mm laparoscope allows use of 5-mm
working ports, which keeps 10-mm holes to a minimum.
The amount of bowel distention in the case of an
acutely obstructed ventral/incisional hernia will dictate
the ease with which adhesiolysis and visualization can be
accomplished. There have been, and continue to be, deaths
due to bowel injuries during lysis of adhesions that are
not detected at the time of surgery. In almost every case
reviewed by the author, harmonic-type scalpels and
Figure 15.2 Incarcerated small bowel.
electrocautery have been used in these cases. We do not

recommend the use of these devices unless the surgeon
knows that he or she is far removed from the bowel. It is
very important to have special graspers for bowel that are
atraumatic in every respect. The best grasper we have
found is made by Applied Medical and utilizes a reusable
instrument with disposable padded cushions that are
placed at the tips of the grasper.
If adhesiolysis can be done safely and totally laparoscopically, such that the incarcerated bowel can be seen,
then the next decision involves reduction of the bowel
from the defect(s) (Figure 15.2). Gentle traction on the
bowel will either allow or not allow reduction. One must
be very careful with this movement; if the bowel is
reduced easily, then one can proceed with a standard
laparoscopic repair. If the surgeon fears the bowel might
be torn, then there are two options. The first option is to
take a well-insulated J-type or L-type hook and use it to
enlarge the hernia defect to aid in reduction. It is critical
that this is done away from the bowel; if the bowel is at
risk, it should not be done, since this involves use of
energy close to the bowel. We have used this maneuver
several times, with good success.
If the incarcerated bowel cannot be reduced laparoscopically, then there is a second option that involves
a small incision directly over the acutely incarcerated
bowel. One should maintain the pneumoperitoneum as
the skin incision is made and monitor progress with the
laparoscope until pneumoperitoneum is lost. The incision does not have to be large, and usually the bowel can
be reduced under direct vision. In several cases, we have
even performed a small-bowel resection through this
small counter-incision, replaced the bowel back into the
abdomen, closed the skin, and finished the procedure
laparoscopically. In no instance has this resulted in
infected mesh or wound infection.
The details of our repair technique are described
elsewhere. Once the obstructed/incarcerated bowel is
Figure 15.3 Dual-sided mesh.
Figure 15.4 Suture fixation of mesh.
reduced, the borders of the defect are determined and the

correct size of mesh is brought to the field (Figure 15.3).
We taught the first organized course in the world on
laparoscopic ventral/incisional hernia repair in 1996 and
based our technique on an open repair, the RivesStoppa
repair, which we teach our residents and has been shown
worldwide to have the lowest recurrence rates for ventral/
incisional hernia repair.2,3 This open repair relies on
retrorectus suture fixation of the mesh (behind the defect)
to the fascia of the abdominal wall for long-term success.
The same holds true for the laparoscopic approach. To
believe that in-growth of various meshes is important for
long-term success fails to recognize that any significant
in-growth is to peritoneum, not muscular fascia, and if
the hernia is of any size then the mesh simply migrates
over time with the peritoneal sac into the fascial defect.
The sutures are placed every 57 cm or more frequently,
based on the size of the defect. The mesh is tacked between
the suture fixation points to prevent internal hernia formation. The tacks add nothing to the long-term strength
of the repair (Figure 15.4).
The types of mesh available have significantly increased
surgeons options in the face of emergent repair of
Laparoscopic repair in the emergent setting 113
Figure 15.5 Final repair.
ventral/incisional hernias laparoscopically. A detailed

description of meshes is beyond the scope of this chapter,
but a few things need to be mentioned. When we, and
others, first developed the technique, expanded polytetrafluoroethylene (ePTFE) became the prosthetic of choice
since it could be placed safely in an intraperitoneal position without the worry of in-growth to the viscera. While
Franklin has shown that polypropylene mesh (PPM) can
be placed laparoscopically against the bowel, we know that
in-growth will occur, and long-term problems are well
described when this has been done in an open fashion.3
Fistulas and extrusion have been reported with PPM.
Various coatings of both PPM (Sepramesh
) and polyester mesh (Parietex Composite
) are being investigated
to prohibit visceral in-growth. Animal studies show some
effectiveness with these coatings.
Strangulated bowel presents a different situation.
First, it should be said that bowel that appears dead often
returns to normal appearance if given time. The incarcerated hernia shown in Figure 15.2 had 20 cm of darkblack-appearing small bowel incarcerated in the defect
once it was reduced. The patient was a physician who
presented with signs and symptoms of acute small-bowel
obstruction. Once the bowel was reduced, the color
returned to normal after several minutes and the procedure was completed (Figure 15.5). However, if the bowel
is truly gangrenous, then two options now exist. Another
big advantage of the laparoscopic approach is that the
hernia does not have to be fixed at the time of finding
truly necrotic intestine. One can simply resect the bowel
laparoscopically or laparoscopically assisted as above,
wash out the abdomen, and come back later for definitive
hernia repair. If the large bowel is involved in an unprepped
colon, then a colostomy can easily be carried out laparoscopically. This is not the case through a large formal
incision, where one is now faced with repairing a large

defect in the face of contamination and/or gangrenous
intestine. This becomes a very complicated and problematic situation, usually with open wounds, nutritional
problems, and prolonged hospitalization. The second
option, in the face of strangulated bowel, is to place the
mesh if contamination is judged to be minimal and the
chance of mesh infection is low (see below).
None of this addresses the ability of the various meshes
to resist infection when placed in a contaminated or potentially contaminated situation, which is what we are faced
with in the emergent setting. Mandala and colleagues
have shown that PPM can usually be placed safely in clean
contaminated situations but they are not as in favor
in contaminated cases (Altemeier classification of wound
contamination 3).4 Studies need to be carried out with
respect to this. More recently, pig submucosa-based mesh
(Surgisis
) has been promoted for use in the contaminated
situation. We have used this on several occasions, without infection of the mesh. Lastly, W. L. Gore has incorporated an antimicrobial coating into its DualMesh Plus
that lasts for five to seven days. Intuitively, this makes us
feel that there is an element of protection. We have used
this mesh in many cases of minimal contamination during laparoscopic ventral/incisional hernia repair, and we
have never had to remove it once due to mesh infection.
Additionally, in animals, Stone has shown that ePTFE
can be used to patch full-thickness defects in bowel without it becoming infected.5 He believes this is due to the
type of bacteria that reside in the bowel.
In conclusion, laparoscopic ventral/incisional hernia
can be done safely in the emergent setting but should
be limited to surgeons experienced in the technique in
the elective setting. Much work needs to be done with
respect to meshes and their abilities to resist infections in
the emergent setting laparoscopically.
REFERENCES
1
Voeller GR, Mangiante EC. Laparoscopic repair of ventral/incisional

hernias. In: Fitzgibbons ER, Greenburg A, eds. Nyhus and Condons
Hernia, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2001:
3739.
2 Rives J, Pire JC, Palot JP, Flament JB. Surgery of the abdominal wall.
Major incisional hernias. In: Chevrel JP, ed. Surgery of the
Abdominal Wall. Berlin: Springer-Verlag, 1987.
3 Flament JB, Rives J, Palot JP, et al. Major incisional hernia. In:
Chevrel JP, ed. Hernia and Surgery of the Abdominal Wall, 2nd edn.
New York: Springer-Verlag, 1997: 12858.
4 Mandala V, Bilardo G, Darca F, et al. Some considerations on the use
of heterologous prostheses in incisional hernias at risk of infection.
Hernia 2000; 4: 26871.
5 Stone H. Abdominal compartment syndrome. Presented at the
American Hernia Society Meeting, Tucson, AZ, USA, May 2002.
16
Herniorrhaphy with the use of
transfascial sutures
KARL A. LEBLANC
Indications
Contraindications
Prosthetic biomaterials
115
116
116
117
Laparoscopic incisional and ventral hernioplasty (LIVH)

was first described in 1993.1 The concepts of this technique are equivalent to the tension-free repair of inguinal
hernias, which has become popular in the past two
decades. The open tissue repair of incisional hernias has a
recurrence rate of 2552 per cent. The use of a prosthetic
biomaterial to repair these fascial defects lowers the recurrence rate to 1123 per cent. The rate of recurrence with
the laparoscopic approach has been reported to be from
1 to 9 per cent.26 It is important to note that in most of
these reports, the results included the early experiences of
the authors as well as the repairs that occurred with the
knowledge gained from that experience (see Chapter 21).
The repair of incisional and ventral hernias by this
approach should be considered an advanced laparoscopic technique. It is best to have the assistance of a
surgeon experienced in performing this particular procedure for at least the first ten to 15 patients if possible.
Of course, to optimize outcome, conversion from the
laparoscopic technique to the open method should be
done at the earliest sign of difficulty. In our experience,
this will be necessary in 3.5 per cent of patients.
Approximately one-third of these will be due to an injury
to the bowel.5 Others have reported that conversion to
the open procedure was necessary in seven per cent of
patients, with a bowel injury rate of four per cent.6 Once
past the learning curve, the participation of an assistant
surgeon who is knowledgeable in advanced laparoscopic
techniques is generally considered optimum for the
repair of all but the smallest defects. Finally, there are a
Intraoperative considerations
Postoperative considerations
Conclusion
References
118
123
124
124
few different methods that are used to perform this procedure; these are described in Chapters 17 and 18.
INDICATIONS
Any patient that could undergo an open prosthetic repair
can be considered for the laparoscopic approach. The
size of the fascial defect will play a significant role in
many circumstances. The size of the defect is not a limiting factor, although I frequently restrict my use of the
laparoscopic procedure to hernias that are larger than
23 cm in their greatest dimension. The size of the incision required for the open repair of a small defect is similar to the combined size of the incisions required for
insertion of the laparoscopic trocars. Because we use only
5-mm trocars to perform this operation, these hernias
will approximate the size of the combined incisions.
Additionally, such small defects can often be repaired
without the use of a prosthetic material. This recommendation would be universally applicable only to thin
patients. Obese patients will have an unacceptably high
rate of recurrence without the use of a prosthesis because
of the increased intra-abdominal pressure.7 Therefore, I
routinely repair these hernias in obese and morbidly
obese patients with the laparoscopic technique (even primary umbilical hernias). Patients with recurrent hernias
should be repaired with this technique even if the size is
less than 3 cm, because they have demonstrated the need
for prosthetic placement. LIVH is the easiest method by
which to repair such hernias and also allows the surgeon

to inspect the entire length of the abdominal wall to
identify any unsuspected fascial defects that were not
apparent clinically. This can be seen in 22 per cent of
patients who undergo LIVH.5 Some patients will have
areas of fascial weakness that are apparent with the
laparoscopic approach (Figure 14.1). These areas of
potential herniation should be repaired when identified.
CONTRAINDICATIONS
As with any operative procedure, the surgeon must evaluate the overall status of the patient before proceeding
with a laparoscopic incisional hernia repair. In general,
if the patient is a medically appropriate candidate for
the open hernioplasty, then they could be considered a
candidate for the laparoscopic approach. Patients with
severe cardiomyopathy or pulmonary disease may not
tolerate the insufflation pressures that are necessary for
any laparoscopic procedure. Therefore, these individuals
must be evaluated carefully preoperatively. Portal hypertension is nearly always a contraindication.
If there is a suspicion of an intra-abdominal infection
or an acute surgical abdomen, then the use of prosthetic
biomaterial is generally prohibited. In this situation, the
laparoscopic approach is contraindicated because of the
risk of infecting the prosthesis. One may elect to initiate
this operation if incarcerated bowel is suspected. Release of
the obstruction will allow the surgeon to inspect the viability of the intestine. If there is no strangulation or perforation, then the operation can proceed. A few centers will
perform a bowel resection and repair the hernia laparoscopically and concomitantly (see Chapters 15 and 18).
A relative contraindication may be the number of
intra-abdominal procedures that the patient may have
undergone prior to the anticipated LIVH. This decision
should be made based upon the surgeons skill level and
the type of the procedures that were performed previously. Frequently, the patient may not have significant
adhesions despite many previous intestinal procedures.
However, one should be very cautious if the patient has
had a previous repair of an incisional hernia that
included the placement of a polypropylene biomaterial
in direct contact with the contents of the abdomen.
There is nearly always a significant amount of very dense
and extensive adhesions. The risk of intestinal injury is
particularly high in these patients.
PREOPERATIVE EVALUATION
Once the patient has been identified as an acceptable
surgical risk, the surgeon should evaluate the condition of
the patients abdomen and the hernia(s) that will be
repaired. A very large fascial defect may sometimes cause
reconsideration of a laparoscopic approach. The operating time required to repair a defect that approximates the
entire surface of the abdominal wall could negate the benefits of the laparoscopic method. These patients are prone
to having significant postoperative ileus, regardless of the
repair employed. The surgeon may think that the increase
in operative time and risk will not justify use of a laparoscopic repair. However, there are currently no hard and
fast rules about this issue. In those patients with very large
defects, I generally prefer to begin the operation laparoscopically and convert to an open repair if that appears to
be the best alternative. More often than not, this proves to
be unnecessary. If there is a significant loss of domain, it
may be impossible to actually enter the abdomen because
the entire musculature of the abdominal wall is absent. In
these cases, conversion to the open method is certainly an
option. If the patient requires preoperative pneumoperitoneum because of the size of the hernia, then it is not
recommended to attempt the repair laparoscopically.
Morbid obesity can occasionally become a limiting
factor. In such patients, the available trocars may be of
insufficient length to maintain adequate access to the
abdominal cavity. It could become necessary to convert
to the open repair because a working channel through
the abdominal wall cannot be maintained. The open
ends of the trocars will be withdrawn continually into
the excessive fatty tissue, which eliminates the working
channel and results in insufflation of the subcutaneous
tissues. One may actually sew the trocars to the skin to
ensure the position, but the newer, longer trocars that are
now available will usually solve this dilemma.
In our series of patients, 90 per cent of the hernias
that are repaired with this method are incisional. Because
the most common incision of the abdomen is placed in
the midline, approximately 90 per cent of those hernias
are located in the midline of the abdomen.5 These hernias are generally easier to approach with this method
than hernias located outside of the midline. However,
as more experience is achieved, the presence of a nonmidline defect or multiple defects that are not adjacent to
each other should not preclude the use of laparoscopy.
Appropriate positioning of the patient and accurate
placement of the trocars will permit an approach to the
entire abdominal cavity in most cases. The use of angled
laparoscopes also facilitates these repairs.
In addition to the site of the hernia, the number and
type of previous open abdominal operations will influence the choice of patient position, the method of abdominal entry, trocar placement, and the position of the
monitors. Decisions regarding these factors should be
made preoperatively and then finalized when the patient is
on the operating table and under general anesthesia. There
will be a greater likelihood of significant adhesions that
will require lysis during the initial phases of the operation
if the patient has had many separate intra-abdominal procedures. Patients in whom a previous repair included the
Herniorrhaphy with the use of transfascial sutures 117
insertion of a polypropylene prosthesis can be expected to

have dense scarring in all areas in which the material was
not covered by omentum; however, this should not deter
experienced surgeons from attempting a laparoscopic
approach. It is important to note that the difficulty of the
procedure will be magnified greatly because of the dissection of the tenacious scarring that will have occurred to
the bowel and/or omentum. Because the risk of enterotomy is increased significantly in such cases, occasionally it
will be necessary to leave remnants of the mesh attached to
the bowel to avoid injury to the intestine (Figure 16.1).
Laparoscopic incisional hernioplasty should be individualized in patients with known ascites because it is
impossible to close the trocar sites in a consistently
watertight manner that averts ascitic leaks. Moreover,
these patients usually have a metabolic problem (e.g.
cardiac, renal or hepatic disease), which can cause poor
healing and predispose to development of multiple
hernias at the trocar sites. However, it is these metabolic
problems that make the laparoscopic approach particularly appealing in these types of patients. If a medical
comorbidity does not preclude the laparoscopic method
from these patients, then one should use 5-mm noncutting or self-dilating trocars to diminish the risk of
prolonged leakage from one of the trocar sites. A Z-path
of entry will help in closure of these puncture sites. It is
preferable to close the trocar site defects even with the
use of these trocars to further decrease the risk of ascitic
fluid leakage. Several types of instruments that allow
the passage of sutures transfascially are used in this
procedure that will also close these defects.
LIVH patients are admitted to hospital day-surgery
units because they can usually be considered for discharge on the day of surgery. Twenty-six per cent of
our patients are discharged on the day of surgery, and
85 per cent of our patients remain in hospital for
23 hours or less.5 The type of hernia and the amount of
dissection required will dictate whether a patient remains

in hospital overnight or for longer. Minimal preoperative
preparation is required, but appropriate laboratory testing should be obtained before the day of surgery. Patients
are routinely given an antibiotic (usually a first-generation cephalosporin) preoperatively. However, if the biomaterial that will be implanted contains antimicrobial
agents (e.g. DualMesh Plus
), antibiotic prophylaxis is
not felt to be mandatory.
Figure 16.1 Laparoscopic view of small intestine with remnant

of polypropylene mesh. The white arrows outline the mesh.
Figure 16.3 Laparoscopic view of the visceral surface color of

DualMesh Plus.
PROSTHETIC BIOMATERIALS
Many products are available for the repair of incisional
hernias. The most commonly used product for this operation is the 1-mm thick expanded polytetrafluoroethylene (ePTFE) prosthesis, DualMeshor DualMesh Plus
(see Chapter 3). My choice of biomaterial for this operation is DualMesh Plus. This contains antimicrobial
agents that impart a brown color to the biomaterial
(Figures 16.2 and 16.3). This color inhibits the glare of
Figure 16.2 DualMesh Plus.
the white surface of the standard product and identifies

the surface that should lie in contact with the intraabdominal organs (brown is down). If one chooses to
use the standard DualMesh, it is recommended that the
parietal surface of the prosthesis is marked with a skinmarking pencil before its insertion to avoid the inadvertent reversal of the orientation of the patch. The
corduroy appearance of the parietal surface also helps
distinguish the two different surfaces of the biomaterial.
(a)
(b)
INTRAOPERATIVE CONSIDERATIONS
Patient preparation and positioning
LIVH repair requires the use of general anesthesia to
achieve the necessary degree of relaxation and sedation.
In most cases, it is not necessary to use a gastric tube or
urinary catheter unless the operative sites are in close
proximity to the stomach or bladder or if the procedure
will be prolonged. Typically, when used, both the gastric
tube and urinary catheter are removed at completion of
the procedure.
Most patients will be placed in the supine position.
Operations upon lateral defects of the abdominal wall,
such as those in a subcostal or flank incision, will be facilitated by the use of a semi-decubitus or full decubitus
position that is maintained with the use of a beanbag.
The additional use of the tilt capabilities of the operating
table (i.e. Trendelenburg or lateral rotation) will assist
in the manipulation of the bowel during dissection by
moving these into the dependent portion of the abdomen.
The patients arms should be tucked in close to the body,
unless the size of the patient is prohibitive, to allow sufficient room to move around the patient. This is especially
important if the hernia is in the lower abdomen.
Instrumentation
There are several choices of laparoscopes (0-, 30- or 45degree) for incisional hernia repair. Because thin patients
with good muscle tone do not accommodate as much
distention as obese patients with poor muscle tone, a
30-degree laparoscope may provide a better view in thin
patients. The 45-degree laparoscope is used rarely, if ever.
Most surgeons prefer to use the 30-degree laparoscope but
I generally use the 0-degree instrument. The angle or size of
the laparoscope itself is not important as long as the view is
the best available. Smaller laparoscopes permit the use of
smaller trocars, which decreases postoperative pain and
minimizes the risk of herniation at the site of the trocar.
Because I prefer the exclusive use of 5-mm port sites,
all of the instruments used will be of that size. However,
the size of the instrument is not important. The critical
(c)
Figure 16.4 Instrument jaws for organ and prosthetic

biomaterial manipulation: (a) aggressive, (b) self-retaining,
and (c) smooth.
choice of these instruments will be the shape of the jaws.

For grasping the bowel, omentum and the prosthesis,
aggressive, thick jaws are preferred (Figure 16.4a). These
allow for the firm grasp that is usually required during
adhesiolysis and placement of the prosthetic biomaterial.
To pull in the biomaterial from the trocar site (see below),
a strong-jawed, self-retaining grasper is necessary (Figure
16.4b). This will be required to maintain a firm grasp of
the prosthesis so that it can be pulled into the abdomen
through the 5-mm port site. The placement of the transfascial sutures should be done with the aid of fine-toothed
instruments (Figure 16.4c). These hold the sutures better
than instruments with aggressive jaws because the suture
will slip between the large spaces of the teeth of the latter
(see Chapter 2).
The most difficult and tedious portion of the hernioplasty is the dissection of adhesions within the abdomen
and/or the hernia itself. The method of dissection is critically important in order to prevent injury to the intestine.
If the adhesions encountered are few and rather filmy, then
one may use scissors with or without the additional application of electrocautery. The use of this and all energy
sources for hemostasis should be judicious and carried out
only if there is absolute certainty that there is no bowel
adjacent to the area that will be affected by the lateral
extension of the heat of the energy source. The upper
abdomen and falciform ligament are the most common
locations for such a situation. In most cases, however,
some dissection of omentum and bowel will be required
to allow the identification of the fascial edges and the
placement of the prosthetic biomaterial. One may choose
to use the Harmonicscalpel (Ethicon Endosurgery, Inc.).
This device has scissor-like jaws that dissect using ultrasonic energy. There is very minimal lateral spread of heat
with this energy source, which enhances the safety in the

dissection near the intestine. It cannot be overstated, however, that improper use of any energy source can result in
an injury to the intestine. Sometimes, a burn may occur
that will not become apparent until the intestinal wall
undergoes necrosis several days postoperatively. If intestine
is encountered that is densely adherent to the abdominal
wall or to a polypropylene biomaterial from a previous
repair, then it is recommended that scissors (without electrocautery) are utilized for the required dissection. Some
surgeons never use any energy to dissect the tissues.
Occasionally, the hernia contents cannot be reduced
with dissection and traction because of incarceration. In
such cases, the surgical enlargement of the fascial defect
will permit the reduction of the involved organs. This
can be done with the use of electrocautery scissors or the
Harmonic scalpel. Generally, a 13-cm incision into the
fascia will suffice. The size of this incision is not critical
so long as the intestinal contents can be reduced safely
because the resulting defect will be covered by the prosthesis that repairs the hernia.
A variety of fixation devices is currently available (see
Chapter 4). These devices are used to secure the prosthetic biomaterial to the abdominal wall between the
transfascial sutures and to prevent the migration of any
portion of the omentum or intestine between the patch
and the abdominal wall. My preference is the Salute
device (Onux Medical, Inc.). This allows the accurate
placement of the constructs while ensuring that the
periphery of the biomaterial is flat against the abdominal
wall. Its function is equivalent to that of the helical coil in
other respects, however.8 Additionally, a removal instrument is available if one decides that the placement of a
construct is not ideal.
Devices to place the transfascial sutures are an integral
part of this operation. Two such devices are the Endoclose
(U.S. Surgical Corp./Tyco International, Inc.) and the
Gore-Texsuture-passer (W. L. Gore & Associates). This
author prefers the latter because it is reusable and has a
consistently sharp tip (Figure 16.5).
Trocar selection
It is understood that the method of access into the
abdomen should always be the safest possible approach.
In patients with a primary ventral hernia or a single incisional hernia defect, a Veress needle could be considered
for insufflation before introduction of the first trocar. In
the repair of incisional hernias, a safe area for needle
insertion is usually in the right or left upper quadrants
because this area is generally free of adhesions of bowel
and omentum, particularly for lower-abdominal hernias.
An entry point in the midline could be used if it can be
placed far enough away from the hernia so that it does
Figure 16.5 Gore-Tex suture-passer holding a suture as it is

withdrawn from the abdomen.
not interfere with the placement of the prosthetic biomaterial, in that the overlap may cover the trocar itself.
Many surgeons will choose to use either an optical
trocar for abdominal entry or an open entry (Hassan
technique) if the Veress needle method is not chosen. My
preference is the non-bladed trocar (Ethicon Endosurgery, Inc.) but other devices are available, such as the
Visiport(U.S. Surgical/Tyco International, Inc.). These
trocars are designed to provide visualization of each layer
of the abdominal wall as the trocar passes through them.
The former is available in 5-, 10- and 12-mm sizes, whereas
the latter is available only in the 12-mm size. While the exact
method in which this is accomplished differs between these
two devices, both of them are used with the laparoscope
inserted into the trocar to view the musculofascial layers as
the trocar is passed through them. The non-bladed variety
can also be used for the additional trocars that are necessary.
Trocar site selection

The location of the trocars will be influenced by the location of the hernia defect(s). Typical sites for these are
shown in Figures 16.6 and 16.7. As can be seen easily, the
effort is to achieve triangulation of the site of the hernia to
allow for its repair. This is typical of most other laparoscopic procedures. While I prefer to place the laparoscope
in the midline and have two surgeons work from opposite
sides of the operating table, others place all trocars on
the same side of the patient. The placement of the monitors will be dictated by the location of the hernia to be
repaired. Generally, upper abdominal hernias will need
the monitors to be at the head of the table while lower
hernias will have them at the foot of the table.
Operative technique
In nearly every patient with an incisional hernia, a complete view of the abdomen is obscured by adhesions.
Following the introduction of the initial trocar, the next
effort of the surgeon is the placement of additional trocars so that the operation can be performed. Because of
these frequent adhesions, the surgeon may be forced to
use the laparoscope itself to dissect them before the
insertion of any other trocars because there is no working space in which to allow these trocars to be placed
under direct vision. After each new trocar is introduced,
the laparoscope should be placed through it to visualize
the abdomen from that new vantage point to identify the
optimal placement of the other trocar sites. Additionally,
the collection of views provided by visualization of the
abdomen through these multiple trocar sites will help to
minimize the risk to the bowel by the necessary surgical
maneuvers. In other words, the two-dimensional view
that is recorded by the laparoscope may not permit the
recognition of any intestinal structures that may be in
harms way during the dissection of the adhesions. These
views will help to avoid an enterotomy.
It is frequently necessary to place and manipulate
instruments from the side of the patient in direct opposition to the viewing laparoscope. This produces a mirror
image of any manipulation that is viewed from that port.
In this case, a move of the laparoscopic instrument to the
left will be seen as a move to the right, and vice versa.
Placement of the laparoscope in the midline, when possible, will prevent this viewing difficulty. Another option
would be to insert an additional trocar(s) on the opposite
side of the patient from where the surgeon is standing so
that the laparoscope is always on the side where the surgeon (or the assistant) is standing. With experience, even
this technical problem can be overcome without the use
of additional trocars. However, additional trocars should
be used when this problem cannot be corrected easily to
ensure the accurate assessment of the intra-abdominal
contents and the proper performance of the operation.
Those surgeons who prefer to place all trocars only on
one side of the abdomen will avoid mirror-imaging, but
such site selection will not allow viewing of the adhesions
from the opposite side of the abdomen. Additionally, this
trocar location on only one side can make fixation
awkward because the use of the fixation devices can be
difficult on the ipsilateral side of the patch biomaterial
(Figures 16.6 and 16.7) (see Chapter 4).
Figure 16.6 Typical trocar site locations for a lower midline

hernia. Blue, trocar locations; green, umbilicus; black,
hernia.
Figure 16.7 Typical trocar site locations for an upper midline

hernia. Blue, trocar locations; green, umbilicus; black,
hernia.
Adhesiolysis and identification of fascial

defect(s)
Before insertion of the prosthesis, the entire fascial
defect(s) must be uncovered. This usually requires lysis
of all of the adhesions within the abdomen unless these
are far away from the operative field, such as in the pelvis
when the hernia is in the upper abdomen (Figure 16.8).
It is important to dissect away from the abdominal wall
any adhesions that may interfere with the subsequent
placement of the prosthetic material. The prosthesis
must contact the fascia without the interposition of any
significant amount of adipose tissue so that tissue
in-growth into the biomaterial will not be impaired. In the
Figure 16.9 Skin marks demarcating the edges of the defect of

a lower midline incisional hernia.
Figure 16.8 Small intestinal adhesions to the anterior
abdominal wall.
areas low in the abdomen, such as in the parapubic sites, it

will be necessary to create a pre-peritoneal flap similar to
that done for the transabdominal pre-peritoneal inguinal
hernia repair so that the biomaterial can be fixed to
Coopers ligament. Only this will ensure strong fixation
and adequate overlap of the prosthesis. It is not necessary
to excise the hernia sac or close the fascia defect.
The defect is measured most accurately with the
insufflation pressure reduced from the working amount
of 1214 mmHg to near-zero. Reducing the pressure prevents the inflation artifact because the distention of the
abdominal wall can substantially increase the apparent
size of the defect. This occurs because the measurement
is typically taken on the external surface of the abdominal wall rather than on the interior surface of the fascial
defect. This measurement would be artifactually larger
than the actual measurement. After desufflation, the
defect is outlined on the skin over the abdomen with a
skin-marking pencil (Figure 16.9). The entire circumference of the defect should be identified to ascertain its
maximum dimensions. To ensure adequate coverage of
the hernia defect, many authors have stated that a minimum of a 3-cm overlap (in all directions) of the prosthetic biomaterial is mandatory.35,9 In general, I strive to
cover the entire length of the original incision even
though an actual hernia defect may be located only at
one site along the incision. This will provide coverage
and prevent the future development of a hernia at the
uncovered portions of the incision and, therefore, avoid a
recurrence of the hernia.5 In this situation, the patient
develops a new hernia that is above or below the original
one that was repaired. In obese patients and/or patients
with very large defects, an overlap that exceeds this
minimum, such as 5 cm, is recommended.
Figure 16.10 DualMesh Plus with marks and initial two ePTFE
sutures.
There are many variations of the technique used to fixate the patch material once it is inserted into the abdominal cavity. Most surgeons will use transfascial sutures in
addition to a metal fixation device, such as a titanium
staple or helical tack, a construct of stainless steel, or a
nitinol anchor (see Chapters 4 and 1722). The number
of sutures that are applied to the biomaterial before insertion into the abdomen will be dictated by the preference
of the surgeon. One method that I choose places two
ePTFE sutures (CV-0) at either side of the midpoint of
the long axis of the patch. Two marks are placed on
both sides of the midpoint of its short axis with a marking
pencil before its insertion into the abdominal cavity
(Figure 16.10). It is important to mark both the visceral
and parietal surface midpoints because once fixation is
initiated, the view of the patch will be only that of the
visceral surface. These initial two sutures and the marks
Figure 16.11 Folded and twisted DualMesh Plus patch as it is

pulled into the abdomen at the site of a 5-mm trocar.
Figure 16.12 Laparoscopic view of the twisted patch as it is

drawn into the abdomen.
will help to ensure the correct axial orientation and

the degree of overlap on all sides of the hernia defect.
Other surgeons place four or more sutures into the patch
before insertion. I find that this creates a tangle of suture
material that is cumbersome to work with in the limited
space available. The placement of only these two initial
sutures assures that the center of the fascial defect
is placed at the middle of the prosthetic biomaterial. This
is particularly evident if the trocars are placed as in
Figures 16.6 and 16.7.
The DualMesh Plus patch, with its attached sutures
placed on the inside of the folds, is folded into sequential
halves for introduction into the abdomen.10 These biomaterials are 50 per cent air by volume, which allows them to
be twisted into a tight roll that substantially reduces their
size (Figure 16.11). In those cases in which the larger
patches are used, the skin incision at the site of patch introduction should be made larger than that necessary for
placement of the trocar itself (typically 68 mm). A strong
grasping instrument (Figure 16.4b) is passed through a
trocar and advanced through another trocar. The trocar
through which the instrument is exited is then removed,
whereupon the instrument will grasp the biomaterial and
pull it into the abdominal cavity (Figure 16.12). The assistant surgeon can assist this maneuver by maintaining the
twist of the patch as it is introduced. This method of folding and introduction into the abdomen and the pliability
of the abdominal wall musculature will allow even the
largest DualMesh Plus patch (26 ! 34 cm) to be inserted
into the abdomen with the exclusive use of 5-mm trocars.
Just before the complete introduction of the patch, the
tight twist must be undone to make the patch as flat as
possible, which facilitates its fixation to the abdominal
wall. This is another important step because it is very
tedious to try to untwist and unfold the patch once it is
introduced into the abdomen.
Placement of the prosthesis

Once the insertion of the prosthetic is complete, the
patch must be unfolded. The surgeon and the assistant
will assist each other in the manipulation of the biomaterial to unfold the patch completely until it is as flat
as possible. The two initially placed sutures are now
pulled through the entire abdominal wall with the use of
a sharp suture-passing instrument inserted through a
small skin incision (Figure 16.5). By pulling the initial
two sutures through the abdominal wall and viewing the
hernia with the laparoscope, one can confirm that the
patch is centered over the defect and that there is a minimum of a 3-cm overlap in all directions. It may be necessary to move the laparoscope to another port to do this
effectively. If there is insufficient tautness of the prosthesis or if the patch is not properly centered over the hernia
defect, then the suture(s) must be repositioned. Once the
optimal position is achieved, the sutures are tied. It is
important to make sure that these (and all of the subsequent sutures) are tied sufficiently tightly to pull the
knots to the fascial level without any laxity.
The next step will be to confirm that the orientation
along the short axis of the patch is correct (e.g. the lateral
aspects of the midline hernia). The biomaterial is
grasped by both surgeons at the previously marked midpoints on either side of the biomaterial to position it over
the desired final location. Either the assistant or the surgeon then uses a fixation device to deliver the metal construct to fix the midpoint of one side by placing only one
or two devices at that location. The fixation instrument is
then handed to the other surgeon and the unattached
opposite midpoint is secured similarly. The use of only a
few constructs at this time will permit the removal of
these devices if it is determined that the prosthesis must
be repositioned. After four-point fixation is achieved, the
Figure 16.13 Correct spacing of the constructs along the

periphery of the patch.
position of the biomaterial is verified again with the

laparoscope. After this inspection, the devices are placed
in a staggered fashion along the periphery of the prosthesis 11.5 cm apart (Figure 16.13).
This initial fixation not only positions the patch at its
correct location but also ensures that bowel cannot migrate
between the prosthesis and the abdominal wall once the
repair is completed. The most important component of
fixation, however, is the use of transfascial non-absorbable
sutures (e.g. ePTFE size CV-0). These sutures will be placed
through all layers of the abdominal wall and are tied above
the fascia in a manner similar to that of the initial two
sutures. A small (23-mm) skin incision is made. Through
this incision the suture-passer, with a suture in its jaws,
is passed through all layers of the abdominal wall. The
assistant surgeon then grasps the suture with a laparoscopic
instrument (Figure 16.4c). The suture-passer is then
removed and re-inserted through the same skin incision.
The assistant hands back the suture to the passer, whereupon the suture is retrieved. During the insertion of all
sutures, it is critical to avoid the application of any instrument or clamp on any portion of the suture material that
will remain within the patient because this will permanently weaken the suture at that site. It may later fracture
at that site, leading to a possible failure of fixation and
recurrence of the hernia.5
These additional sutures are placed at intervals that are
no more than 45 cm apart. Once fixation is completed,
the patch should now obliterate the fascial defect. A final
examination of the prosthetic is performed to ensure
that all sutures are tight and that all edges of the patch
are secured (Figure 16.14). When any of these sutures are
tied, a dimple of the skin may develop at the site of
the incision where the suture has been passed because the
subcutaneous tissue may have been drawn down when
the suture was tied. This dimple can be removed by the
placement of a fine-pointed hemostat into the incision to
lift the skin, which releases the tissue from the suture
knot. After this is done, one should view the sutures
Figure 16.14 Completed repair of the hernia. The proper

placement of the sutures and Onux constructs are seen on the
DualMesh Plus.
laparoscopically to confirm that this action did not result

in a loosening of the suture. If this has occurred, the
suture must be cut to prevent migration of any intraabdominal contents into the loop and another suture
must be placed.
The repair is now complete. At this point, a reasonable
precaution may be to scan the intestine to identify any
possible injury that may have gone undetected. The
trocar cannulas are removed, but before their removal
the suture-passer should be used to pass an absorbable suture to close any port sites larger than 5 mm. The
skin incisions can then be closed with or without a
subcutaneous suture and the use of Steri-Strips(3M
Healthcare) or Dermabond(Ethicon, Inc.) adhesive.
Band-Aid-type dressings or small gauze sponges should
be placed over the wounds. The use of an abdominal
binder that will be left in place for at least 72 hours will
aid in the prevention of a postoperative seroma at the site
of the hernia and eases postoperative pain. The use of
this binder for as long as 714 days is preferred, especially
for very large hernias.
POSTOPERATIVE CONSIDERATIONS
Patients are sent to the postanesthesia care unit, where
they are usually given a single dose of ketorolac intravenously. Once recovered from anesthesia, they are
transferred to the day-surgery unit. Most (85 per cent)
patients are discharged within 24 hours. In our practice,
the average length of stay is slightly over one day. Patients
can consume their diet of choice on the day of surgery
and can resume any regular medications immediately.
Oral or parenteral sedatives are given as needed.
Pain may be used as the guide to determine when
patients can resume their normal activities. They are
allowed to shower the next day. Patients may return to
their daily activities, including work, as soon as they can
do so without marked pain. Most are able to drive within

a week and resume job-related activities in 714 days.
We do not restrict their activities but allow their pain to
be their own guide.
2
3
CONCLUSION
LIVH continues to gain popularity. There are several
modifications of this technique that can be adopted
according to ones preferences. Surgeons who perform
this advanced operation must have a thorough understanding of the specific factors that ensure that the procedure will be associated with an acceptable outcome.
Continued research and experience will result in continued modifications to this operation. Technical refinements will undoubtedly occur that will enhance the
fixation methods that are currently available.
The laparoscopic repair of incisional and ventral hernias may become the standard of care in the future. As
the population of general surgeons adopts this methodology, the recurrence rates associated with this difficult
malady will, hopefully, decline.
REFERENCES
1

10
Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and
190: 64550.
2000; 180: 1937.
LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes KV. Laparoscopic
incisional ventral hernioplasty: lessons learned from 200 patients.
Hernia 2003; in press.
Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications
with laparoscopic intraperitoneal expanded
polytetrafluoroethylene patch repair of postoperative ventral
Arroyo A, Garcia P, Perez F, et al. Randomized clinical trail
comparing suture and mesh repair of umbilical hernia in adults.
Br J Surg 2001; 88: 13213.
LeBlanc KA, Stout RW, Kearney MT, Paulsen DB. Comparison of
adhesion formation associated with Pro-Tack (US Surgical) versus
a new mesh fixation device, Salute (ONUX Medical). Surg Endosc
2003; in press.
Koehler RH, Voeller G. Recurrences in laparoscopic incisional
hernia repairs: a personal series and review of the literature.
J Soc Laparoendosc Surg 1999; 3: 293304.
LeBlanc KA. A new method to insert the DualMesh prosthesis for
laparoscopic ventral herniorrhaphy. JSLS 2002; 6: 34952.
17
SRGIO ROLL, WAGNER C. MARUJO AND RICARDO V. COHEN
Incisional hernias
Principles of treatment
Indications for laparoscopic repair
Laparoscopic transabdominal pre-peritoneal repair
Personal series results
125
125
127
127
129
INCISIONAL HERNIAS
Incidence
Incisional hernias represent one of the more common
complications of abdominal surgical procedures. The true
incidence of incisional hernias has not been well defined,
although a number of reports suggest that 313 per cent
of patients undergoing laparotomy will develop a fascial
defect in their abdominal scar.1 The majority of incisional hernias occur within the first postoperative year.
However, the limited follow-up of most series may
underestimate late hernia occurrence.
Diagnosis
Most patients with small, uncomplicated incisional hernias are asymptomatic or have only minor or intermittent complaints. However, these postoperative hernias
may be a significant source of morbidity. Patients with
incisional hernias alter their lifestyles so as not to exacerbate their abdominal wall hernia and often complain of
their esthetic appearance or suffer from discomfort, pain
or, occasionally, intestinal obstruction.
Predisposing factors
Predisposing factors for the development of incisional
hernias include advanced age, male gender, and systemic
Comparative studies of open versus laparoscopic repair

Advantages and disadvantages of different
laparoscopic techniques
Conclusion
References
129
130
130
131
diseases such as obesity, cancer, chronic hepatic and

cardiopulmonary failures, severe anemia, and malnutrition.2,3 The underlying pathological process, such as
prostatism, radiotherapy, steroid therapy, and operative
technical issues are also fundamental factors. Although
clinical experience seems to suggest that vertical celiotomy
and certain types of suture (e.g. continuous suture and
mass tissue closure) may increase the risk of incisional
hernias, randomized studies have failed to show that any
of these factors significantly alters the incidence of postoperative incisional hernia. Wound infection is associated with a five-fold increase in the risk of developing a
hernia.1,4
PRINCIPLES OF TREATMENT
The classical principles of ventral hernia repair are wound
closure without excessive tension, suture placement into
healthy tissue, and the use of strong material to support
the wound through the critical period of healing. In many
cases of incisional hernia with small defects, fascial closure can be achieved by apposing the fascial edges, which
closes the defect. When the fascial defect is large, a number of techniques have been proposed, including relaxing
incisions, internal retention sutures, muscle or fascial
flaps, fascial grafts, and mesh repair.5 However, the results
have often been disappointing. Primary repair with
suture only has been associated with 2552 per cent failure rates.6 The use of a prosthetic material to cover the
hernia defect has reduced substantially the incidence of

recurrence. In a multicenter randomized trial that enrolled
100 patients in each arm, Luijendijk and coworkers compared the results of suture alone with those of open mesh
repair for incisional hernias.7 After a follow-up of 36
months, the three-year cumulative rates of recurrence
among patients who had suture only and those who had
mesh repair of a primary hernia were 43 and 24 per cent,
respectively. The recurrence rates were 58 and 20 per cent,
respectively, for repair of the first recurrence. The risk factors for recurrence were suture repair, infection, prostatism, and previous surgery for abdominal aortic aneurysm.
The size of the hernia did not affect the rate of recurrence.
The majority of the recurrences were in the first two years
following the repair of the hernia. The same factors involved
in the genesis of these incisional hernias may contribute
to these results.
Prosthesis materials
The use of prosthetic materials to assist in incisional
hernioplasty usually demands a more extensive dissection and may increase the risk of wound complications
slightly.5,8 The synthetic material should be physically
unmodified by tissue fluid, chemically inert, and noncarcinogenic. It should also induce no inflammatory or
foreign-body reaction, allergy or hypersensitivity.9,10
Finally, it should resist mechanical stresses, be able to be
tailored into the form required, and be easily and fully
sterilizable. The most popular prosthesis materials are
made of polypropylene, polyester, and expanded polytetrafluoroethylene (ePTFE). These are all nonabsorbable,
and there is no clear evidence from the literature that
supports a preference for the clinical use of any one of
the three main materials.11 Polypropylene shows a relatively small inflammatory response with a far lesser
degree of foreign-body reaction than does polyester
mesh. ePTFE elicits less chronic inflammatory cell reaction but greater foreign-body reaction. Mesh infection
rates in selected laparoscopic series for repair of ventral
and incisional hernias vary from 0.5 to 12 per cent.12
Despite different characteristics regarding fibroblastic
reaction and the time required for incorporation,
polypropylene and polyester prosthetic materials are
associated with a high incidence of dense adhesions.
Their biological behavior increases the risk of adhesions
and fistula formation when the mesh is placed in contact
with the peritoneum.13 There is strong evidence that
adhesions are more common with polypropylene and
polyester than with ePTFE. It is acceptable to place the
latter in contact with the bowel, as lower complication
rates were reported when using ePTFE. Polypropylene
and polyester require reperitonization to avoid mesh
contact with intra-abdominal structures. The use of
these materials should be balanced in some situations

(e.g. the feasibility of closing the peritoneum over the
mesh, and the issues of cost) when selecting all prosthetic
biomaterials.
Repair strategies
Although the modern era of hernia repair began more
than a century ago, controversies continue to exist regarding the optimal surgical technique to repair incisional
hernias. Open techniques involve a large incision and
extensive subcutaneous and intra-abdominal dissection,
and often necessitate the placement of drains. Complication rates range from 8 to 19 per cent after open ventral
repair.14,15 Fistula rates after elective open hernia mesh
repair vary from 2 to 5 per cent.6 Moreover, the infected
prosthesis should be excised, demanding another, more
complicated repair. Transabdominal approaches carry
the risk of injury to the viscera adherent to the undersurface of the scar. The basic strategy of the open repair is
based upon the Stoppa technique: the peritoneal cavity
should not be entered and the mesh is secured to the fascial edges in the pre-peritoneal space.16 However, the risk
of re-entering the site of a previous incision is an inadvertent enterotomy. The open repair does allow the
concomitant excision of a usually wide, irregular and
unesthetic scar. If this is the case, it is not unusual to
enter the abdominal cavity.
Surgical laparoscopy has become an increasingly popular method of treatment for many diseases because it
potentially offers cost-savings as a result of shorter hospital stays, less postoperative pain, and a more rapid
return to work.17 Laparoscopic hernioplasty has been
reported to be a safe and feasible technique, with low
morbidity and low rates of early recurrence. LeBlanc and
Booth first reported the laparoscopic approach to repair
incisional hernias in 1993,18 and several series have now
demonstrated the efficacy of minimally invasive surgery
in incisional hernia repair. Laparoscopic repair involves
no long incision, no wide fascial dissection or flap
creation, and usually no drains. It also minimizes the
manipulation of a potentially contaminated site because
the trocars are placed far from the original wound.19
Additionally, the pneumoperitoneum facilitates the necessary adhesiolysis in order to identify the edges of the
defect and the hernia sac. Enterotomy rates in selected
laparoscopic series of ventral hernia repair, including
incisional hernias and many with previous open mesh
repair, vary from 0 to 14 per cent (Table 17.1). Mesh
infection rates vary from 0.5 to 12 per cent.12 One of the
drawbacks of the laparoscopic approach is that it does
not allow an esthetic reconstruction of the abdominal
wall since the old scar that covers the hernia defect is
left untouched. The need for an overall esthetic result
Pre-peritoneal herniorrhaphy 127

Table 17.1 Results of laparoscopic ventral/incisional hernioplasty
Complications
Reference
Patients
(n)
Intraoperative
(n)
Postoperative
(n)
Constanza et al. (1998)14

Franklin et al. (1998)34
Toy et al. (1998)24
Sanders et al. (1999)35
Scott-Roth et al. (1999)20
Heniford et al. (2000)6
Roll et al. (2000)25
31
176
193
12
73
415
28
0
0
4
0
2
5
1
2
9
28
3
14
48
3
should not be underestimated because the patient frequently demands this outcome.
INDICATIONS FOR LAPAROSCOPIC REPAIR

The size of the defect and the characteristics of the patient
should dictate the best technical strategy. Patient selection
for laparoscopic incisional hernioplasty is usually based
upon a demonstrable fascial defect under a previous
abdominal incision or a highly suspect abdominal wall
defect in a very obese patient, such as in Spigelian hernia.
The patient must be able to tolerate general anesthesia
and abdominal insufflation.20 Patient size is not a prohibiting factor; nor is a history of previous abdominal
explorations or previous attempted repairs with or without placement of prosthetic material. A massive incisional
hernia with the protrusion of a substantial portion of
the abdominal viscera may be a contraindication for a
laparoscopic approach. Significant loss of the abdominal
domain by the intestine might preclude the placement of
the functional trocars because of insufficient lateral space.
A densely scarred abdomen, an inability to establish safely
a pneumoperitoneum, and the presence of infected material in the abdomen may also contraindicate the laparoscopic approach. It should be noted that the intensity and
extent of adhesion formation is unpredictable. Because of
this, multiple previous abdominal operations do not preclude laparoscopy, since an entry port for the first trocar
can be obtained. The so-called Swiss cheese hernia is a
good indication for the laparoscopic approach since it
allows a very clear delineation of the wall defects and a
more precise repair. Hernias very close to the costal margin may be difficult to treat through an open approach
since they usually lack a good rim of strong tissue to secure
the mesh. In this situation, the laparoscopic approach is
more appropriate, because the mesh can be easily tacked
and/or sutured to the internal surface of the abdominal
cavity. Moreover, full-thickness stitches around this area
are usually followed by pain.
Hospital
stay (days)
2.0
2.2
2.0
3.5
2.9
1.8
1.2
Follow-up
(months)
Recurrence
(n)
18
30
22
12
17
23
36
1
2
9
1
7
14
0
LAPAROSCOPIC TRANSABDOMINAL
PRE-PERITONEAL REPAIR
Patient preparation and room set-up
A thorough preoperative evaluation is performed. The
patient is informed fully of the risks of recurrence and
the chance of conversion into an open procedure.
Educational handouts are given in order to aid the
patient during the period of convalescence with a particular emphasis on pain management. Factors that might
increase the recurrence rate are corrected, if at all possible,
in the preoperative period. Special attention is given to
respiratory care before admitting the patient to the hospital. In-hospital standard guidelines to prepare patients
for abdominal surgery are followed. Mechanical bowel
preparation is not usually necessary, and the patient is
asked to void just before leaving the ward.
The patient is placed on the operating table in a dorsal
recumbent position with the arms padded alongside the
body. It is important that the patient is strapped securely
to the operating table in order to permit the extremes
of table positioning, which is occasionally necessary for
visceral displacement or retraction. General anesthesia is
instituted, and an orogastric tube is inserted for gastric
decompression. Patients are given antibiotic prophylaxis,
usually with a first-generation cephalosporin.
For most midline hernias, the surgeon stands on
either the patients left or right side. The video monitor is
positioned on the opposite side of the patient so the surgeons view on the screen is parallel and in line with the
laparoscopic repair of the hernia within the abdomen.
The assistant stands opposite the surgeon, and a second
monitor is placed in a suitable position.
Operative technique
Good laparoscopic skills are mandatory, since each
anatomical situation may be unique. The surgeon must
always keep a low threshold for conversion to an open
repair. Access to the abdominal cavity is obtained in an

area away from the hernia using the Veress needle or, more
frequently, by the open technique. Pneumoperitoneum is
established by insufflating the abdomen to 12 mmHg with
carbon dioxide. A 30-degree laparoscope is introduced
through the initial trocar, and the abdomen is explored.
The hernia defect and any associated adhesions are identified. Usually two or three additional trocars are inserted
under direct vision. The ultimate number and the exact
site of the trocars depend on each individual case. For an
optimal view and exposure, it is better to place the working ports as far away as possible from the hernia defect.
Since the mesh must overlap the defect by about 3 cm, a
very lateral or inferior position of the trocar sites maximizes the view and the efficiency of the instruments.
The repair technique is based on the Stoppa technique
utilized in the open surgical procedure, in which the prosthetic material is placed posteriorly to the anterior fascia.21 Adhesiolysis is performed to free the bowel from the
abdominal wall, and the margins of the hernia defect are
defined clearly. External manual pressure on the abdominal wall helps to delineate the edges of the hernia defect; it
also changes the angles of vision and usually facilitates the
dissection. Once the entire abdominal wall is cleared up
and any incarcerated omentum or bowel reduced, the
hernia defect is measured by introducing a sterile ruler
into the peritoneal cavity. The surgeon must be very cautious when dissecting the bowel wall or omentum off the
hernia sac, which typically encompasses attenuated fascia
and peritoneum. The adhesiolysis is almost always the
most challenging part of this procedure, especially if a
previous mesh repair has already been attempted. Any
energy source is capable of causing a full-thickness injury
to the bowel wall. The harmonic scalpel may obviate the
risk of an inadvertent injury. The standard approach in
the advent of an enterotomy is immediate closure of the
site with simple suturing. If this injury is complicated by
a significant spillage of luminal fluids, then an open primary repair might be performed or a staged laparoscopic
mesh placement should be advised.
The hernia sac contents are reduced and the peritoneal
sac is now opened, followed by the precise delineation of
the fascial defect, with at least 4 cm of healthy tissue surrounding it. When possible, small fascial defects may be
closed simply by suturing the edges of the defect without
tension. The suture closure is then covered by a mesh
to reinforce the herniorrhaphy. This procedure may prevent the annoying sensation of the mesh just underlying
the skin.
Dissection within the pre-peritoneal plane, in an effort
to develop an intact layer of peritoneum to separate the
mesh from the abdominal contents, might be extremely
difficult in some patients. If unsuccessful, this might result
in a large peritoneal defect, leaving the mesh exposed internally. This is especially true in patients with only a thin layer
of subcutaneous fat and skin overlying the hernia. In this
Figure 17.1 The hernia sac is opened and the healthy fascia
along the defect rim is defined clearly.
case, some authors recommend interfacing the omentum

between the mesh and the bowel. However, we make a vigorous effort to interface the sac layer between the mesh and
the abdominal contents (Figure 17.1). It is easier to dissect
out the healthy fascial edges within the pre-peritoneal space
of certain hernias, including incisional hernias secondary
to extraperitoneal surgical incisions, such as lumbar discectomies or Pfannenstiel incisions, and defects away from the
midline. If the pre-peritoneal technique is deemed impossible, then the hernia sac is not reduced, resected or opened,
and the mesh is positioned intraperitoneally according to
the onlay technique.22
Prosthetic materials have been used with increasing
confidence in direct contact with the abdominal contents. Complications have been few, but this may reflect
selective reporting of good results. We always attempt
to perform a transabdominal pre-peritoneal repair that
uses a mesh prosthesis to cover and close the hernia
defect. Three trocars are usually employed, and it is ideal
to triangulate them around the hernia defect. As the
abdomen is explored, care must be taken to identify and
dissect the hernia defect. Gentle grasping and separation
of the peritoneal sac are important steps. At this point,
tears in the peritoneum must be recognized and managed. Generally, it is not easy to dissect and actually have
a good peritoneal flap prepared in order to have it closed
over the anchored prosthesis. If a tear occurs, it should be
carefully dissected and more peritoneum preserved. If
this is impossible due to firm adhesions to the abdominal
wall, then in order to cover the mesh safely an omental
flap may be created and used to cover the tear. The mesh,
under some tension, should be secured to the abdominal
wall using a hernia stapler or a tacking device, or sutured
into position with full-thickness transabdominal stitches
buried in the subcutaneous tissues. The stitches along
the outer border of the mesh should leave a 3-cm margin
Defect
Mesh
Hernia
sac
Healthy
fascia
Figure 17.2 The mesh is positioned into the pre-peritoneal

space and secured to the abdominal wall. The stitches along the
outer border of the mesh must overlap the rim of the hernia
defect by at least 3 cm.
lateral to the edges of the fascial defect (Figure 17.2).

Drains are not used. The trocar sites are then closed in
the usual fashion.23
Immediate postoperative care

Postoperatively, patients are given narcotics for appropriate analgesia. A liquid diet is started on the same day,
and patients are encouraged to ambulate as soon as possible. Bowel function usually resumes early in the postoperative period.24 Some patients go home on the day of
the operation, but 85 per cent are discharged on the first
postoperative day. Most patients develop an area of
induration at the previous hernia site, but this resolves
without complications or treatment within four to six
weeks. In general, patients are allowed to return to work
at their convenience and may resume heavy physical
activities two to four weeks later.
The most common early complications after laparoscopic repair are suture-site pain (when using transabdominal stitches) and seroma. The former is probably
related to some muscular ischemia and nerve entrapment. The development of seroma is secondary to the
creation of a dead space and a secretory reaction to the
prosthetic material. Only large, symptomatic collections
should be aspirated.
PERSONAL SERIES RESULTS

From January 1997 to January 2002, 52 (21 female, 31
male) patients underwent attempted laparoscopic incisional hernia repair.25 We excluded from this series
Spigelian hernias and incisional hernias that required the
intraperitoneal onlay technique. There was a total of
53 hernia repairs (one patient with two incisional hernias).
One patient required conversion to an open repair

because of dense adhesions and inadvertent intestinal
injury. The defect sizes ranged from 64 to 230 cm2. The
original surgical procedures were hysterectomy (11),
appendectomy (12), prostatectomy (10), gastrectomy
(two), nephrectomy (eight), laparotomy (three), epigastric herniorrhaphy (four), and umbilical herniorrhaphy
(three). In all cases except one (two incisional hernias),
the defect was covered with a single large piece of mesh. In
all but three patients (in whom polyester mesh was
placed), we used a polypropylene mesh for the repair. The
average operating time was 60 minutes (range 30240
minutes), varying directly with the degree of adhesiolysis
that was required. All patients were discharged in the first
24 hours, with the exception of one patient, who had an
enterotomy recognized during the procedure. The mean
length of hospital stay was 1.2 days (range 14 days).
Patients required minimal post-surgical analgesia. Bowel
function returned quickly in most patients.
There were no deaths. Seven complications were
recorded (13.4 per cent of patients), most of which were
minor (four seromas, two hematomas, one accidental
small bowel enterotomy). Patients were followed closely
postoperatively for three to 60 months (mean 41
months). Two (3.8 per cent) patients were found to have
evidence of hernia recurrence. They were among the very
first cases, and they had large defects. Recurrences were
diagnosed within the first 12 months after the operation.
Lack of experience and large defects may be related to the
reason for recurrence. Most patients developed an area of
induration at the hernia site, but this resolved without
any treatment within four to six weeks. Apart from this
transient induration, we have encountered no complications as a result of excising the hernia sac.
COMPARATIVE STUDIES OF OPEN VERSUS

LAPAROSCOPIC REPAIR
Two retrospective studies and one prospective study have
compared the results of open surgery techniques versus
the laparoscopic approach for the repair of ventral hernias. These studies consisted of a majority of incisional
defects (Table 17.2). In 1997, Holzman and colleagues
compared 21 patients with ventral/incisional hernias
repaired laparoscopically with a group of 16 patients
who had undergone conventional open mesh repair.26
The mean follow-up period was similar, and two recurrences occurred in each group. The investigators concluded that the advantages of the laparoscopic approach
seem to be a reduced rate of postoperative complications, fewer wound healing problems, and more rapid
recovery after surgery. In 1998, Park and coworkers
compared 56 laparoscopic prosthetic repairs of large incisional hernias with 49 open surgical procedures.27 The

Table 17.2 Comparison studies of laparoscopic versus open repair of ventral/incisional hernia
Complications
Reference
Holzman et al.
(1997)26
Park et al.
(1998)27
Carbajo et al.
(1999)28*
IntraPostReopera- Hospital
Cost
Repair Patients Size
Time operative operative tions
stay
Follow-up Recurrence
(US$) type
(n)
(cm2) (min) (n)
(n)
(n)
(days)
(months) (n)
7299
4395
Open
Lap
Open
Lap
Open
Lap
16
21
49
56
30
30
148
105
105
99
141
139
98
128
78
95
111
87
0
1
1
0
0
0
5
4
17
10
35
5
2
0
0
2
1
1
4.9
1.6
6.5
3.4
9
2
18
20
53
24
27
27
2
2
17
6
2
0
*Prospective study.
mean follow-ups were 24 months for the laparoscopic

group and 53 months for the open procedure. The hernia
recurred in six (11 per cent) patients in the laparoscopic
group and in 17 (34 per cent) patients in the open repair
group, but the investigators could not make a meaningful
comparison of the recurrence rates because of the large
difference in the follow-up periods. They found that the
laparoscopic procedure took longer to perform, but it
was associated with fewer complications and shorter
postoperative hospital stays.
In the only prospective randomized study of laparoscopic repair versus open repair, Carbajo and colleagues
randomized 60 patients over a three-year period into two
homogeneous groups to be operated on for major ventral hernias using mesh.28 With an average follow-up of
27 months, they noted that two hernias in the open repair
group and none in the laparoscopic group recurred. They
concluded that laparoscopic repair offers several advantages over the classic surgical repair of abdominal wall
defects, including a reduction in the rate of complications
and recurrence.
ADVANTAGES AND DISADVANTAGES OF

DIFFERENT LAPAROSCOPIC TECHNIQUES
Critical assessment of the reported results is difficult and
potentially misleading due to the significant variations in
terminology, patient selection, and operative techniques.29
No data are available to support unequivocally an overt
advantage of any particular technique to repair incisional
hernias. Clinical judgment, previous experience, and team
surgical skills should guide the technical choice that is
applied to a particular patient. Despite the pitfalls of the
available data (mainly from retrospective studies of
selected patients), recurrence rates are slightly lower and
complications less frequent in the laparoscopic group,
regardless of the technique employed. The most popular
laparoscopic technique of incisional hernia repair proposes a transperitoneal approach using either an ePTFE
or a composite mesh prosthesis in the intraperitoneal

location.30,31 Biomaterials have become an important
tool because they can permanently replace the defective
transversalis fascia and permit the creation of a truly
tension-free hernioplasty. However, utilization of biomaterials is associated with four major concerns: rejection,
infection, early adhesion formation and host tissue incorporation. It is well known that a peritoneal defect or the
presence of a foreign body in the abdominal cavity creates
adhesions.13 This in turn may result in major complications, including intestinal obstruction, migration of the
foreign body and erosion into the bowel, fistula, and infection. In general, complications resulting from intraperitoneal adhesions account for a significant number of
emergency surgical admissions and abdominal operations.7 These concerns have prompted the development of
a further refinement in the transabdominal laparoscopic
approach: the pre-peritoneal laparoscopic mesh repair.
Dissecting within the pre-peritoneal plane in order to create an anatomical room for the mesh may sometimes be
extremely difficult. However, our own experience shows
that this approach is technically feasible in many circumstances and, indeed, this procedure is an extension of our
current laparoscopic techniques for repairing inguinal
hernias.32 However, we should also underscore the fact
that even pre-peritoneal repairs of inguinal hernias have
not been free of adhesions and associated bowel complications. Only a longer follow-up period of our patients will
allow us to determine whether the theoretical advantages
of positioning the mesh in the pre-peritoneal location will
overcome the possible disadvantages of a more tedious
procedure that usually demands a longer operative time.33
CONCLUSION
The laparoscopic route has made possible the introduction of new surgical techniques for the repair of major
abdominal wall defects. The laparoscopic surgeon is able
to minimize the great degree of tissue trauma involved in
classic open surgery, typically associated with large fascial dissection, tense sutures, and postoperative drains.
Laparoscopic repair of incisional hernias is a promising
but still new technique that may be seen as a further refinement of the current surgical armamentarium to treat this
common problem in general surgery. As with any new
operation, we should initially be more careful about
patient selection before embarking on a broader application of this technique. Adequate training and judicious
indication can certainly ensure good surgical outcomes.
Until now, patients in several series have tolerated the
procedure well and had shorter postoperative hospitalizations in comparison to open procedures. Accordingly,
given the potentially lower morbidity due to the smaller
abdominal wall incisions, the overall hospital cost may be
reduced, making this a more attractive approach to incisional hernias. Moreover, laparoscopy allows comprehensive exploration of the abdominal cavity, adequate
assessment of the adhesions in the hernia process, and a
clear delineation of the anatomy. It may be the procedure
of choice in patients who develop a recurrence following
a previous open hernia repair.
Laparoscopic incisional hernia repair can be performed safely with no increased morbidity or mortality,
but the ultimate outcome in assessing the success of any
hernia repair must be the rate of recurrence. The literature suggests that the laparoscopic approach, regardless
of where the mesh is placed, has a midterm recurrence
rate that is at least as good as that seen after the open
operation. However, long-term assessment from large,
well-controlled, prospective studies is needed to confirm
the expected advantages of the laparoscopic approach.
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1
2
3
5
6
7
Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am 1993;
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Makela JT, Kiviniemi H, Juvonen T, et al. Factors influencing wound
dehiscence after midline laparotomy. Am J Surg 1995; 170: 38790.
Niggebrugge AH, Hansen BE, Trimbos JB, et al. Mechanical factors
influencing the incidence of burst abdomen. Eur J Surg 1995; 161:
65561.
Meissner K, Jirikowski B, Szecsi T. Repair of parietal hernia by
overlapping onlay reinforcement or gap-bridging replacement
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Larson GM. Ventral hernia repair by the laparoscopic approach.
Surg Clin North Am 2000; 80: 132940.
Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic ventral and
incisional repair in 407 patients. J Am Coll Surg 2000; 190: 64550.
Luijendijk RW, Hop WC, van den Tol P, et al. A comparison of suture
repair with mesh repair for incisional hernia. N Engl J Med 2000;
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Leber GE, Garb JL, Alexander AI, et al. Long-term complications
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Amid PK, Shulman AG, Lichtenstein I, et al. Preliminary evaluation
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Ann Chir 1995; 49: 539.
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35
Amid PK. Classification of biomaterials and their related

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Morris-Stiff H. The outcomes of nonabsorbable mesh. J Am Coll
Surg 1998; 186: 352.
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Marchal F, Brunaud L, Sebbag H, et al. Treatment of incisional
hernias by placement of an intraperitoneal prosthesis: a series of
128 patients. Hernia 2000; 3: 141.
Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of
recurrent ventral hernias. Am Surg 1998; 64: 11267.
Luijendijk RW, Lemmen MHM, Hop WCJ, et al. Incisional hernia
recurrence following vest-over-pants or vertical Mayo repair of
primary hernias of the midline. World J Surg 1997; 21: 625.
Stoppa R. The treatment of complicated groin and incisional
hernias. World J Surg 1989; 13: 54554.
Hashizume M, Migo S, Tsugawa Y, et al. Laparoscopic repair of
paraumbilical ventral hernia with increasing size in an obese
patient. Surg Endosc 1996; 10: 9335.
Scott-Roth J, Park AE, Witzked, et al. Laparoscopic incisional/
ventral herniorrhaphy: a five-year experience. Hernia 1999; 4: 209.
Wants GE. Incisional hernioplasty with Mersilene. Surg Gynecol
Obstet 1991; 172: 129.
Barie PS, Mack CA, Thompson WA. A technique for laparoscopic
repair of herniation of the anterior abdominal wall using a
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Larson GM: Laparoscopic repair of ventral hernia. In: Scott-Conner
CEH, ed. The SAGES Manual. New York: Springer-Verlag, 1998: 379.
Toy FK, Bailey RW, Carey S, et al. Prospective multicenter study of
laparoscopic ventral hernioplasty. Surg Endosc 1998; 12: 9559.
Roll S, Benatti M, Roncada, P, et al. Laparoscopic incisional
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Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral
and incisional hernioplasty. Surg Endosc 1997; 11: 325.
Park AE, Birch DW, Lovrics P. Laparoscopic and open incisional
hernia repair: a comparison study. Surgery 1998; 124: 816.
Carbajo MA, Martn del Olmo JC, Blanco JI, et al. Laparoscopic
treatment vs open surgery in the solution of major incisional and
Chevrel JP, Rath AM. Classification of incisional hernias of the
abdominal wall. Hernia 2000; 4: 7.
Alexandre JH, Aouad K, Bethoux JP, et al. Recent advances in
incisional hernia treatment. Hernia 2000; 4: 1.
Balique JC, Alexandre JH, Arnaud JP, et al. Intraperitoneal
treatment of incisional and umbilical hernias: intermediate results
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composite mesh. Hernia 2000; 4: 10.
Roll S, DePaula AL, Miguel P, et al. Laparoscopic transabdominal
inguinal hernia repair with a preperitoneal mesh. Surg Endosc
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Saiz AA, Willis IH, Paul DK, et al. Laparoscopic ventral hernia repair:
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Sanders LM, Flint LM. Initial experience with laparoscopic repair of
incisional hernias. Am J Surg 1999; 177: 22731.
18
SALVADOR MORALES-CONDE AND SALVADOR MORALES-MNDEZ
Principles
Double-crown surgical technique
Results of our series
133
135
141
Laparoscopic surgery continues to advance in achieving

further benefits over the conventional approach for certain
pathologies. In 1991, LeBlanc and coworkers carried out
the first laparoscopic repairs of ventral hernias.1 Although
ventral hernia was not originally considered to be a
pathology that could benefit from this approach, laparoscopic repair of ventral hernias has attained wide acceptance in recent years because of the significant advantages
afforded by improvements in prosthetic materials and in
attachment methods, as well as in the surgical technique
used. The laparoscopic procedure offers greater comfort
during the postoperative period, reduces hospitalization
time, and lowers complication rates. Even though many
series still have a limited follow-up, the technique has
shown lower rates of recurrence than the open methods,
making it a procedure that solves a long-standing
challenge to the surgeon.
Nevertheless, there are certain points of controversy
that should be clarified, starting with the simple fact of
establishing more precise indications. In addition, a multitude of more specific technical details should be discussed, including how to perform adhesiolysis, how to
manage the hernia sac, the postoperative seroma, the
type and size of the mesh, and how to insert and secure
the mesh. One of the most interesting points currently
being debated is whether it is necessary to use sutures or
tacks. We have developed a laparoscopic procedure without sutures for the repair of ventral hernias, a technique
we have come to call the double-crown technique.
This system avoids the use of external (transfascial)
sutures by fixing the mesh with a double crown of
tacks alone (Figure 18.1). This ensures proper anchorage
of the mesh, decreasing surgery time and diminishing
Conclusion
References
142
142
Hernia
Figure 18.1 Double-crown technique for laparoscopic ventral

hernia repair. External sutures are avoided, and the mesh is fixed
with a double crown of tacks alone.
postoperative pain at this level, and with the same recurrence rate as described by groups using transfascial
sutures.
PRINCIPLES
Indications and contraindications
Indications for the double-crown technique are the
same as indications for laparoscopic hernia repair with
transfascial sutures. Basically, all ventral hernias can
be repaired by laparoscopy as the standard procedure.
Emergency operations performed in cases of strangulated hernias must be analyzed on an individual basis to
assess whether laparoscopy should be used. However,

various factors place limits on the indications for laparoscopic repair, such as the size of the defect and the site
where the defect has occurred. Subxiphoid, suprapubic,
lumbar and parastomal hernias require special considerations for laparoscopic repair, and several technical
details must still be considered. At the lower end of
the size spectrum, hernias that can be repaired with
local anesthesia, encompassing those under 34 cm, are
usually excluded. However, in patients requiring laparoscopic surgery for other concomitant conditions and in
obese patients, laparoscopic repair would be indicated
despite the small size of the hernia. At the upper end of
the hernia size spectrum, our group has performed many
successful repairs of massive abdominal wall defects. We
conclude, therefore, that until the limits are established
clearly, the degree of difficulty in managing the instruments within the abdominal cavity is the only actual
limit to the technique as far as large hernias are concerned. On the other hand, the characteristics of the sac
of the hernia are important to determine the contraindications of this technique, since the evolution and complication of the seroma and the cosmetic results would be
different depending on the type of sac. Definitive guidelines will have to be elaborated on the basis of results
from prospective studies.
transfascial sutures.4,7,8 In fact, they demonstrated that

one of the essential factors to avoid recurrence is the use
of these sutures.9 Analysis of the data derived from these
early series data that were later the basis for recommendations on the use of sutures shows that other factors could have been involved in the development of
recurrence in these patients besides the use (or not) of
transfascial sutures:
Sutures versus no sutures with

double-crown technique
Why are transfascial sutures recommended?

Laparoscopic surgery for ventral hernias offers enormous
advantages over open surgery during the immediate postoperative period, with clearly lower morbidity24 and
lower general costs of surgery.5,6 Another important issue is
that patients who were operated on by laparoscopy appear
to have lower recurrence rates.24
Despite the lower recurrence rate, various authors
have made efforts to analyze the causes for recurrence in
order to define adequately the laparoscopic technique
and thereby achieve an even lower recurrence rate. Initial
laparoscopic ventral hernia repair series established a
direct correlation between recurrence and the absence of
Prostheses initially recommended were small,

overlapping the defect by only 22.5 cm1012 in all
directions, and not the minimum of 3 cm currently
recommended. Recently, we have demonstrated in an
experimental study that expanded polytetrafluoroethylene (ePTFE) prostheses decrease in size once
they have been implanted (by 1.634 cm after five
weeks), probably because of the scar tissue reaction
and the encapsulation process experienced by the
mesh,13 so recurrence in these initial experiences
could have happened mainly because of the smaller
size of the mesh.
The method of fixation was also inadequate, since
tacks were not yet available and mesh patches were
anchored with the old endo-staplers that did not
ensure secure attachment of the material. This problem
was particularly important with the ePTFE mesh
because of its thickness. Thus, the use of transfascial
sutures was necessary in these cases, and the real
purpose of the endo-staplers was to prevent the
bowel from slipping between the sutures rather than
to fix the mesh.10,11,14
The learning curve of these initial series could be
related more directly to the appearance of
recurrences than to the placement (or not) of
transfascial sutures.
Disadvantages of using transfascial sutures

Based on the reasons noted above, we do not believe that
these sutures are needed to reduce the recurrence rates,
as reported by several authors. Nevertheless, they are
associated with a number of disadvantages (Table 18.1):
Longer surgery time: surgery times associated with

transfascial suture placement are longer because
Table 18.1 Comparison of factors related to the use of transfascial sutures

Technique
Double-crown (S. Morales-Conde)
Other technique without
transfascial sutures3
Series with transfascial sutures
Mean operating
time (min)
79
62
120
Mesh infection
rate (%)
Long-term
pain (%)
Recurrence
rate (%)
0
0
0
0
2.86
2
4.87
1.97
3.98
Hernioplasty with the double-crown technique 135
sutures are recommended every 5 cm,14 45 cm,12 or

even 34 cm,9 in addition to at the four corners. The
operating time in our series is around 79 minutes.
The time in the other published series that use only
tacks and no sutures is between 62 and 87 minutes.2,3
The operating times for groups using sutures were
between 82 minutes4 and 210 minutes,15 with a mean
of 120 minutes,4,12,1517 showing a significant
increase in surgery time due to the maneuvers
needed to place these sutures.
More incisions in the skin: transfascial suture
placement involves incisions of 23 mm at a preestablished distance of 35 cm, as mentioned earlier.
Poorer cosmetic results: small incisions are needed to
place the sutures. The incisions require only a SteriStrip and typically leave a small scar; however, they
do contribute to a higher number of scars.
Greater infection rate: in our series, the mesh
infection rate was zero, in keeping with results
reported by other authors who do not use these
sutures.6 The infection rate reported by groups using
transfascial sutures was as high as 11.1 per cent,5
with a mean infection rate of 4.87 per cent.4,5,18 In
addition to mesh infection, the subcutaneous sutures
can become infected, or a superficial infection can
develop in the small incisions in the skin. In the only
case in our series in which sutures were used, the
patient presented with a superficial skin infection at
the site of the incisions made to place two of the
sutures.
Pain during the early postoperative period: the use of
transfascial sutures involves taking 12 cm of tissue,
trapping it, and compressing it by tying at the
subcutaneous tissue level. This is associated with
greater pain during the early postoperative period
and in the longer term. In the short term, some
authors defending the use of these sutures recognize
that there is more pain during the immediate
postoperative period than after laparoscopic
cholecystectomy and that this pain could extend
hospitalization.9 There may also be discomfort at the
suture level during the first two weeks of the
postoperative period.17
Long-term postoperative pain: the more significant
problem is long-term pain, whether continuous or
associated with movement, and the pulling sensation
at the site of the sutures. In some cases, oral
narcotics, non-steroidal anti-inflammatory drugs, or
even injections of local anesthetics at the suture site
have been required, perhaps due to nerve
entrapment.17,18 Postoperative diagnostic
laparoscopy has been recommended to assess the
condition of the mesh and the sutures. This will
allow the section of the offending sutures, if
necessary.19
Recurrence rate: a reason to use the double-crown

technique
Irrespective of the disadvantages associated with sutures
listed above, if the recurrence rate in our series were higher
than in the series using transfascial sutures, then their use
would be warranted. In series that advocate the use of
sutures, the recurrence rate ranges anywhere from zero11
to 8.3 per cent,15 with a mean of 3.98 per cent.4,5,911,1418
The recurrence rate of our series is 2.86 per cent, with a
mean follow-up of 24 months. As we noted earlier, recurrence after laparoscopic repair of ventral hernias tends to
appear more frequently during the first few months of the
postoperative period. Analysis of our recurrences shows
that they were not related directly to the use of sutures: one
case was due to use of a short mesh at the beginning of our
series and the other two cases were two suprapubic hernias
with recurrence at the inferior margin. Recurrence in these
two cases resulted from inadequate exposure of the pubis
and Coopers ligament in order to anchor the mesh more
securely at this level. This is a complicated area, which
presents particular difficulty when placing transfascial
sutures. Even authors who advocate the use of sutures do
not recommend them at this level.
DOUBLE-CROWN SURGICAL TECHNIQUE

A clinical preoperative evaluation is performed, and the
indication for laparoscopic approach is set based on previous considerations. Patients are informed fully about
the risk of the surgery, the possibilities of conversion into
an open procedure, and the high frequency of the development of postoperative seroma (so that they do not
confuse this seroma with an early recurrence).
We administer antibiotic prophylaxis in all cases with a
preoperative dose of a second-generation cephalosporin.
If the patient has any risk factor, such as diabetes, the prophylaxis is continued with two additional doses in the
postoperative period. Mechanical bowel preparation is
not usually necessary; only patients who have undergone
several previous surgeries and who are thought to have
densely adherent or incarcerated viscera will undergo this
preparation.
Instrumentation
Laparoscope
A 30-degree-angled laparoscope is essential to perform
the laparoscopic approach of ventral hernias, since this
offers an excellent view of the entire anterior abdominal
wall and of the defect that will be repaired.
Trocars
A variety of trocar sizes are available commercially,
including 2-, 3-, 5-, 10-, 11- and 12-mm trocars. In general, we perform the technique using one 10-mm trocar
and two 5-mm trocars. A series of factors should be
considered when choosing the trocars:
A trocar of at least 10 mm is required for introducing

a mesh. Contamination of the mesh due to
microorganisms on the skin of the abdominal
wall can potentially occur when the mesh is
introduced through the opening left by the trocar
once it is removed. Because of this, we prefer to
introduce the mesh through the trocar. As a result,
we select the trocar based upon the size of the ePTFE
patch. We most frequently use the sizes 10 ! 15 cm,
15 ! 19 cm and 18 ! 24 cm (as well as others of
larger size). We use a 10-mm trocar when we expect
to use a 10 ! 15-cm mesh, an 11-mm trocar for a
15 ! 19-cm mesh, and a 12-mm trocar for an 18 !
24-cm prosthesis. For larger mesh sizes, we use a 10mm trocar and insert the mesh through the opening
left in the skin by the trocar after it is removed, since
larger meshes cannot be passed through any of the
trocars. In such cases, the mesh to be inserted is
wrapped in a sterile plastic material that covers the
mesh in order to prevent contamination from
microorganisms on the abdominal wall; this plastic is
subsequently removed from the abdominal cavity.
We prefer to use a 10-mm, 30-degree laparoscope
because the visualization and illumination provided
by the 5-mm, 30-degree laparoscope are not optimal
in our institution. This, of course, requires a trocar of
at least 10 mm.
A 5-mm trocar is used for introduction of the ProTack device (U.S. Surgical Corp./Tyco International).
Before this fixation system appeared on the market,
this step was performed using an endo-stapler, which
required the use of 12-mm trocars.
Under these premises, we believe that a 10-, 11- or 12mm trocar (depending on mesh size) should be used for
laparoscopic repair of ventral hernias, as these accommodate a 10-mm, 30-degree laparoscope and can be used
to introduce the mesh. A 5-mm trocar should be used to
introduce the tacks (or other fixation device) that attach
the mesh. Another 3- or 5-mm trocar should be used as a
working trocar.
Graspers, scissors, and other laparoscopic
instrumentation
Atraumatic bowel graspers are needed to manipulate the
bowel and to provide gentle traction to reduce the contents of the hernia sac. Sharp scissors are required for
proper dissection and prevention of bowel injury.
Different hemostatic systems, such as clips, must be available should their use become necessary. A needle-holder
should be available in case of an enterotomy, so that one
may repair the injury, thereby allowing the procedure to
continue laparoscopically. If we find a full-thickness injury
to the small intestinal wall that penetrates into the lumen,
we usually repair it, either by laparoscopy or by an assisted
mini-laparotomy, and then continue the technique by
placing the mesh intraperitoneally. However, if a colonic
injury occurs, we prefer to repair the bowel and, in the case
of a large defect, repair the hernia defect by placing the
patch a few days later or, in the case of a small defect,
convert to an open repair without the use of a patch.
Energy sources
Monopolar cautery is acceptable as long as it is not used in
close proximity to any viscera. Adhesiolysis must be performed with extreme care since missed bowel perforation
could be life-threatening for the patient. For this reason,
electrocautery should be used in a bleeding area after the
adhesions are freed. During dissection, there is frequent
hemorrhage, but this is usually minimal and insignificant
if the proper plane of dissection is maintained.
The harmonic scalpel has been advocated for lysis of
adhesions, but the blunt tip of this instrument does not
allow the easy localization of the proper plane to free the
adhesions of the bowel. For this reason, we use this source
of energy only for the lysis of omental adhesion and only
when we are convinced that there is no bowel attached to
the anterior abdominal wall behind the fatty tissue. This is
particularly useful in cases in which the round ligament
or the urachus must be dissected to guarantee a proper
fixation of the mesh, since dissection of these structures is
a time-consuming maneuver due to frequent bleeding.
Prostheses
Improvements are being made to attain the ideal prosthetic material, i.e. one that is biologically inert, that
produces little or no foreign-body reaction, that is strong
yet pliable, that maintains its shape after implantation,
and that resists the formation of adhesions while supporting fibrous in-growth of connective tissue.20 Polypropylene
mesh has been the most widely used prosthetic material in
hernia repair since it was introduced in 1963.21 Numerous
materials are currently available, such as ePTFE, with
excellent properties closely resembling the ideal prosthesis,
i.e. being biologically inert, producing fewer adhesions,22
and causing little or no inflammatory reaction, with its
porous microstructure providing a lattice for the incorporation of connective tissue.23,24
Clinical and experimental experience indicates a variety of complications that may be related to the physical
properties of polypropylene, such as the risk of bowel
obstruction and/or fistula formation.2527 Additionally, a
recent experimental study conducted in our laboratory

revealed that polypropylene does not attach to the
peritoneum as well as it does to the other layers of the
abdominal wall previously dissected. ePTFE appeared to
attach more firmly to these layers. The new ePTFE material is designed specifically to be placed intraperitoneally,
since one (visceral) surface has very small pores, which
inhibits tissue in-growth, while the opposite (parietal)
surface that is placed on to the peritoneum has large
pores to permit significant tissue in-growth.
We usually use the DualMesh Plus with Holes
(W. L. Gore & Associates), which is impregnated with
chlorhexidine and silver. These antimicrobial agents
decrease the possibility of contamination of the mesh.
Chlorhexidine and silver also change the color of the
ePTFE to brown; this minimizes the bright glare of the
ePTFE, which can otherwise hamper the management of
the mesh within the abdominal cavity because of the
brightness of the light of the laparoscope. We also advocate the use of the mesh with holes since it will facilitate
the drainage of the fluid retained between the mesh and
the sac during the first hours of the postoperative period.
The use of an external compressive bandage is also recommended, as this will aid in decreasing the size of the
seroma that we have seen in some of our patients.
Fixation devices
We fix the mesh in all cases with helical tacks, which provide proper fixation of the mesh to the anterior abdominal wall, thereby avoiding the need of transfascial sutures.
A new fixation device is now available, the SaluteTM
(Onux Medical, Inc.), which delivers a cylindrical construct of stainless steel.
We do use sutures in hernias that require a mesh
larger than 18 ! 2 4 cm to facilitate orientation and
initial fixation of the mesh. These sutures may be of any
type of material since they will be removed. They are
placed at the four cardinal points of the patch and are
passed through the abdominal wall with the aid of a
suture-passer (W. L. Gore & Associates). These sutures
are not tied once the mesh is fixed with the tacks. Instead,
they are removed completely when the outer crown of
tacks is placed and the mesh is properly extended.
hernias, midline hernias located in the lower of the

abdomen, or if operation is likely to be prolonged. We use
a nasogastric tube to decompress the stomach in patients
with subxiphoid hernias or hernias in the upper third of
the midline of the abdomen.
Operative technique
Creation of pneumoperitoneum and placement
of trocars
In all cases, we start by creating the pneumoperitoneum
using a Veress needle in the left hypochondrium. We do
not use the Hasson trocar, regardless of the number of
previous laparotomies that the patient has undergone.
Our group has performed more than 4000 laparoscopic
procedures for a variety of pathologies, and there has
never been an injury to any structure because of the use
of the Veress needle. Hence, we feel confident when
creating the pneumoperitoneum with this technique,
even in patients with a history of multiple operations.
Once the pneumoperitoneum is created, we generally
approach the hernia from the patients left side, placing
three trocars in line, introducing the 1012-mm trocar
first and then placing the other 5-mm trocars under direct
vision; the larger trocar is placed in the middle of the other
two trocars. An important thing to remember when placing these trocars is to stay as far away as possible from the
margin of the defect closest to the surgeon. This will provide proper visualization of the margin, making it easier to
achieve a wide overlap of the mesh and perform any
maneuvers needed to secure the prosthesis (Figure 18.2).
When it is not possible to maintain a suitable distance

The description below is based upon the repair of small
to medium-sized (310 cm) primary or incisional hernias located in the midline but about 3 cm from the
xiphoid and suprapubic areas.
We usually place the patient in the supine position,
with the surgeon and the assistant to the patients left and
the monitor in front of them to the patients right. A urinary drainage catheter is used in patients with suprapubic
Figure 18.2 Pneumoperitoneum is created using a Veress

needle in the left upper quadrant of the abdominal wall. The first
trocar is introduced far enough from the defect so we do not
have difficulty in fixing the proximal part of the mesh.
from this margin, we introduce another 5-mm trocar in

the patients opposite flank in order to adequately fix the
mesh on the margin closest to the trocar through which
the laparoscope is placed. If necessary, a contralateral
10-mm trocar can be inserted to help anchor the mesh.
Adhesiolysis
Once the trocars are introduced, the adhesions are
evaluated. We consider adhesiolysis to be a key point of
this procedure, since incorrect performance of the adhesiolytic process can have extremely serious consequences for
the patient. Nevertheless, if there are any doubts regarding
the possibility of bowel perforation, the operation should
be converted to the open technique or, alternatively, one of
the trocar holes may be enlarged to evaluate the bowel.
This is critical because a missed enterotomy is associated
with high morbidity and mortality.
entire defect on the skin of the patient. In obese patients,

it is difficult or impossible to feel the grasper on the outside. In these cases, we insert an intramuscular needle
through the skin and abdominal wall. The tip of the
needle is visualized inside the abdominal cavity under
laparoscopic vision and, with multiple passes, is used to
detect and trace the hernia defect on the patients skin
(Figures 18.4 and 18.5).
An exact measurement of the defect is determined
when the abdomen is fully desufflated. The patch is then
chosen to provide an overlap of at least 3 cm. We systematically use a DualMesh Corduroy Plus with Holes.
Once the mesh is selected, several marks are traced on
the patients abdomen and on the mesh surface that
Identification of the defect and selection of

the mesh
Once the adhesiolysis process is completed, we proceed
to identify the defect and the sac (Figure 18.3). We use
the electrocautery to coagulate the entire area where the
adhesiolysis was performed. This is done to avoid any
bleeding in these areas, which could then create a hematoma at this level. If this were to occur, tension could be
produced that could result in the detachment of the tacks
following implantation of the prosthetic biomaterial.
Once the hernia is identified, the actual hernia defect
must be delineated by marking the margins of the hernia
(not the sac) on the skin of the patient. To facilitate the
accurate identification of the fascial edges, a laparoscopic
grasper is used (under direct vision) to exert pressure at
the margins of the defect. The pressure exerted by this
instrument is palpated on the outside of the abdominal
wall. This is used to accurately outline and mark the
Figure 18.3 Defect of the hernia that needs to be covered once

the adhesiolysis process is completed.
Figure 18.4 Once adhesiolysis has been performed, the defect

is identified since it will be where the inner crown of tacks will
be placed. In obese patients, the best way to localize the defect
is by using needles from the outside under direct vision.
Figure 18.5 The defect identified previously is drawn on the

patients skin and the needles are removed. The three trocars
placed in line can be observed; one 10-mm trocar and two 5-mm
trocars are usually used.
will be placed in contact with the viscera, in order to

facilitate orientation of the prosthesis within the cavity
(Figure 18.6). A circular mark is traced at the cranial end
of the mesh. An identical mark is placed on the patients
abdomen to denote the location where the mesh will be
anchored. A triangle is then drawn at the caudad end of
the mesh and the abdominal wall, followed by a line that
passes through the triangle, starting at the lower limit of
the hernia defect. This is the line where the caudad tack
will be positioned, since the outside measurements are
different from the internal measurements. Once the cranial tack is placed internally, the distance will not correspond exactly to the triangle drawn on the patients
abdomen when the mesh is tightened. The second (caudad) tack will be placed at the level of the line that passes
through the middle of the triangle. A cross is then drawn
on the left side of the patients abdomen and on the
mesh, and two crosses are drawn on the right in order to
extend the mesh properly in both directions.
Afterwards, we roll the mesh along its long axis, leaving
the mesh side that will be in contact with the bowel rolled
towards the inside (Figure 18.7a). This will make it easier
to perform the maneuvers needed to expand the mesh

once attachment has begun. We prefer to introduce the
mesh through one of the trocars to prevent potential contamination, which may occur if it is inserted through the
skin, a strategy that is preferred by some authors (Figure
18.7b). If a large prosthesis is needed ("18 ! 24 cm), we
prefer to remove the trocar and insert the mesh wrapped
in sterile plastic through the trocar hole, and then remove
the plastic from inside the cavity.
Placement and fixation of the mesh
Once the mesh is inside the cavity and unrolled properly,
it must be oriented by using the circle drawn on the
mesh. The corresponding area of the abdominal wall
where the mesh is to be fixed is located by pushing on the
abdominal wall at that site. If the patient is extremely
obese, we insert a needle at the level of the circle on the
abdomen in order to locate the area where the first tack
should be placed. When this tack is placed (Figure 18.8),
(a)
(a)
(b)
(b)
Figure 18.6 (a) Different signs are drawn on the mesh to orient
it once it has been introduced in the cavity. (b) The same signs
are drawn on the patients skin on the cardinal points.
Figure 18.7 (a) The mesh is rolled along its long axis, with the
area prepared to be placed in contact with the bowel in the
inside. (b) Once it has been rolled, the mesh is grasped with a
strong grasper to be introduced in the abdominal cavity through
the 1012-mm trocar.
(a)
Figure 18.8 The first tack is placed where the circle is drawn
on the mesh, one of the cardinal points. The exact point to be
placed is localized by pressing from the outside on the circle
drawn on the skin.
we stretch the mesh in the caudad direction and perform

the same maneuver, placing the second tack in the line
that intersects the triangle traced earlier (Figure 18.9).
Subsequently, the lateral tacks are placed following the
same system with the crosses, avoiding the tendency of
the mesh to move in the opposite direction from the
point where the laparoscope is introduced.
Once the mesh is fixed in the four cardinal points, we
extend it adequately, adding an outer crown of tacks that
are placed right on the margin of the mesh (Figure 18.10).
These tacks are separated from each other by a distance of
1 cm, which is adequate to ensure that the intestinal loops
do not slip between the tacks resulting in an acute incarceration. While the crown is being placed, the surgeon
must exert strong pressure against the tacker from the
outside to ensure that the mesh is attached to the surfaces
closest to the wall surface, thereby reaching the muscle
fascia. Once the mesh is extended adequately with the
tacks of the outer crown, we check for any mesh areas that
may not be extended adequately and that are adherent to
the anterior wall of the abdomen, because adhesions
would occur at the hanging sections of the mesh (we
have observed this phenomenon in an experimental study
conducted by our group).13 We add the necessary tacks at
this level to extend the mesh adequately so that these
potential areas of adhesions are prevented.
Once the outer crown is finished, we add the inner
crown of tacks. Since this level contains a smaller amount
of pre-peritoneal fat, the inner crown is placed at the margin of the hernia sac to ensure better attachment of the
mesh (Figure 18.11). Similarly, to identify the sac margin,
we draw the defect on the abdomen of the patient before
inserting the mesh inside the cavity. Pressure can then be
exerted from the outside, or a needle can be introduced at
(b)
Figure 18.9 (a) The second tack is placed on the opposite

cardinal point (caudal) where the triangle was drawn. (b) If we
have difficulty in localizing the place where we want the tack,
we introduce a needle from the outside.
Figure 18.10 Once the tacks are placed in the four cardinal
points, the outer crown of tacks is placed right at the margin of
the mesh.
this level in obese patients, so that we can identify the area

where the inner crown of tacks should be placed. These
are also executed while exerting pressure from the outside
to ensure good anchorage at this level. As in the case of the
effort to prevent seroma development. This bandage is

kept in place for one week and is removed at the seven-day
follow-up visit. Skin sutures are also removed at this time.
Once the procedure is completed, we start the patient
on fluid intake about six to eight hours after surgery,
progressing to solid foods as tolerated. The patient is
normally discharged within 24 hours of surgery. In terms
of physical activity, we do not impose any limitations on
the patient, but recommend only gradual resumption of
regular daily activities based on the patients progress
during postoperative recovery. Patient follow-up is carried
out at one month, three months, six months, one year,
and with yearly visits thereafter.
Figure 18.11 The inner crown of tacks is placed at the margin

of the hernia sac to ensure better attachment.
Figure 18.12 The double crown of tacks is completed.
tacks used for the outer crown, the inner crown tacks are
placed about 1 cm apart.
Once all the tacks are placed (Figure 18.12), we proceed to identify and remove any that are left hanging
from the wall or that are placed improperly, since they
should be inserted through the entire thickness of the
mesh. Poorly positioned tacks will lead to adhesions, as
we have shown in our experimental study, and could
cause major complications in the future, such as fistulas
or obstruction.13
Once the procedure is completed, the abdomen is desufflated and trocar sites larger than 10 mm are closed. A
compressive bandage is placed at the level of the hernia sac
to reduce the space between the mesh and the sac in an
RESULTS OF OUR SERIES

Between November 1998 and April 2002, we operated
upon 105 ventral hernias on 102 patients using the doublecrown technique. Our series included 63 women and
42 men, with a mean age of 57.59 years (range 2680 years).
The ventral hernias included eight primary hernias (four
umbilical hernias, four epigastric hernias) and 97 incisional hernias. The hernia site varied considerably, with
87 midline hernias and 18 lateral hernias. The mean size
of the defect repaired was 115.87 cm2.
Only three cases were converted to open surgery: one
patient with extremely strong adhesions who had been
operated upon previously for acute peritonitis of tuberculous origin; one patient who was converted due to
technical difficulties; and one patient who was converted
due to a strong adhesion from the colon to the hernia sac.
Intraoperative complications included three intestinal
perforations; one of these was sutured by laparoscopy
and the other two required enlarging one of the trocar
holes to perform resection and anastomosis, continuing
later by laparoscopy. The following complications were
encountered during the postoperative period: three clinical seromas that required drains, two abdominal wall
hematomas, two prolonged paralytic ileus, and three
reoperations. One of the reoperations was for missed
intestinal perforation and peritonitis requiring emergency laparotomy. We sutured the bowel perforation and
removed the mesh. The second reoperation was in a
patient who had fever of 45 days duration. The seroma
fluid was drained repeatedly, but cultures were negative.
It was assumed that the patient had a foreign-body reaction and the mesh was removed. The third reoperation
was performed due to small bowel ischemia, the etiology
of which is undetermined.
The mean hospital stay was 1.75 days, with a mean of
2.48 days in our first 45 cases and dropping to 1.12 days in
the last 60 cases of our series. There were three recurrences, accounting for 2.86 per cent of all our cases, with
a mean follow-up of 24 months. These recurrences

occurred in one patient in our initial series in whom a
small mesh was implanted and in two cases of suprapubic
hernias in which the pubis and Coopers ligament were
not exposed adequately for suitable fixation of the mesh.
9
10
11
12
CONCLUSION
Our results indicate that the use of transfascial sutures is
not necessary and that the double-crown technique,
which uses only tacks, offers a number of clear advantages over the combined suture-and-tack method. When
using the technique described, we obtained a similar
recurrence rate as series that use sutures, while also reducing the hospital stay and short-, medium- and long-term
postoperative pain. Hence, we consider the double-crown
technique to be a valid alternative to ventral hernia repair
with sutures.
13
14
15
16
17
REFERENCES
1

Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment
of ventral abdominal wall hernias: preliminary results in 100
patients. JSLS 2000; 4: 1415.
Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of
laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65:
82732.
DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal
polytetrafluoroethylene (PTFE) prosthesis patch repair of ventral
Morales-Conde S, Lpez F, Tutosaus JD, et al. Cost-effectiveness
of Double Crown technique for laparoscopic ventral hernia vs
open repair. Presented at the 9th International Congress of he
European Association for Endoscopic Surgeons, Maastricht,
1316 June 2001.
hernia repairs: a personal series and review of the literature. JSLS
1999; 3: 293304.
Chari R, Chari V, Eisenstat M. A case controlled study of laparoscopic
ventral hernia repair. Surg Endosc 1998; 12 (suppl): S09.
18
19
20
21
22
23
24
25
26
27

LeBlanc KA, Booth W, Whitaker JM. Laparoscopic repair of ventral
hernias using an intraperitoneal onlay patch: report of current
results. Contemp Surg 1994; 45.
Park A, Birch DW, Lovrics P. Laparoscopic and open incisional
Morales-Conde S, Cadet I, Tutosaus JD, et al. Macroscopic
evaluation of mesh incorporation placed intraperitoneally for
laparoscopic ventral hernia repair. Experimental model. In: Lomanto
D, Kum CK, So CK, Goh PMY, eds. Proceedings of the 7th World
Congress of Endoscopic Surgery (Singapore June 14, 2000).
Bologna, Italy: Monduzzi Editore, 2000: 45560.
Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of
laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc
1998; 12: 9559.
Sanders LM, Flint LM, Ferrara JJ. Initial experience with
laparoscopic repair of incisional hernias. Am J Surg 1999; 177:
22731.
Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience
with the four-before laparoscopic ventral hernia repair. Am Surg
2000; 66: 4659.
Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair: a
report of 100 consecutive cases. Surg Endosc 2000; 14: 41923.
190: 64550.
LeBlanc KA. Current considerations in laparoscopic incisional and
ventral herniorrhaphy. JSLS 2000; 4: 1319.
Condon RE, DeBord JR. Expanded polytetrafluoroethylene
prosthetic patches in repair of large ventral hernia. In: Nyhus LM,
Condon RE, eds. Hernia, 4th edn. Philadelphia: Lippincott Williams
and Wilkins, 1995: 32836.
Usher FC. Hernia repair with knitted polypropylene mesh. Surg
Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and
Gore-Tex to repair abdominal wall defects in the rat. Can J Surg
1989; 32: 244.
Bauer JJ, Salky BA, Gelernt IM, Kreel I. Repair of large abdominal
wall defects with expanded polytetrafluoroethylene (PTFE). Ann
Surg 1987; 206: 765.
Law NW, Ellis H. Adhesion formation and peritoneal healing on
prosthetic materials. Clin Mater 1988; 3: 95.
Kaufman Z, Engelberg M, Zager M. Fecal fstula: a late
complication of Marlex mesh repair. Dis Colon Rectum 1981; 24:
543.
Voyles CR, Richardson JD, Bland KI. Emergency abdominal wall
reconstruction with polypropylene mesh: short-term benefits
versus long-term complications. Ann Surg 1981; 194: 219.
Ponce Gonzlez JF, Barriga Beltrn R, Martn Zurita I, et al.
Prosthetic materials in incisional hernia. Experimental study. Cir
Esp 1998; 63: 18994.
19
Parastomal hernia repair
KARL A. LEBLANC
Types of hernia
Principles of management
Indications and contraindications to surgery
Preoperative preparation
Operative techniques
143
144
144
145
145
Hernias that develop at the site of the various intestinal

stomas are quite common and often lead to many problems. Parastomal hernias may present as problems of
stoma care, difficulty with the fit of the appliances or irrigation, leakage of the fluids produced, a significant cosmetic deformity, or as complications of the hernia, such
as intestinal obstruction or strangulation. The presence
of a large protrusion may make repair a necessity irrespective of its other side effects because of a significant
cosmetic deformity. Herniation is less frequent with
ileostomy than colostomy, but the overall incidence of
parastomal herniation is difficult to quantify.
Burns, in 1970, found 16 paracolic hernias among
307 colostomates, an incidence of five per cent.1 Other
authors have quoted figures that range from five to 48 per
cent.26 It is apparent that few (approximately 20 per
cent) of these hernias are repaired surgically. This may be
due to the lack of significant symptoms in the majority of
these patients and/or the age or infirmity of these individuals, which may prohibit surgical intervention.7,8 The
incidence of para-ileostomy hernia is between five and
ten per cent, while that of para-urostomy stomas in
urological practice is between two and ten per cent.9,10
However, one radiological study of 28 ileostomies using
clinical and computerized tomography (CT) evaluation
found that the rate of herniation was 35 per cent; this was
the same whether the ileum exited through or lateral to
the rectus muscle.11
Results
Conclusion
References
147
148
149
149
TYPES OF HERNIA
The anatomy of the herniation is variable. Four principal
types can be identified:
Subcutaneous: there is herniation alongside the

stoma, with a subcutaneous hernia sac containing
omentum or small or large intestine. This is the
most common form of paracolostomy hernia
and, not infrequently, the colon is found in the
sac situated just proximal to the stoma. This
positioning of the intestine alters the path of the
colon such that the ostomy can be very difficult
to irrigate.
Interstitial: there is a hernia sac lying within the
muscle/aponeurotic layers of the abdominal wall,
which may contain omentum or small or large
intestine. In these cases, the stoma is asymmetrical,
and is edematous and cyanotic if its vascular supply
is compromised. The interstitial and subcutaneous
hernias are considered to be variants of a sliding
hernia. Because the ring of tissue that surrounds the
contents of the hernia can be quite narrow, these
hernias are particularly at risk of incarceration and
strangulation.
Prolapse: all stomas can prolapse, but transverse
colostomies prolapse three times more frequently
than any other stoma. A prolapsed stoma contains a
hernial sac within itself; other viscera, especially the

small intestine, can enter this sac and even become
strangulated. Large hernial sacs that can be
associated with prolapse are often seen in neonates
with a transverse colostomy for anorectal agenesis.
Intrastomal: this type of hernia is seen only with end
ileostomies. A loop of intestine may herniate
alongside the stoma and lie between the emergent
and the everted layer of the stoma. Intestinal
obstruction has been described in such hernias.
PRINCIPLES OF MANAGEMENT
The exact classification of the hernia is not critical to the
laparoscopic surgeon. The approach to these different
hernia types will not vary significantly, except in the situation in which the intestine may be strangulated. In this
case, the use of the laparoscopic technique may be
contraindicated. In the elective operation, the condition
of the patient and any predisposing factors, such as
cachexia, malignancy, obesity, and steroid usage, should
influence the decision to proceed with surgical intervention, as it would for any operation.
However, an accurate diagnosis and assessment of the
anatomy of the hernia are essential. Therefore, the patient
must be examined (1) supine and relaxed, (2) supine
with the muscles tensed, and (3) in the erect position.
Investigation of the detailed anatomy with CT scanning
is useful to delineate large parastomal defects in the
abdominal wall. CT scanning can also detect small
impalpable defects around ileostomies that present with
dysfunction.12 This information will assist the surgeon in
the planning and execution of the operation. I have seen
a herniation through the ileal conduit mesentery during
the repair of a para-urostomy hernia. This was suspected
by the findings on the preoperative CT scan and was
confirmed at surgery. That procedure was modified
intraoperatively due to this fact (see below).
Patients who have had cancer surgery must be screened
for recurrence before surgery is advised. Similarly, it is
prudent to exclude recrudescent inflammatory bowel
disease before undertaking operations in patients with
ileostomies, although it should be noted that the risk of
para-ileostomy herniation is similar in patients with
ulcerative colitis and Crohns disease. An additional consideration that has become more commonplace is the life
expectancy of the patient. An increasing number of
patients of advanced age are seen with multiple medical
problems that add to the risk of general anesthesia. If
these illnesses will significantly shorten the life of the
patient (i.e. by two to three years or more), or if they prohibit anesthesia, then one may not wish to proceed if
there is no immediate need for surgical intervention.
There are four surgical options for treating a parastomal hernia:

1 Local repair of the stoma, in which case it is
mobilized locally, the peritoneal sac is identified and
the sacs contents are reduced. The peritoneum and
the musculo-aponeurotic defect are then closed. This
is associated with an unacceptable recurrence rate.
2 Prosthetic repair by either an extraperitoneal or
extraparietal route. There have been reports of erosion
and perforation of the colon by the mesh used in this
repair.13
3 Stoma relocation either with formal laparotomy or
with limited transperitoneal transfer of the stoma.
This can be a very effective procedure.14 However,
many patients are quite comfortable with the
location of the stoma and would rather maintain the
current site if feasible.
4 Laparoscopy offers several advantages that
encompass many of the attributes noted above. The
laparoscopic approach offers the surgeon the ability
to visualize the entire abdominal wall so that any
incisional hernias may also be repaired at the same
time. Additionally, the anatomical detail of the
hernia is nearly always identified easily with the view
that is provided with this technique. This repair
requires that the prosthetic biomaterial be placed
in the intraperitoneal position. The use of
polypropylene has been described, but I believe
that the preferred biomaterial is expanded
polytetrafluoroethylene (ePTFE).1518 The experience
with this technique, however, is not vast; nor is there
any significant long-term follow-up of the few
patients that have undergone this hernioplasty.
Currently, the initial reports are promising but the
optimal method of repair has not been finalized.
When attempted, it is very unusual that one cannot
repair these hernias laparoscopically. However, it may
sometimes be advisable to identify a potential site for
relocation of the stoma if this proves necessary during the
operation due to an inability to complete the procedure
either laparoscopically or open.
INDICATIONS AND CONTRAINDICATIONS

TO SURGERY
Surgery is imperative in all cases of intestinal obstruction
or strangulation related to any parastomal hernia. Urgent
emergency surgery is also absolutely indicated in all cases
of paracolostomy hernia where perforation has occurred
during irrigation. Operative intervention is also the
treatment of choice when a parastomal hernia causes
abdominal wall distortion and the resultant difficulties
Parastomal hernia repair 145
with the fitting of an appliance or irrigating a stoma.

Surgery should also be considered if the stoma has
become out of the patients range of vision, or if its site
on a hernia bulge makes it unmanageable in elderly
patients, especially those with arthritis. The disfigurement caused by a bulging parastomal hernia may warrant surgery for cosmetic reasons. In special circumstances,
the repair may need to be accompanied by an abdominoplasty to permit a good fit of the appliance.
Contraindications to surgery include such general
problems such as cardiorespiratory failure, inability to have
general anesthesia, recurrent Crohns disease, extreme obesity, disseminated malignancy, and a short life expectancy
from any disease process. However, even these may not
be obstacles to surgery, depending upon the presentation
of the patient. If the patient exhibits significant skin
excoriation in the areas where the transfascial sutures are
likely to be placed, then the open procedure may be preferred, unless these lesions can be eliminated by preoperative care.
PREOPERATIVE PREPARATION
These patients are usually elderly and should be cleared
for surgery in the manner that is common to all operations. If the patient has a colostomy secondary to a
malignant resection, it may be advisable to carry out preoperative colonoscopy to assure that there is no recurrent
disease. However, this will be dependent upon the number of disease-free years. As noted earlier, a preoperative
CT scan is frequently helpful to identify the anatomy and
the contents of the hernia. This is especially true for the
para-ileal conduit hernia.
I prefer to use gentle cleansing enemas on the day
before the operation for patients that have a paracolostomy hernia. This does not assist in the operative
procedure, but it may diminish the risk of infection if
there is a colonic injury during laparoscopy. Preoperative
antibiotics are not necessary if an antimicrobial is
impregnated into the biomaterial that will be used to
repair the hernia (e.g. DualMesh Plus).
OPERATIVE TECHNIQUES
The patient is placed in the supine position on the operating table. It is best to place a roll underneath the ipsilateral side of the hernia. This elevates the patient and
enables easier access to the area where the sutures will be
placed (Figure 19.1). Typically, a gastric tube is placed for
decompression, and a urinary catheter is used. The video
monitors are usually located at the foot of the table and
on the ipsilateral side of the hernia. The surgeon will
Figure 19.1 Patient position on a roll to elevate the ipsilateral

side of the patient. Note the circle that is marked on the skin to
identify the outermost site of the appliance.
stand on the contralateral side and position the trocars to

triangulate the defect (see Chapter 16). The assistant surgeon will place a fourth trocar in the upper quadrant in
the side of the abdomen with the hernia. We use 5-mm
trocars exclusively for this procedure.
A 2 ! 2-cm gauze is placed over the paracolostomy or
para-ileostomy stoma to prevent leakage during the
procedure. If the ostomy is an ileal conduit, a urinary
catheter is inserted to provide continuous drainage.
The balloon is inflated with approximately 3 ccs rather
than 5 ccs of saline due to the size of the bowel lumen.
The entire abdomen is then covered by a sterile, iodineimpregnated plastic drape. Before the placement of this
drape, the outer aspect of the position of the stomal
appliance is marked on the skin with a marking pencil.
This identifies the outermost boundaries of the potential
sites of transfascial suture placement (Figure 19.1).
The non-bladed trocar (with the laparoscope within
it) is used for the initial entry into the abdomen.
Occasionally, a Veress needle or the open approach may
be preferred, but in our experience this is seldom necessary. As with other intra-abdominal hernia repairs,
dissection of the adhesions is the most tedious and timeconsuming portion of the procedure. This should be
done either sharply without electrocautery or with the
cautious use of the Harmonic scalpel (see Chapter 16).
The instruments that are used for this are shown in
Figure 16.4. Although the use of a large catheter placed
within the ostomy to palpate the stoma intraoperatively
is appealing, it frequently provides little benefit.
As with the usual incisional hernias, the entire fascial
defect and the adjacent abdominal wall must be cleared of
all adhesions (Figure 19.2). It is at this point that the measurement of the defect can be performed. This is somewhat
difficult because of the presence of the stoma and the
Figure 19.3 Central cut-out and slit in the prosthesis of the

initial DualMesh Plus prosthesis.
Figure 19.2 Fascial edges of the paracolostomy hernia. The
arrows demarcate the borders of the hernia.
gauze that was placed at the outset of the operative procedure. It is usually necessary to use an oversized patch to
provide a wide margin of coverage. The most frequently
used biomaterial is the 15 ! 19-cm DualMeshPlus patch
(W. L. Gore & Associates). This will invariably result in at
least a 5-cm margin around the fascial defect.
There are variations in the use of these prosthetic
products to repair these hernias. To date, no one technique has proven to be superior to the others. We have
used three different methods to repair these hernias,
which are presented below. Continued follow-up of these
patients will allow us to decide upon the best approach to
the repair of parastomal hernias.
One method involves the placement of two ePTFE
products. In one version, we used two DualMesh Plus
products; in another version, we used one MycroMesh
Plus product and one DualMesh Plus product. In both, a
central circle is cut to allow for the exit of the intestine,
and a slit is made to allow the patch to be placed around
the stoma (Figure 19.3). Usually, this central circle is
33.5 cm, which is adequate for the colon exit, but with
the ileostomy 2.53 cm is preferred. This first patch is
inserted and secured to the anterior wall in a manner that
is similar to that of the incisional hernia repair. The slit is
placed adjacent to the colon and directly opposite the
fascial defect so that good fixation can be made at that
point, and the defect is covered completely with the initial patch (Figure 19.4). Sutures are used adjacent to the
bowel to re-approximate this slit. These sutures are
pulled transfascially with a suture-passing instrument
(see Chapter 16). Additional fixation of the patch is
then applied using the Onux Saluteconstructs (Onux
Medical, Inc.). This initial step has been done using
either the DualMesh Plus or the MycroMeshPlus biomaterial, as noted above (see Chapter 3). The holes in the
Figure 19.4 Position of the initial prosthesis with the slit

placed opposite the hernia defect. In the photograph, the slit is
on the left and the hernia defect is covered with the prosthesis
on the right.
latter product may provide better fixation for the second

patch that will be placed in this method because no
in-growth of collagen will occur through this first patch
into the second one.
A second biomaterial is then used, usually 18 ! 24-cm
DualMesh Plus, so as to completely cover the initial
15 ! 19-cm patch. In this way, there will also be ingrowth of tissue to the periphery of the second patch.
Additionally, this larger product will provide greater support than the smaller one to the anterior abdominal wall.
Many of these patients will have a significant deformity
of the anterior abdominal wall because of the size of the
hernia itself. It is believed that the use of this second and
larger prosthesis will result in a better cosmetic result and
fit of the appliance. This second patch is cut similarly to
the first one, inserted into the abdomen, and fixed with
Figure 19.5 The potential space that can exist between the
intestine and the opening in the prosthesis is shown by the arrows.
One may elect to suture the colon at this site. The ePTFE sutures to
the second patch are also seen on the left side of the colon.
Figure 19.6 Final appearance of the completed repair. One

suture that has sutured the colon to the opening is seen in the
middle of the photograph.
the initial sutures similar to the initial patch. However,

the slit that is made in this patch is placed opposite the
location of the slit in the initial patch. This placement
is chosen to prevent herniation through the slit in the
initial patch because the second patch protects that slit
(Figure 19.5). The intent is to cover the first slit with the
second patch so that the ring cannot enlarge and result in
re-herniation.19 Fixation is then completed with the constructs and multiple transfascial sutures that are placed
to include both the first and second patches, as described
in Chapter 16. Occasionally, one may choose to suture
the colon to the edge of the hole in the patch if it appears
that there is a risk of passage of bowel into that space
(Figure 19.6). The final appearance reveals good coverage
of the defect (Figure 19.6).
Figure 19.7 Typical suture placement in the prosthesis for the

onlay type of parastomal hernia repair.
Another method by which to repair these hernias

is based upon the onlay technique described by
Sugarbaker.20 A critical step in this operation is the
lateralization of the intestine against the sidewall of the
abdomen. This is done by suturing the herniated intestine at several locations at the antimesenteric border to
secure it to the abdominal wall with permanent suture.
The laparoscopic approach duplicates this repair but, in
most patients, the use of the DualMesh Plus prosthesis
has been chosen rather than polypropylene, which was
used by Sugarbaker. The important points to this procedure include complete dissection of the adhesions that
are present and identification of the fascial edges. A margin of at least 5 cm is also preferred with this repair. I prefer to place one suture at the midpoint of one axis of the
prosthesis and two sutures at the other side of the patch
(Figure 19.7). These latter sutures will be pulled on either
side of the viscera that leads to the stoma. The exact location of these on the biomaterial will be dependent upon
the size of the intestine and the location and size of the
hernia itself. One must be careful that these two sutures
are not pulled so tightly that a relative obstruction could
result. Based upon our prior experiences with incisional
hernia repairs, additional sutures are placed a minimum
of 5 cm apart, and Salute constructs are placed 1 cm
apart, along the periphery of the patch, as with all of
these parastomal hernia repairs (see Chapters 16 and 20).
This results in the placement of several sutures. Others,
however, do not place as many sutures.6,21
Patients are usually maintained in the surgical unit, which
allows for a one-night postoperative stay. The gastric and
urinary tubes are discontinued in the recovery room.
Patients are allowed a liquid diet immediately, although
most have a short-term ileus. The diet is advanced as tolerated. Abdominal binders, which are used routinely for

Table 19.1 Laparoscopic parastomal hernia repair publications
Reference
Patients
(n)
Prosthesis
Location of
prosthesis
Length of hospital
stay (days)
Length of follow-up
(months)
Porcheron et al. (1998)15

Bickel et al. (1999)16
Voitk (2000)17
Kozlowski et al. (2001)21
LeBlanc et al. (2002)18
Berger (2002)6
1
1
4
4
3
15
ePTFE
Polypropylene
Polypropylene
ePTFE
ePTFE
ePTFE
Pre-peritoneal
Intraperitoneal
Intraperitoneal
Intraperitoneal
Intraperitoneal
Intraperitoneal
4
6
2 (3 patients), 9 (1 patient)
3.8
1 (all patients)
N/A
12
12
N/A
233
311
312
the incisional hernias, are placed selectively for this repair.

The decision to use these is based upon the patients
request, as they do aid in the management of postoperative pain and in the prevention of seromas. The level of
activity of the patient is based upon the pain tolerance of
the individual, and no restrictions are given.
RESULTS
The laparoscopic repair of parastomal hernias has been
utilized as a method to repair these defects only recently.
At the time of writing, I am aware of only six reports in
the literature of this methodology.6,1417 Each of these
articles detailed a slightly different technique, involving
few patients (Table 19.1).
Pocheron and coworkers closed the hernial orifice and
used the patch only as a reinforcing layer with no slit used
to allow egress of the colon.15 Bickel and colleagues created two strips of mesh, securing one to the abdominal
wall and the other to the intraperitoneal colon.16 Voitk
used a technique that mimicked that of Sugarbakers
intraperitoneal repair.17 All of these authors used tacks
alone to provide fixation to the abdominal wall. Although
Bickel used polypropylene mesh (PPM) for the repair of
that patient, he commented that the use of intraperitoneal PPM may lead to adhesion formation and that the
use of a dual mesh nonadherent surface on one side may
be preferable. Kozlowski and coworkers used an onlay
technique with four sutures; the exact technique is not
described specifically in their paper, however.21
Berger uses an onlay technique that involves fixation
with transfascial sutures and tacks.6 Unless the patch is
greater than 20 cm, he does not use any more than four
sutures. He also prefers an overlap of 5 cm for this procedure. As noted in Table 19.1, Berger has reported upon 15
patients. In the immediate postoperative period, one
patient developed a hematoma and one patient required
reoperation because of incarceration of the small bowel
between the patch and the abdominal wall. This latter
complication was due to a dislocated tack. Three of
the patients (20 per cent) developed a recurrent hernia
between two and four months. One could certainly
postulate that the method of fixation may be inadequate

because of the relatively few transfascial sutures that were
used in this repair. I believe that it is critical that these
sutures are used at not more than 5 cm apart along the
entire periphery of the patch unless there is a structure,
such as the iliac bone, that prohibits its placement.22 In
this case, the patch should be secured with many more
metal fixation devices than would be the usual recommendation. Some surgeons have trephined the bone to
place sutures to ensure fixation.
My surgical group has now performed one of the
operations described above on a total of nine patients
(Table 19.2). The average length of stay is somewhat
longer than our experience for incisional hernias, which
is 1.25 days. This is not surprising, however, given the fact
that all of these patients had multiple operations previously and several had recurrent parastomal hernias.
The enterotomy occurred in the patient with the paraurostomy hernia. He had undergone two previous
repairs, the latter of which included the repair of an incisional hernia with PPM intraperitoneally. I repaired this
injury laparoscopically but did not repair the hernia at
that time. His length of stay was increased because he
remained in hospital until the hernia repair was carried
out four days later. Interestingly, a counter-incision for
open access was required during the second procedure
because of the inability to accurately assess and reduce
the incarceration of the hernia. In addition to the incarcerated small bowel in the hernia, the patient also had a
herniation through the mesentery of the urostomy
(Figure 19.8). This was reduced, and the repair was
completed laparoscopically.
The recurrence that was seen in the para-ileostomy
hernia occurred after nearly one year. Small bowel had
herniated through the slit of both of the patches used in
the repair. This was reduced laparoscopically, and the
small bowel was sutured to the abdominal sidewall to
prevent migration into the slit again. The latter was also
tightened. This failed after one year, and the patient has
now undergone an open repair, which relocated the
stoma to the left side of his abdomen.
The other patients have done very well over the
follow-up period, with the exception of the one fatality.

Table 19.2 Parastomal hernioplasty experience
Type of repair
Hernia type (n)
Average length
of stay (days)
Complications
Average follow-up
(months)
Two DM%
Paracolostomy (2)
Para-ileostomy (1)
Paracolostomy (3)
Para-urostomy (1)
Paracolostomy (2)
2.33
1
1.67
7
2
Seroma (1)
Recurrence of para-ileostomy hernia
Ileus (1)
Enterotomy (1)
Death (1)
21
20
8
2
2
Paracolostomy (7)
Para-ileostomy (1)
Para-urostomy (1)
1.86
1
7
Ileus (1)
Seroma (1)
Enterotomy (1)
Recurrence (1)
Death (1)
11 (range 225)
Onlay of DM%
MM and DM%
Total
DM%, DualMesh Plus; MM, MycroMesh.
laparoscopic recurrence rate of 20 per cent reported by

Berger.6 The critical considerations are the use of a large
biomaterial and adequate fixation. This fixation must
include the use of metal fixation devices at 11.5 cm
apart, preferably in a staggered fashion, and transfascial
sutures placed circumferentially along the entire periphery of the patch (not more than 5 cm apart).
Undoubtedly, there are other techniques that are being
used today that have not been reported. I know of surgeons who are using a single prosthetic biomaterial with
the keyhole and slit that was described above. Additionally,
some surgeons are using other prosthetic biomaterials to
complete this repair. Long-term follow-up is critical to
identify the best procedure and biomaterial that should be
chosen for this hernioplasty.
Figure 19.8 Mesenteric herniation of a para-ileal conduit
hernia that was reduced with the incision lateral to the defect.
The forceps are placed through the hernia defect.
This patient aspirated in the immediate postoperative

period, suffered a cardiorespiratory arrest, and did not survive the latter event. Seromas and ileus are well-recognized
occurrences following laparoscopic hernia repair, such that
I do not consider them a true complication unless they
are persistent or require intervention. The ideal method
of repair for these hernias that should be used routinely
has yet to be identified. However, with the experience of
the recurrence of the ileostomy hernia, I would suggest
that the preferred repair of the parastomal hernia that
involves the small intestine should be the onlay technique. The peristalsis of the small bowel may predispose
the other segments of that organ to invaginate into the
slits of the two-patch repair.
Currently, however, the recurrence rate of eight
per cent is quite admirable. This is an improvement in
the open repair of these defects and is better than the
CONCLUSION
The repair of incisional hernias laparoscopically has provided us with the technology to repair parastomal hernias. The ideal method has not been identified, but the
initial experience shows promise.
REFERENCES
Burns FJ. Complication of colostomy. Dis Colon Rectum 1970; 13:
44850.
2 Phillips P, Pringle W, Evans C, Keighley M. Analysis of hospital
based stomatherapy service. Ann R Coll Surg Engl 1985;
67: 3740.
3 Sjodahl R, Anderberg B, Bolin T. Parastomal hernia in relation
to the site of the abdominal wall stoma. Br J Surg 1988; 75:
33941.
4 Londono-Schimmer EE, Leong APK, Phillips RKS. Life table analysis
of complications following colostomy. Dis Colon Rectum 1994;
37: 91620.
1

5
8
9
10
11
12
13
Ortiz H, Sara MJ, Armendariz M, et al. Does the frequency of

para-colostomy hernias depend on the position of the colostomy
in the abdominal wall? Int J Colorectal Dis 1994; 9: 657.
Berger D. Laparoscopic parastomal hernia repair: indications,
technique, and results. In: Morales-Conde S, ed. Laparoscopic
Ventral Hernia Repair. Paris, Springer-Verlag, 2002: 3837.
Burgess P, Matthew VV, Devlin HB. A review of terminal
colostomy complications following abdominoperineal resection for
carcinoma. Br J Surg Engl 1984; 71: 1004.
Martin L, Foster G. Parastomal hernia. Ann R Coll Surg 1996;
78: 814.
Marshall FF, Leadbetter WF, Dretler SP. Ileal conduit parastomal
hernias. J Urol 1975; 113: 442.
McDougal WS. Use of intestinal segments and urinary
diversion. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds.
Campbells Urology. Philadelphia: W. B. Saunders Co., 1998:
312161.
Williams JG, Etherington R, Hayward MWJ, Hughes LE.
Para-ileostomy hernia: a clinical and radiological study. Br J Surg
1990; 77: 13557.
Toms AP, Dixon AK, Murphy MP, Jamieson NV. Illustrated review
of new imaging techniques in the diagnosis of abdominal wall
hernias. Br J Surg 1999; 86: 124350.
Aldridge AJ, Simson JN. Erosion and perforation of colon by
synthetic mesh in a recurrent paracolostomy hernia. Hernia 2001;
5: 11012.
14
15
16
17
18
19
20
21
22
Rubin M, Schoetz DJ, Matthews JB. Para-stomal hernia: is the

stoma relocation superior to fascial repair. Arch Surg 1994;
129: 41319.
Porcheron J, Payan B, Balique JG. Mesh repair of paracolostomal
hernia by laparoscopy. Surg Endosc 1998; 12: 1281.
Bickel A, Shinkarevsky E, Eitan A. Laparoscopic repair of
paracolostomy hernia. J Laparoendosc Adv Surg Tech 1999; 9:
3535.
Voitk A. Simple technique for laparoscopic paracolostomy hernia
repair. Dis Colon Rectum 2000; 43: 14513.
LeBlanc KA, Bellanger DE. Laparoscopic repair of para-ostomy
hernias: early results. J Am Coll Surg 2002; 194: 2329.
De Ruiter P, Bijnen AB. Successful local repair of paracolostomy
hernia with a newly developed prosthetic device. Int J Colorectal
Dis 1992; 7: 1324.
Sugarbaker PH. Peritoneal approach to prosthetic mesh repair of
paraostomy hernias. Ann Surg 1985; 201: 3446.
Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of
incisional and parastomal hernias after major genitourinary or
abdominal surgery. J Endourol 2001; 15: 1759.
2000; 180: 1937.
20
Lumbar hernia and denervation hernia repair
KARL A. LEBLANC
Anatomy
Indications and contraindications for surgery
Operative technique
151
152
152
Primary and acquired lumbar hernias are quite uncommon. There have been about 300 cases of primary hernias reported in the literature.1 Acquired lumbar hernias
are the result of flank incisions for renal or other retroperitoneal operations, notably anterior lumbar interbody
fusion. These acquired hernias can also be the result of
division of the anterior branches of nerves that originate
from T6 to T12. In these latter circumstances, there is no
fascial defect with these denervation injuries, so they are
not true hernias. These pseudo-hernias are difficult to
treat surgically. Rarely, they can also be seen with diabetic
radiculopathy.
Approximately 55 per cent of these hernias are primary, 25 per cent are acquired, and the remainder are
congenital in origin.2 The latter can sometimes be bilateral. Primary lumbar hernias are found most frequently
on the left side; two-thirds of these are seen in men.3,4
ANATOMY
The lumbar area is bounded above by the twelfth rib,
below by the iliac crest, behind by the erector spinae
muscles (sacrospinalis), and in front by the posterior
border of the external oblique (a line passing from the tip
of the twelfth rib to the iliac crest). Within this area, two
triangles are described: the superior lumbar triangle (of
Grynfelt) and the inferior lumbar triangle (of Petit). The
superior lumbar triangle is an inverted triangle: its base
is the twelfth rib, its posterior border is the erector spinae
muscles, its anterior border is the posterior margin of
the external oblique, and its apex is at the iliac crest
Results
Conclusion
References
153
153
154
inferiorly. The base of the inferior lumbar triangle is the

iliac crest, its anterior border is the posterior margin of
the external oblique muscle, its posterior border is the
anterior edge of the latissimus dorsi muscle, and its apex
is superior (Figure 20.1).
Lumbar hernias may contain a variety of intraabdominal organs. Hernias of the colon are the most frequent, but small intestine, stomach and spleen are also
likely candidates for herniation. A particular curiosity is
the sliding hernia of the colon, which causes intermittent
obstructive symptoms.
Differential diagnoses include tumors of the muscles,
lipoma, hematoma associated with blunt trauma, abscess,
and renal tumors. Small fatty protrusions of retroperitoneal fat through the lumbodorsal fascia have been
implicated as a cause of lower back pain. Computerized
tomography (CT) is the best test for delineating the
etiology and defining the anatomy of the hernia.
Patients that have the denervation injury that leads to
the protrusion of the flank will frequently complain of
back pain related to the defect. It is difficult to explain the
source of this, as many of these patients will have had a
long, pre-existing complaint of back pain requiring disk
surgery. The most common presentation is the acknowledgment of the significant cosmetic deformity that is
caused by the musculature paralysis. This will cause a
broad laxity of the affected abdominal wall (Figure 20.2).
This appearance will become most pronounced if the
process is long-standing, if the patient experiences significant weight gain, or if the patient is morbidly obese. CT
scanning is not so helpful for delineating this problem,
but it can eliminate other pathological entities.
Serratus posterior
External oblique muscle
12th rib
Superior (Grynfelt's) triangle
Latissimus dorsi
Internal oblique
Inferior (Petit's) triangle
External oblique
Figure 20.1 Anatomy of the true lumbar hernias.
Umbilicus
Iliac crest
Trocar sites
Arm on
pillow
Figure 20.3 Typical patient position for repair of lumbar

hernias. Easy access to the posterior aspect of the patient
must be preserved.
Figure 20.2 Appearance of the abdominal wall following a
right nephrectomy that resulted in a denervation hernia.
INDICATIONS AND CONTRAINDICATIONS

FOR SURGERY
These defects will increase in size over time. The cosmetic appearance will deteriorate because of this, but
there is a risk of incarceration and strangulation with
primary hernias. All primary hernias should be repaired,
but it is not clear whether surgery can offer a permanent
solution to the pseudo-hernia. Careful follow-up is
needed to evaluate the effectiveness of the laparoscopic
approach to this entity.
OPERATIVE TECHNIQUE
The open approach to a primary, acquired or denervation
hernia is generally a formidable operation. Suture closure
of these hernias is associated with a high failure rate

because of the tension that occurs with the repair. The use
of a prosthetic biomaterial placed in the pre-peritoneal
position has been shown to be the most effective method
of repair for true hernias.5 The open procedure often
requires a very extensive incision to repair these defects.
Pseudo-hernias are sometimes repaired with abdominal
wall plication followed by placement of a prosthetic
biomaterial over the plicated muscle, but this also requires
a large incision if the mesh is to cover the entire area of
paralysis.
The laparoscopic approach has been applied to this
type of herniation. Its concept is similar to the repair of
incisional hernias (see Chapter 16). A tube to decompress the stomach is used routinely, but a urinary
catheter is placed only selectively. One significant difference is that the patient must be turned in the semi- or full
lateral decubitus position (Figure 20.3). A beanbag
greatly assists in this position. Trocar site positions
are critical for this operation. As with incisional hernia
repair, the initial efforts focus upon the dissection of the
adhesions and the identification of the fascial edges.
With the superior hernias, this must extend posterior to
Lumbar hernia and denervation hernia repair 153
the kidney. The colon will usually be reflected for either

hernia.
The use of DualMeshPlus is recommended because
this procedure is intraperitoneal. The prosthesis should
be at least 45 cm larger than the defect itself. This is
slightly larger than that considered necessary for traditional incisional hernia repair. It appears that fixation in
these areas is rather difficult, and this larger overlap will
help prevent a recurrence. When undertaking the repair
of a denervation hernia, I prefer to use a minimum of
56 cm of overlap, but I would recommend the use of as
large a patch as possible. Fixation on to the diaphragm
will frequently be necessary. One must not enter the
chest with the use of these fixation methods. It is usually
necessary to sew the upper portion of the biomaterial to
the diaphragm itself to provide fixation of that portion
of the biomaterial. Suture placement that encircles the
ribs will frequently result in long-term pain that is difficult to treat. Therefore, this is not recommended unless
absolutely necessary. The use of transfascial sutures and
metal fixation devices is identical to the incisional hernia,
except as noted above.
Repair of a pseudo-hernia necessitates the use of a
very large prosthesis. This must cover the entire paralyzed muscle from the lumbar area to a point across the
midline of the patient. Because of the positioning of the
patient, fixation may be very difficult near the midline.
It is sometimes necessary to place two trocars laterally
through the biomaterial to allow the visualization and
fixation at that site. These holes are then closed with
sutures placed with a suture-passing device.
RESULTS
There have been only ten laparoscopic lumbar hernioplasties reported in the literature.68 All were case reports,
except for one report that included seven patients.9 This
latter report included five hernias that were acquired; two
were congenital and two were recurrent. Two patients had
two or three separate hernia defects. The hernias ranged
in size from 1.5 ! 1.5 cm to 8 ! 11 cm, averaging 77.8 cm2.
As noted above, a large overlap of the expanded polytetrafluoroethylene (ePTFE) patches was used; the average
patch size was 336.4 cm2. One of these patients developed
an abscess over the repair, which required removal of
the prosthesis. The remaining six patients were free of
recurrence after 115 months of follow-up.
This author has repaired six denervation hernias. All
were performed using the technique described above. One
of these patients had an implantation of DualMesh Plus
with Holes. This product is 1.5 mm thick, compared with
the 1-mm thickness of DualMesh without Holes. It was
hoped that the thicker material would result in a better
Figure 20.4 Postoperative (six months) appearance of a repair

of a denervation hernia subsequent to an anterior lumbar
interbody fusion.
cosmetic result. With these patients, the intent is that the

shrinkage of the tissues caused by scar contraction will
result in an acceptable cosmetic result.
One patient had prolonged postoperative pain
thought to be related to the use of suture around a rib.
One patient developed a symptomatic seroma. Both of
these problems resolved without intervention. Follow-up
ranged from nine months to three years. The cosmetic
result with this method has been acceptable to all the
patients and has been excellent in some (Figure 20.4).
CONCLUSION
The incidence of lumbar hernias is low. The problem of
denervation hernias may become more prevalent in the
future due to the increasing use of the anterior approach
for disk disease by spine surgeons. Repair of these deformities can be difficult and fraught with failure if it is not
approached in a reasoned manner. The use of prosthetic
reinforcement is thought to be best, and the laparoscopic
approach may be of benefit, although more studies and
follow-up are needed.
REFERENCES
1
Gentileschi P, Kini S, Gagner M. Laparoscopic repair of unusual

hernias: lumbar, spigelian and other special hernias. In: MoralesConde S, ed. Laparoscopic Ventral Hernia Repair. Paris: SpringerVerlag, 2002: 36374.
2 Swartz WT. Lumbar hernias. J Ky Med Assoc 1954; 2: 6738.
3 Thorek M. Lumbar hernia. J Int Coll Surg 1950; 14: 36793.

4
5
Watson LE. Hernia, 3rd edn. St Louis, MO: Mosby, 1948: 4435.
Knol JA, Eckhauser FE. Inguinal anatomy and abdominal wall
hernias. In: Greenfield LJ, ed. Surgery: Scientific Principles and
Practice. Philadelphia: JB Lippincott, 1993: 1081107.
Burick AJ, Parascandola SA. Laparoscopic repair of a traumatic
lumbar hernia: a case report. J Laparoendosc Surg 1996; 6:
25962.
7
8
Bickel A, Haj, Eitan A. Laparoscopic management of lumbar hernia.

Surg Endosc 1997; 11: 112930.
Woodward AM, Flint LM, Ferrera JJ. Laparoscopic retroperitoneal
repair of recurrent postoperative lumbar hernia. J Laparoendosc Adv
Surg Tech A 1999; 2: 1816.
Arca MJ, Heniford BT, Pokorny R, et al. Laparoscopic repair of
lumbar hernias. J Am Coll Surg 1998; 2: 14752.
21
Results of laparoscopic incisional and
ventral hernia repair
RODRIGO GONZALEZ AND BRUCE J. RAMSHAW
Results of series
Results of comparative studies
155
157
Although the principles of abdominal wall repair are

well established and the complication rate has decreased
significantly over the past decade, the complication and
recurrence rates for open incisional hernia repair are far
from ideal. A prospective, randomized, multicenter study
recently reported a 46 per cent recurrence rate after primary open repair of ventral hernias when a prosthetic
material was not employed.1 Others have reported recurrence rates of 25 per cent and 52 per cent for fascial defects
smaller and larger than 4 cm, respectively.24 Recurrences
are also associated with the number of repairs performed,
with 1843 per cent after initial repair and over 50 per cent
after recurrent repair.1,3
It is common to perform a primary repair for ventral
hernias smaller than 4 cm in diameter. For larger defects,
the use of a prosthetic material is recommended to allow
for a tension-free repair. The use of a variety of mesh
materials for open hernia repairs has resulted in a lower
recurrence rate compared with primary repairs,1,5 but
they have been associated with other types of complications, including wound infection, seromas, mesh extrusion, fistula formation, and adhesions.57 Infections can
occur in up to 15 to 45 per cent of open mesh repairs and
may also correlate with recurrence rates.1,8 This high
infection rate is thought to be secondary to the large incision with which the mesh is in contact and the wide dissection necessary for adequate mesh placement. The
laparoscopic technique involves access to the abdominal
cavity away from the defect, avoiding placement of the
mesh through a large incision, thereby reducing the probability of contamination and infection.9 It also allows
Conclusion
References
159
160
fixation of a large mesh without subcutaneous tissue dissection in patients with large hernia defects.1012
Laparoscopic ventral hernia repair is based on the
method described by Stoppa for open incisional hernia
repair,4 reported to have the lowest recurrence rate.
It involves posterior reinforcement of the abdominal
wall with a large piece of prosthetic material based on
Laplaces law. The large surface area of the mesh allows
substantial ingrowth of tissue for permanent mesh fixation, and the intra-abdominal pressure tends to hold the
mesh in apposition to the posterior abdominal wall over
a wide surface area.13,14
RESULTS OF SERIES
Patient demographics
Since the first report of laparoscopic ventral hernia
repair,15 numerous series have been published supporting
the use of this technique. Table 21.1 summarizes the
results of 2002 laparoscopic ventral hernia repairs published in the literature. We have tabulated these data
and will discuss the averages from this information.
Demographic data show a slightly higher predominance
of females (56 per cent), with a mean age of 55 years.
Fifty-six per cent of the patients were obese, with a mean
body mass index (BMI) of 34 kg/m2. Consistent with previous literature, the prevalence of incisional hernias (89
per cent) is higher than for primary hernias (11 per cent).
Table 21.1 Results of laparoscopic ventral hernia repair
Reference
Saiz et al. (1996)17
Park et al. (1996)18
Tsimoyiannis et al. (1998)19
Toy et al. (1998)21
Constanza et al. (1998)22
Sanders et al. (1999)23
Kyzer et al. (1999)24
Roth et al. (1999)25
Koehler and Voeller (1999)26
Balique et al. (2000)27
Farrakha (2000)28
Carbajo et al. (2000)29
Reitter et al. (2000)30
Szymanski et al. (2000)33
Chowbey et al. (2000)34
Birgisson et al. (2001)37
Moreno-Egea et al. (2001)38
Bageacu et al. (2002)39
Ben Haim et al. (2002)40
Total
a
Seromas persisting # 6 weeks.

Seromas persisting " 4 weeks.
Prior
repairs
(%)
Hernia
size
(cm2)
Operating
room time
(min)
28
10
28
11
176
144
16
12
53
75
32
29
18
100
49
100
415
44
202
17
100
64
20
159
100
7
20
39
26
100
58
55
41
33
37
49
33
20
18
42
75
23
25
104
98
130
101
93
87
100
20
155
34
7
68
108
49
120
210
89
105
101
85
62
152
88
97
50
240
130
89
119
2002
32
89
114
Patients
(n)
Conversion
rate
(%)
Hospital
stay
(days)
Seroma
rate
(%)
Infection
rate
(%)
Mesh
removed
(%)
Follow-up
(months)
Recurrence
rate
(%)
0
0
0
0
3
6
8
4
3
0
1
4
0
2
9
0.5
0
4
0
0
14
7
2
4.1
3
2.3
2
3.5
3.3
2.9
1.9
3.2
1.2
4.3
1.6
1.8
1.8
1.2
1.7
3.5
5
4
10
0
9
0a
16
36
14
33
10
0
3b
5a
2
18
7
5
15
16
11
4
10
4
9
2
3
8
2
4
6
3
0
0
2
2
2
5
2
2
4
0
3
1
4
0
0
1
4
0
2
0
0
2
2
1
1
0
0
10
8
15
30
7
18
13
12
20
22
30
27
23
23
35
51
10
12
49
19
0
0
4
0
1
4
6
8
2
9
9
6
2
6
3
3
5
1
12
9
2
0
16
2
1.9
7.5
1.5
26
3.3
2.2
Results of laparoscopic incisional and ventral hernia repair 157
This includes 11 per cent umbilical and 0.6 per cent

Spigelian hernias. Sixteen per cent of the hernias were
multiple and 32 per cent were recurrent.
is estimated that about 80 per cent of hernias are repaired

utilizing ePTFE mesh, 15 per cent with polypropylene
mesh, and five per cent with polyester mesh.
Intraoperative complications
Operative and postoperative results
Laparoscopic repair was shown to be safe, even in large

ventral defects, with an intraoperative complication rate of
one per cent. The most frequent major intraoperative
complication was bowel injury, occurring in 0.8 per cent of
cases. Conversions to open repair were reported in three
per cent of cases and were more frequent during the early
phase of the learning curve.9 The most common reasons
for conversion were bowel injuries, failure to reduce incarcerated hernias, and extensive adhesions. Enterotomies are
most likely to occur during adhesiolysis and reduction of
hernia sac contents. The occurrence of an enterotomy is
considered a reason for conversion by some surgeons; it
may also be a contraindication for mesh placement due to
potential contamination. The incidence of unrecognized
or delayed bowel injury is reported to be between zero and
five per cent. These can be the result of missed injury
or thermal or partial-thickness injury that progresses to
full-thickness injury over time, and can result in serious
complications such as sepsis and even death.10,11,30
The mean operative time was 114 minutes, with an estimated blood loss of 80 cc. The return of bowel function
was 1.7 days after surgery. The average hospital stay was
1.9 days, and the average return to normal activities was
two weeks after the operation. Postoperative wound complications were minimal after laparoscopic ventral hernia
repair. They included infection (2.2 per cent), seroma
persisting for more than six weeks (7.5 per cent), and
hematoma formation (six per cent). In 1.5 per cent of
patients, mesh removal was required due to mesh infection or reoperation for missed or delayed bowel injury.
Other complications included ileus (2.4 per cent), urinary
retention (1 per cent), bowel obstruction (0.5 per cent),
and trocar site bleeding (0.3 per cent). Chronic pain can
develop at sites where full-thickness abdominal wall
sutures are used for mesh fixation; this has been reported
in 0.22 per cent of patients. Most instances of pain
resolve without intervention. Some authors have reported
the use of injection of local analgesics for the relief of pain.
Occasionally, repeat injections are necessary to achieve
pain relief. Reoperation for suture removal is required
rarely. These sutures are considered an essential step by
most surgeons to help reduce hernia recurrences by
preventing mesh migration.
Choice of prosthetic
Laparoscopic surgery allows placement of a large overlay
of mesh without soft-tissue dissection. The mean size of
all hernia defects was 89 cm2 and the mean mesh size was
201 cm2. Most surgeons used expanded polytetrafluoroethylene (ePTFE) DualMeshas the prosthetic material
of choice. The 3-&m-size pores on the side of the mesh in
contact with the abdominal contents result in a low incidence of adhesion formation between the biomaterial
and the viscera. More importantly, even if bowel is adherent to the mesh, the ePTFE DualMesh inhibits ingrowth,
preventing fistula formation and bowel obstruction. A
variety of composite mesh products are available and are
being evaluated (see Chapter 4). One side of the composite mesh is made of polypropylene or polyester to promote ingrowth into the abdominal wall (although the
mesh is actually placed in direct contact with the peritoneum in most cases). The other side of the mesh is
made of either permanent ePTFE or an absorbable antiadhesion barrier. This side is placed toward the abdominal cavity with the intention of preventing ingrowth
to the polypropylene (ePTFE permanent material) or
preventing adhesions (absorbable material). The great
majority of authors who have published series of laparoscopic ventral hernia repair refrained from using
polypropylene or polyester mesh that would allow potential direct contact with intra-abdominal organs, especially
large and/or small intestine. Based on published series, it
Recurrence
The mean recurrence rate from the series in Table 21.1
was 3.3 per cent, at a mean follow-up of 26 months. Few
additional recurrences are expected in these series, since
up to 90 per cent of recurrences occur within the first two
years after ventral hernia repair.1,31 In fact, future recurrence rates for laparoscopic ventral hernia repair may
actually be lower, because most of these reports included
surgeons experience during their learning curve. A common cause for recurrence noted in some series is a lack of
suture fixation.26,32,36
RESULTS OF COMPARATIVE STUDIES

Comparative studies between laparoscopic and open ventral hernia repairs have consistently reported advantages
for the laparoscopic approach, especially in the evaluation
of wound complications and recurrence rates. Results of
eight of these series are summarized in Table 21.2. In most
comparative series, the technique is selected based on
each surgeons experience, and most are retrospective
Table 21.2 Results of comparative studies between laparoscopic and open ventral hernia repair
Reference
Technique
Patients
(n)
Holzman et al. (1997)41
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open with mesh
Open without mesh
Laparoscopic
16
20
49
56
30
30
174
79
18
21
14
14
23
31
90
119
86
Park et al. (1998)42

Carbajo et al. (1999)43*
Ramshaw et al. (1999)10
DeMaria et al. (2000)44
Chari et al. (2000)45
Robbins et al. (2001)13
Wright et al. (2002)12
*Prospective randomized study.
Previous
repairs
(n)
Hernia
size
(cm2)
Operating
room time
(min)
Length
of stay
(days)
Postoperative
complication
rate (%)
Infection
rate (%)
Seroma
rate (%)
Follow-up
(months)
Recurrence
rate (%)
4
8
9
16
22
23
51
36
3
11
28
6
15
148
105
105
99
141
140
34
73
79
12
112
98
128
78
95
112
87
82
58
78
124
102
70
131
5
1.6
6.5
3.4
9.1
2.2
2.8
1.7
4.4
0.8
5.5
5
2.5
1.5
1.5
31
23
37
18
50
20
26
15
72
57
14
14
28
22
24
6
5
2
0
18
0
3
0
33
10
0
7
30
16
13
10
9
0
5
2
4
67
13
50
19
12
4
9
19
10
54
24
27
27
21
21
24
24
32
24
24
13
10
35
11
7
0
21
3
0
6
6
9
1
Results of laparoscopic incisional and ventral hernia repair 159
studies. Surprisingly, in many reports, the patients in the

laparoscopic group had a tendency to have larger hernia
defects10,13,44 and a higher incidence of previous hernia
repairs10,41,42,44 than in the open group. This suggests that
the results are even more favorable for the laparoscopic
repair, since recurrences occur more frequently in large
defects and after previous repairs.3,42
Some series have reported increased operative times
with the laparoscopic technique.13,42 This is important
when considering anesthesia times and operating room
expenses. However, once beyond the learning curve, the
laparoscopic repair can frequently be completed in a
shorter time than a comparable open repair, even in the
presence of large hernia defects.10,34 Laparoscopic repair
is also associated with reduced estimated blood loss.10
Most comparative series have reported lower overall
postoperative complication rates with the laparoscopic
technique than with the open technique (20 v. 31 per cent,
respectively) (Table 21.2). The laparoscopic approach
results in lower wound complication rates,10,11,13,42 including fewer seromas,42,43 fewer infections,10,11,13,44 and fewer
dehiscences.13 Since wound complications that may be
present after laparoscopic hernia repairs occur in small
trocar incisions, they tend to be less severe, to be treated
more easily, and to require mesh removal less frequently
than in open repairs.10,43 Seromas are frequently observed following a ventral hernia repair whether performed
through an open or laparoscopic approach. Ultrasound
examinations revealed seroma formation in 100 per cent
of patients, with a peak occurrence seven days after the
operation, and almost complete resolution after 90 days.46
Seromas may be a source of concern to patients not
informed of the likelihood of their occurrence. Most surgeons agree that they should not be considered a complication unless they persist, increase steadily in size, or
cause symptoms. Aspiration of seroma contents should be
approached with caution, since even under sterile conditions there is a potential for contamination. Infection
requiring mesh removal has been reported following aspiration of a seroma.44 After repair of large hernias, the use
of binders can be considered in an attempt to reduce
seroma formation.
Another advantage consistently reported with the
laparoscopic technique is the shorter length of hospitalization.10,4244 This may be due partially to decreased pain,44
fewer complications,10,11,13,42,43 earlier oral intake,45 infrequent use of drains,10 and reduced postoperative ileus.10,42
In general, these patients ambulate earlier than patients
undergoing open repair. Laparoscopic ventral hernia repair
can be performed on an outpatient basis in some cases.41,44
The shorter operative time and length of stay after laparoscopic repair may offset the increased operative costs for
surgical equipment compared with open techniques.41 One
study shows lower costs for the laparoscopic approach, even
when accounting for the costs of treating complications.44
Finally, the favorable cosmetic results for primary ventral

hernia repair with the laparoscopic technique may be an
important consideration for some patients.
Wright and colleagues compared the laparoscopic
approach with two techniques of open repair, with and
without use of mesh.12 The group that underwent open
repair with mesh had a higher incidence of previous
repairs. The laparoscopic group had larger hernia defects
and larger mesh sizes. The laparoscopic technique resulted
in a longer mean operative time and lower wound complication rates. The laparoscopic approach also resulted in
lower recurrence rates, but the difference was significant
only when compared to open repair without mesh.
In the only prospective randomized study so far,
Carbajo and coworkers reported a shorter operative time
and hospital stay, as well as lower recurrence and complication rates (including infections and seromas) with the
laparoscopic approach.43 The patients in each group had
a similar incidence of previous repairs and hernia size.
Two recurrences occurred in the open group with a 27month follow-up. Two mesh explantations were required
in the open group for postoperative infections. There
were no recurrences or late complications in the laparoscopic group.
A primary goal for ventral hernia repair is to minimize recurrence rates. Factors associated with recurrences
include larger hernias,3,42 previous hernia repairs, lateral
defects, and postoperative complications (mainly infections). The laparoscopic technique has resulted in lower
recurrence rates, even in the presence of larger defects,10,13
and higher rates of previous repairs.10,42 Indeed, as
demonstrated in Table 21.2, the recurrence rate was 15
per cent for the open repair, with a 33-month follow-up,
and 4.5 per cent for the laparoscopic technique, with a
22-month follow-up.
CONCLUSION
Laparoscopic repair of ventral and incisional hernias is an
attractive approach for a difficult problem. The achievement of a low recurrence rate while minimizing wound
complications is a combination of goals that has eluded
open approaches for ventral hernia repair. While the
laparoscopic approach makes sense and is being adopted by
many surgeons, it remains an advanced laparoscopic procedure with inherent potential complications, especially during the learning curve. Results of the studies presented in
this chapter point out the importance of good patient selection and recognition of the potential for intraoperative and
delayed visceral injury. Improvements in training and education of minimally invasive surgical procedures will help
to maximize the safe adoption of advanced laparoscopic
techniques, such as laparoscopic ventral hernia repair.
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1
2
3
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5
6
7
8
9
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11
12
13
14
15
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18
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20
21
22
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24
Luijendijk RW, Hop WCJ, van der Tol MP, et al. A comparison of
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Larson GM. Ventral hernia repair by the laparoscopic approach.
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Hesselink VJ, Luijendijk RW, de Wilt JHW, et al. An evaluation of
risk factors in incisional hernia recurrence. Surg Gynecol Obstet
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Stoppa RE. The treatment of complicated groin and incisional
Korenkov M, Sauerland S, Arndt M, et al. Randomized clinical trial
of suture repair, polypropylene mesh or autodermal hernioplasty
for incisional hernia. Br J Surg 2002; 89: 5056.
Cassar K, Munro A. Surgical treatment of incisional hernia.
Br J Surg 2002; 89: 53445.
Leber GE, Barb JL, Albert AI, Reed WD. Long-term complications
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George CD, Ellis H. The results of incisional hernia repair in a
12-year review. Ann R Coll Surg 1986; 68: 1857.
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Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of
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Morris-Stiff GJ, Hughes LE. The outcomes of nonabsorbable mesh
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Wright BE, Niskanen BD, Peterson DJ, et al. Laparoscopic ventral
hernia repair: are there comparative advantages over traditional
methods of repair? Am Surg, 2002; 68: 2916.
Robbins SB, Pofahl WE, Gonzalez RP. Laparoscopic ventral hernia
repair reduces wound complications. Am Surg 2001; 67: 896900.
Temudom T, Siadati M, Sarr MG. Repair of complex giant or
recurrent ventral hernias by using tension-free intraperitoneal
prosthetic mesh (Stoppa technique): lessons learned from our
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LeBlanc KA, Booth WV, Whitaker JM. Laparoscopic repair of
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Saiz AA, Willis IH, Paul DK, Sivina M. Laparoscopic ventral hernia
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Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopic
intraperitoneal onlay mesh repair of incisional hernia. Surg
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Constanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of
Sanders L, Flint LM, Ferrara JJ. Initial experience with laparoscopic
repair of incisional hernias. Am J Surg 1999; 177: 22831.
Kyzer S, Alis M, Aloni Y, Charuzi I. Laparoscopic repair of
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26
27
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29
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32
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38
39
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44
45
46
Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic

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Farrakha M. Laparoscopic treatment of ventral hernias. Surg
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Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment
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Bageacu S, Blanc P, Breton C, et al. Laparoscopic repair of
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Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications
with laparoscopic intraperitoneal expanded
polytetrafluoroethylene patch repair of postoperative ventral
Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral
Park A, Birck DW, Lovrics P, et al. Laparoscopic and open incisional
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DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal
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Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of
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22
SAMUEL K. MILLER, STEPHEN D. CAREY, FRANCISCO J. RODRIGUEZ AND ROY T. SMOOT, JR
Bowel injury
Laparoscopic assisted hernia repair
Mesh infection
Seroma
Postoperative/suture pain
161
163
164
165
166
A ventral hernia is any protrusion through the anterior

abdominal wall with the exception of the inguinal area.
Ventral defects include those found in the umbilical, epigastric, Spigelian, incisional, and parastomal locations.
Five to fifteen per cent of laparotomies will result in ventral
incisional hernias, with the incidence of incisional hernia
rising to nearly 40 per cent following wound infection.1,2
Approximately 100 000 ventral hernias are repaired in
the USA each year, comprising about 13 per cent of all
hernia repairs annually.
Over the past decade, techniques for the laparoscopic
approach to ventral hernia repair have been developed.
Potential advantages include avoidance of large incisions
with associated flaps and drains, tension-free repairs
stabilized by intra-abdominal pressures (Laplaces law),
reduced length of stay with reduced convalescence and
more rapid return to full activity, and lower complication
and recurrence rates.
A review of the literature on laparoscopic ventral and
incisional hernia repair as well as our clinical experience
over ten years was undertaken. A Medline search demonstrated 18 articles suitable for analysis. These articles
contained data on complications and recurrences. This
chapter will give an overview of the complications associated with laparoscopic ventral and incisional hernia
repairs, and will suggest strategies to address these complications. Table 22.1 lists the articles chosen for review.
In comparison to open hernia repairs, overall complication rates for laparoscopic hernia repairs are much
lower. Complication rates reported for recent series of
open repairs may be high as 2734 per cent.16,19,21,22
Prolonged ileus/persistent nausea and vomiting

Recurrence of hernia
Conclusion
References
166
166
168
168
Review of laparoscopic hernia repairs demonstrates an

overall complication rate ranging from five to thirty per
cent,316,18,19 with a mean of 15.2 per cent. The major
advantage of laparoscopic ventral hernia repair is a
decreased rate of major wound complications19 and
lower recurrence rates.318,20
BOWEL INJURY
The most feared complication associated with the laparoscopic approach to ventral hernia is enterotomy. Bowel
injury has resulted in serious morbidity and mortality.
Several authors report bowel injuries,3,4,9,1113,18 with an
overall average incidence of 1.1 per cent. Table 22.2 presents the series reporting bowel injuries. Holzman and colleagues describe a single enterotomy during laparoscopy
that required conversion to an open procedure to avoid
placement of prosthetic material.3 Toy and coworkers
mention two enterotomies in their prospective multicenter study but do not give any further details.4 Ramshaw
and colleagues had two serious bowel injuries: one was
recognized and repaired at the time of injury but subsequently it dehisced and required reoperation; the second
went unrecognized and required reoperation with mesh
removal.9 Ramshaw and colleagues also had one minor
serosal bowel injury with no sequelae.9
Koehler and Voeller mention two unrecognized bowel
injuries, with one patient ultimately dying of hepatic failure on the twenty-ninth postoperative day.11 This death

Table 22.1 Reported series analyzed, with recurrence rates and total complication rates
Reference
Cases (n)

Toy et al. (1998)4
Costanza et al. (1998)6
Park et al. (1998)8
Koehler et al. (1999)11
Reitter et al. (2000)17
Personal series (2002)
Total
Mean
20
144
176
15
10
56
79
53
34
75
14
96
100
21
42
407
31
17
182
Mean follow-up
(months)
Recurrence
(%)
Complications
(%)
10.2
7.4
33.6
18
15
24
21
12
20
17
51
30
27
23
31
1.0
4.2
1.1
0
0
11.0
2.5
0
8.8
9.3
7.0
9.3
2.0
4.8
7.1
3.4
11.8
2.7
25
25
5
13
30
18
19
11
21
19
14
15
16
10
13
16
24
17
22.7
65/1541
4.2
233/1530
15.2
1572
Table 22.2 Series reporting bowel injuries

Reference
Toy et al. (1998)4
Reporting no injuries
Total
Cases
(n)
Enterotomies
(n)
Complications
(%)
20
144
79
34
75
14
407
799
1
2
3
2
2
2
6
0
5.0
1.4
3.8
5.9
2.7
14.3
1.5
0
1572
17
1.1
occurred in a patient requiring lysis of densely adherent

small-intestinal loops to the polypropylene mesh. The
other patient presented on the fifth postoperative day with
an enterocutaneous fistula, and required removal of the
patch and segmental resection of the small bowel. Kyzer
and coworkers had two recognized small-bowel injuries,
which were both converted to open laparotomy: one
required a bowel resection and the other required simple
suture closure.10 Roth and colleagues had two cases of
intraoperative enterotomies recognized at the time of
operation: in one case, the operation was converted to
an open procedure; the second enterotomy was closed
laparoscopically, but no prosthetic patch was placed.12
Chari and coworkers, in a small casecontrol study,
describe two patients with enterotomies in the laparoscopic group.13 One patient required removal of the
mesh due to infection. The second enterotomy resulted

in a prolonged postoperative course, with respiratory
failure and sepsis; the patient survived.
Finally, Heniford and colleagues, with the largest
retrospective study involving 407 patients, describe
six patients with small bowel enterotomies.18 Minimal
spillage was noted in four cases. These four patients had
their enterotomies repaired laparoscopically and the hernia repairs completed. The fifth patient was converted to
an open repair. None of the five patients had infectious
complications or recurrence of the hernia. The sixth
patient had an unrecognized enterotomy and subsequently underwent a laparotomy with resection of a
short segment of small bowel and removal of the mesh.
Bowel injury can occur during initial entry into the
peritoneal cavity, although no such injury has been
reported in the literature describing laparoscopic ventral

incisional hernia repairs. Most surgeons, including
Voeller and Heniford,18,23 prefer the Hasson technique in
a site well away from the hernia defect and in a quadrant
free of previous surgery. We agree with this technique and
use the Hasson technique for nearly all cases. LeBlanc,
however, favors the use of the Optiview trocar (Ethicon
Endosurgery, Inc.).23
Nearly all reported bowel injuries have occurred during lysis of adhesion. Ramshaw and coworkers9 and Park
and coworkers23 considered this to be the most dangerous
part of laparoscopic ventral hernia repair, and Koehler
and Voeller described it as the most challenging part of
laparoscopic incisional ventral hernia repair.11 Robbins
and colleagues, however, believe that the most difficult
part of the procedure is adhesiolysis and reduction of the
hernia contents.19 The mechanisms of injury include
direct injury during sharp dissection and thermal injury
from various energy sources.24,25 We recommend that all
adhesiolysis is done with cold scissors under direct vision,
with absolute minimal use of energy. Ramshaw and colleagues,9 Park and colleagues,23 Robbins and colleagues,19
and others support this position. Cautery and harmonic
dissection can produce immediate perforations as well as
delayed perforation. Delayed perforations are more common with harmonic dissection because the edges are
sealed immediately and the mucosa is not seen readily.
Kyzer and coworkers note several special situations in
which the risk of bowel injury is particularly high.10
These include patients with previous episodes of peritonitis, patients in whom a previous repair utilized
intraperitoneal Marlex mesh, and cases of giant hernias
that contain multiple irreducible bowel loops. Koehler
and Voeller also warn of the dangers during adhesiolysis
in the setting of previous synthetic mesh repair.11
Adhesions to the prosthetic material can be fairly dense,
and lysis of adhesions may be almost impossible. An
excellent strategy in this situation is conversion to open
enterolysis, closure of the abdominal wall, and completion of the hernia repair laparoscopically. Many others
are advocates of this technique.9,10,13,23 Heniford and
coworkers describe conversion to open surgery in eight of
415 patients:18 two patients were opened because of an
inability to reduce incarcerated intestine, one was
opened for loss of abdominal domain, one for resection
of strangulated bowel, and one for enterotomy.
As noted above, a special circumstance in which
enterotomy may occur is in the setting of previous hernia
repair with the use of synthetic mesh. Adhesions to
polypropylene and polyester mesh tend to be dense and
vascular, with clear planes of dissection that are difficult to
define. Our one enterotomy occurred in the face of a previous repair with Prolene mesh. This prompted us to be
especially wary of the risk of enterotomy when working
adjacent to a previous mesh repair. A good rule to follow is
beware of mesh, although a previous mesh repair is not a

contraindication to the laparoscopic approach.
Management of enterotomies requires sound clinical
judgment. In most cases, we recommend conversion to
open laparotomy to repair bowel injuries. Koehler and
Voeller advise the same, especially for surgeons that are
still early in their laparoscopic ventral hernia repair experience.11 The decision to place any prosthetic material in
the setting of bowel perforation depends on the degree of
contamination and whether the injury involves the
colon. If a colonic injury is suspected, then prosthetic
hernia repair must be aborted.11,26 The injury must be
addressed, and the incisional hernia can be repaired at a
later time. In the setting of a small bowel injury, we recommend conversion to a laparotomy and repair of the
bowel injury in most cases. A decision to place prosthetic
material in a contaminated field must be taken with great
caution. We would err on the side of conservatism and
avoid the use of any prosthetic material because of the
risk of infection. Many others agree with this.10,11,13 The
only exception to this would be in a setting where there is
a skilled laparoscopic surgeon who can routinely repair
bowel perforation in a proficient manner and there is
minimal contamination. Heniford and colleagues
describe six bowel injuries.18 In four patients, the enterotomy was repaired laparoscopically, one was converted to
open repair, and the hernia repair was completed in each.
In spite of their good outcomes with no mesh infections,
they caution strongly against placement of mesh in the
setting of bowel perforation and contamination. If there
is any doubt about the situation, then we recommend
conversion to laparotomy. Once the enterotomy is
repaired and a decision is made not to proceed with the
mesh repair, then the patient can be closed, placed on
intravenous antibiotics, and returned to the operating
room in three to seven days for completion of the laparoscopic hernia repair.23 Koehler and Voeller describe a
similar second-stage patch placement if an enterotomy is
made and repaired.11
Lastly, sage advice given by Koehler and Voeller is that
one should always consider the possibility of the conversion of an occult partial-thickness injury into a fullthickness bowel injury when a patient is clinically
deteriorating after an uneventful laparoscopic ventral
hernia repair.11 We second this opinion and do not hesitate to relaparoscope a patient who is not doing well
clinically and who is deteriorating.
LAPAROSCOPIC ASSISTED HERNIA REPAIR

The techniques of laparoscopic assisted ventral hernia
repair should be part of the armamentarium of all surgeons who perform hernia repairs using the laparoscopic
approach. Indications for this approach include inability

to gain access to the peritoneal cavity, inability to complete safe lysis of adhesions laparoscopically, any question
of visceral injury, and incarcerated hernias for which
reduction using laparoscopic techniques is impossible.
When these indications are encountered, the abdomen is
opened through a limited incision. The bowel is inspected
if visceral injuries are suspected, and any injuries are
repaired in the appropriate fashion. The remainder of the
adhesiolysis is then completed with the abdomen open.
The defect is then measured, and an appropriately sized
patch is prepared, including placement of pre-tied
sutures. The patch is then introduced into the abdomen,
unrolled, and oriented. The abdomen is closed in an airtight fashion. The pneumoperitoneum is re-established
and the procedure completed in the standard laparoscopic fashion. Other authors have employed this
technique.9,10,13,23
The laparoscopic assisted technique provides the surgeon with an alternative to complete abandonment of the
laparoscopic approach should the problems described
above be encountered. It also provides the surgeon with a
safe alternative if visceral injury is suspected. Until a surgeon gains experience with laparoscopic ventral hernia
repair, this may initially be the procedure of choice.
MESH INFECTION
Mesh infections (Table 22.3) are a very serious complication reported in multiple series, with an average reported
incidence of 1.4 per cent.46,8,1012,16,18,19 Infection rates
for open incisional hernia repairs are 16 per cent.27
Avoidance of infection includes strict attention to sterile
technique. The patient should be carefully prepped and
draped. Many surgeons recommend the use of an adhesive barrier drape, as is commonly done in vascular
surgery. The mesh itself should be treated in the same
fashion as any vascular graft, in that contact with the skin
should be avoided. Even the largest expanded polytetrafluoroethylene (ePTFE) patches can easily be drawn into
the abdomen through a standard Hasson trocar. Use of
antibiotic-impregnated prosthetics may offer some measure of protection against infection. The lower infection
rates in laparoscopic repairs may be due to the avoidance
of long incisions, wide dissection or flap creation, opening of the hernia sac, and placement of drains.4,8,18,28
With rare exception, all infected biomaterials placed
laparoscopically to repair incisional hernias must be
removed to control infection and sepsis. Toy and colleagues describe five wound infections, four of which
started at a trocar site.4 Three responded to intravenous
antibiotic therapy without mesh removal, and two cases
required removal of the mesh. Franklin and coworkers
document only a single mesh infection with staphylococcus in series of 176 patients.5 The mesh infection occurred
14 months postoperatively and the mesh was removed.
Kyzer and coworkers had a single mesh infection that
required removal and subsequently led to a recurrent hernia.10 Koehler and Voeller11 and Roth and colleagues12
mention two mesh infections in each of their respective
series, but they fail to give any further clinical details.
DeMaria and coworkers had a single mesh infection
requiring mesh removal because of an abscess.16 The
author felt that seroma aspiration led to contamination
and subsequent abscess formation. Heniford and colleagues had four mesh infections in 407 patients, and all
required removal of the mesh.18 Two had prior mesh
infections with open hernia repair. One developed skin
necrosis over the mesh, which eventually became exposed.
The last patient developed a mesh infection several weeks
Table 22.3 Series reporting mesh infections

Reference
Toy et al. (1998)4
Costanza et al. (1998)6
Park et al. (1998)8
Koehler et al. (1999)11
Reporting no mesh infections
Total
Cases
(n)
Mesh infection
(n)
Complications
(%)
144
176
15
56
53
34
75
21
407
31
182
378
2
1
1
2
1
2
2
1
4
1
5
0
1.4
0.6
6.7
3.6
1.9
5.9
2.7
4.8
1.0
3.2
2.7
0
1572
22
1.4
postoperatively. Robbins and coworkers reported 31

laparoscopic hernia repairs with a single abdominal wall
abscess in the hernia site.19 Ultimately, the mesh had to be
removed. In our series, we had one infection that required
patch removal; the hernia recurred and was later repaired
laparoscopically.
Once the infected mesh is removed, options for closure
of the abdominal defect include primary closure of the
fascia or closure of the fascial defect with biological grafts.
The wound is generally left open to close secondarily. After
the open wound has closed completely, and at least three
to four months have passed since the infection developed
and the mesh was explanted, the patient can return to the
operating room for laparoscopic hernioplasty.
SEROMA
The standard laparoscopic techniques for ventral hernia
repair involve reduction of the hernia contents followed
by coverage of the defect with an appropriately sized
piece of mesh. The hernia sac is left in situ. Fluid accumulation in the hernia sac is very common in our experience and confirmed by many others.35,79,11,12,14,15,18,23
LeBlanc and colleagues considered postoperative seromas to be the most common minor complication.14
Heniford and coworkers state that many patients develop
small, self-limited collections of fluid over the mesh.18
The definition of significant collection varies among
reported series. Some authors define a significant fluid
collection as one that requires aspiration because of
steady growth or clinical symptoms. Others define a
significant fluid collection as one that lasts for more than
six weeks.8,18 Review of the literature demonstrates a
reported average incidence of 4.4 per cent, with a range

of 016 per cent (Table 22.4). Toy and colleagues describe
the largest number of seromas in their prospective, multicenter study.4 Seromas occurred in 23 (16%) patients.
Fifteen of these seromas resolved within 30 days, two
resolved after 30 days, and six required aspiration. These
six patients required aspiration because of the size of the
seroma, per patient request, or because there was suspicion of infection. None of the seromas became infected
after aspiration. Tsimoyiannis and coworkers describe a
single seroma that was aspirated, but they give no details
of the indication for drainage.7 Park and colleagues
aspirated two seromas because of symptoms or their
presence for more than six weeks.8
Ramshaw and coworkers described two seromas, one
of which was drained under computerized tomography
(CT) guidance.9 The patient subsequently developed a
subcutaneous abscess that required open drainage, but
the underlying mesh did not have to be removed.
Koehler and Voeller had two obvious seromas, but neither required drainage and both resolved over a period of
three to six weeks.11 LeBlanc and colleagues had seven
seromas, none of which required aspiration.14 They have
instituted bulky dressings for 72 hours to help minimize
seroma fluid accumulation. Heniford and coworkers described eight seromas that were defined as fluid collections over the mesh that lasted for six to ten weeks.18
They stated that no long-term complications occurred,
regardless of whether the seromas were aspirated.
Most fluid collections can simply be observed, because
they will resolve spontaneously over four to ten weeks.
Therefore, we recommend observation for the vast majority of postoperative seromas.14,23 Not all authors agree,
however. Carbajo and colleagues described ten seromas, all
of which were managed with aspiration.15 No comments
Table 22.4 Series reporting seromas

Reference
Toy et al. (1998)4
Park et al. (1998)8
Reporting no seromas
Total
Cases
(n)
Seromas
(n)
Complications
(%)
20
144
176
10
56
79
34
75
96
100
407
182
193
1
23
2
1
2
2
2
3
7
10
8
8
0
5.0
16.0
1.1
10.0
3.6
2.5
5.9
4.0
7.3
10.0
2.0
4.4
0
1572
69
4.4
were made as to when and why these seromas required

aspiration. DeMaria and coworkers also aspirated all
seromas; they stated that most resolved with one or two
aspirations, with three attempts at most.16 DeMaria and
coworkers also described an abdominal wall abscess
developing in a patient who had a seroma aspirated in the
early postoperative period. The mesh ultimately had to be
removed, and they concluded that the infection occurred
because of inadequate sterile technique during seroma
aspiration. Park and colleagues feel that routine aspiration
of seromas has resulted in mesh infection, and they advise
against this practice.23
Although not well described in the literature, our
experience shows that many postoperative seromas will
display subtle signs of inflammation, such as localized
warmth, erythema, and minimal tenderness to palpation,
but do not represent true infections. Subtle signs of
inflammation do not require any specific treatment other
than observation. There is also no associated leukocytosis
or fever. These findings generally resolve spontaneously as
the fluid is reabsorbed. The level of comfort in observing
these subtle signs will depend upon ones clinical experience. Close clinical follow-up is critical in this setting.
Development of worsening pain, fever, and increasing
erythema would all be indications to start oral antibiotics.
There are very few indications for the aspiration of
seromas. Toy and colleagues stated that they try to avoid
aspiration because it may contaminate the seroma and
cause an abscess.4 Aspiration may be required for seromas that are painful and enlarging. Park and coworkers
and other experts feel that aspiration of seromas tends to
increase the rate of mesh infections.23 Removing fluid
may be both therapeutic and diagnostic in this setting.
Clear, straw-colored fluid is normal; however, turbid and
purulent fluid is highly suggestive of infection, requiring
removal of the prosthetic material.
POSTOPERATIVE/SUTURE PAIN
We have found that laparoscopic ventral and incisional
hernia repairs tend to be exceedingly painful compared
with other minimally invasive surgeries. Ramshaw and
colleagues report similar findings.9 They believe that the
pain is related to the number of full-thickness sutures
and posterior fascial tacks used. Length of hospital stay
will be proportional to the degree of pain. We generally
keep patients in the hospital for three to four days for
postoperative pain management. This is several days
longer than the average length of stay reported in the literature. Our preferred method of analgesia is patientcontrolled analgesia (PCA) with morphine.
The reported incidence of suture and/or protracted
pain is around 1.3 per cent. Heniford and colleagues
defined prolonged suture site pain as pain lasting for

more than eight weeks.18 They describe eight cases in
their report, most of which resolved with time (in six
patients) or injection (in two patients) of bupivacaine.
PROLONGED ILEUS/PERSISTENT NAUSEA

AND VOMITING
Several authors report prolonged ileus or persistent nausea and vomiting following these procedures. The cumulative reported incidence is two per cent.3,4,8,9,12,14,18,20
Other authors have also reported prolonged ileus and
persistent nausea and vomiting, but they did not comment
further.
We generally do not use nasogastric tubes in the postoperative period. If patients develop nausea, this is treated
with anti-emetics, such as ondansetron hydrochloride
4 mg every four hours, as necessary. If patients develop
protracted emesis along with their ileus, a nasogastric
tube will be placed, but this will be removed as soon as
possible. Early ambulation and activity are encouraged to
prevent ileus.
RECURRENCE OF HERNIA
Overall recurrence rates for open ventral incisional hernia repairs have been high and range from 30 to 60 per
cent.4,2937 A review of the literature demonstrates that
laparoscopic hernia repair has lowered this dramatically
to approximately four per cent (with a mean follow-up
period of 22.5 months) (Table 22.1).
Several factors are reported to increase the risk of
recurrence after ventral hernia repairs. These include
infection at the original operation38 and size of the original hernia.31 Other authors have noted wound infections, obesity, advanced age, pulmonary complications,
hepatic insufficiency, and male gender as risk factors for
recurrence.6 Park and colleagues report higher recurrences with larger hernias, hernias in a central or midline
location compared with lateral hernias, and wound complications after hernia repair.8 Roth and coworkers, on
the other hand, found no association between the size
and the number of previous repairs, age, postoperative
complications, or location of recurrence.12 Koehler and
Voeller warn us to consider occult liver disease in any
hernia recurrence that cannot be explained by infection
or collagen-vascular disease, and they give supporting
references.11,39,40 LeBlanc and colleagues state that their
recurrences are generally associated with large and multiple defects, the use of only one method of fixation for
the prosthetic patch, and an inadequate patch size.14
Hesselink and coworkers noted a 41 per cent cumulative
recurrence rate at five years, with second, third and

fourth incisional hernia repairs having recurrence rates
of 56, 48 and 47 per cent, respectively.31
Several factors are crucial for the maintenance of low
recurrence rates. The defect must be defined completely,
the adhesions must be separated, and the repair must not
have any tension. The prosthetic patch should be below
the plane of the fascial defect, and the size of the patch
must be larger than the hernia defect.41,42
The use of prosthetic materials is by far the most
important step in the evolution of recurrent hernia
repairs.37,39,43,44 In the early reports of laparoscopic ventral
and incisional hernia repairs, many authors reported that
their early recurrences were due to the use of only one type
of fixation method, such as staples or tacks alone, without
properly fixing the mesh with sutures. Conversely, pure
suture repair of hernias without using mesh is also
not advisable. This advice is confirmed by Franklin and
colleagues, who report that one recurrence (out of two)
was due to the lack of use of a prosthetic patch.5
Tension-free placement of a prosthetic patch on the
posterior surface of the abdominal wall is important, and
this alone has led to lower recurrence rates.26,29,31,35,41,4547
The intra-abdominal pressure tends to hold the mesh in
place by Laplaces law.
We believe, like others, that tissue in-growth into the
mesh material is important for long-term fixation.4,4850
However, in the immediate postoperative period, sutures
and spiral tacks play a critical role in fixation. Franklin
and colleagues5 and Reitter and colleauges17 all place
strong emphasis on full-thickness transabdominal wall
sutures to prevent recurrent hernias. However, they felt
that tacks and staples were necessary only to hold the
mesh in place initially and to fill in the gaps between the
sutures. Ramshaw and coworkers describe one recurrence
in a laparoscopic repair where only a hernia stapler was
used for fixation (i.e. without sutures or tacks).9 They
subsequently modified their technique using sutures and
tacks in all but the smallest (#2 cm) hernia defects.
Heniford and colleagues state that 43 per cent (6/14) of
their recurrences developed in patients in whom sutures
were not used at all or not placed in difficult areas, such as
the costal margins.18 We feel, as do Heniford and coworkers,6 Ramshaw and coworkers,9 and LeBlanc and coworkers,14 that suture fixation is extremely important to the
success of the laparoscopic hernia repair. Without suture
fixation, the prosthetic patch can pull away from the
abdominal wall, eventually leading to recurrence. This has
been documented clearly.3,11,14,18,26,5154 However, we and
Park and colleagues8 feel that spiral tacks are just as
important. The mesh should be secured to the abdominal
wall with spiral tacks placed 1 cm apart. Not all authors
agree: Carbajo and colleagues felt that sutures led to
more complications (hematomas, increased postoperative pain) and abandoned them for helical tacks only.15
We believe that sutures and spiral tacks are needed in all

repairs.
To place transabdominal nonabsorbable sutures, we
employ a suture-passer to place them 45 cm apart.
Heniford and coworkers also place full-thickness abdominal-wall sutures every 45 cm.18 The sutures should be
placed no more than 5 cm apart. Koehler and Voeller state
that tacks should be placed every 1.5 cm on the periphery,
with sutures every 6 cm.11 They also suggest using three to
four tacks around the edges of the hernia defect to minimize the dead space. LeBlanc and colleagues believe that
both sutures and tacks are important for securing the
mesh.14
Overlapping the hernia defect with the prosthetic patch
of an adequate size is also critically important. Several
studies have demonstrated that side-to-side suturing of
the patch to the edge of the hernia defect leads to recurrence rates of 1142 per cent.5557 Tsimoyiannis and colleauges7 and Park and colleagues8 state that the overlap
must be at least 2.5 cm. Ramshaw and coworkers,9 LeBlanc
and coworkers,14 and Robbins and coworkers19 prefer a
34-cm overlap beyond the edge of the defect. Kyzer and
colleagues10 and Koehler and Voeller11 suggest that the
overlap should be 5 cm or greater. Koehler and Voeller
describe a recurrence due to patch disruption with a 9-cm
overlap but with no suture fixation.11 Gillion and colleagues have shown clearly that overlapping the mesh with
the hernia defect lowers the recurrence rate significantly.58
We feel that complete coverage of the entire incision is
important whenever possible, even though the actual
recurrent hernia defect may encompass only a small portion of the entire incision. Koehler and Voeller also state
that coverage of the entire incision is crucial to minimize
recurrence risk.11 For example, if a patient has a midline
incision with a recurrence at one end, we would cover
the entire midline incision with the prosthetic material
to minimize recurrence. In our personal series, several of
the recurrent hernias were noted above or below the previously placed prosthesis. We have not seen a recurrence
in which the prosthetic material failed intrinsically.
Most laparoscopic recurrences tend to occur within
the first two years, and this has also been our experience.
Toy and colleagues had six patients (other than those
recurrences from removal of infected mesh) with recurrences of their ventral hernias.4 All six recurrences
presented by nine months postoperatively, with none
thereafter. Franklin and coworkers report two recurrences, one at four months and the other at 13 months
following the operation.5 The first recurrence occurred
after a non-prosthetic umbilical hernia repair. The second recurrence followed the removal of an infected prosthetic biomaterial. LeBlanc and colleagues report nine
hernia recurrences at a mean of 24 months, with a range
of four to 47 months.14 Recurrence in one patient was
recorded at 47 months. If this patient is excluded, then
the mean time of recurrence was 22 months. LeBlanc and

coworkers also report four of nine recurrences occurring
after 30 months.14
We have had five recurrences in 182 laparoscopic hernia repairs. They all occurred within the first 24 months
after repair. Other series report nearly all of the recurrences by two years.8,11,12,16
5
6
7
CONCLUSION
With the adaptation of laparoscopic techniques to general
surgical procedures over the past 15 years, several questions have arisen relative to ventral hernia disease. Could
ventral and ventral incisional hernias be repaired laparoscopically? Would the laparoscopic approach result in a
reduction in surgical complications as well as a reduction
in recurrence rates? Finally, would the techniques result in
increased patient satisfaction with reduced convalescence
and early return to full activity and work?
Over ten years experience with laparoscopic ventral
hernia repair has helped us to answer these questions.
The laparoscopic techniques could easily be adapted to
ventral hernia repair. The procedure is technically feasible and can be mastered by surgeons skilled in advanced
laparoscopic surgery. In addition, the procedure has
resulted in reduced morbidity, with a reduction in operative and postoperative complications. Recurrence data
are very encouraging and appear to reveal a marked
reduction in recurrence rates versus open repair. Patient
satisfaction is very high, with patients who have undergone multiple repairs of recurrent hernias finally finding
a solution to their problem. The data on length of stay,
return to full activity, and return to work attest to the
benefits of the laparoscopic approach.
Laparoscopic ventral hernia repair has shown itself to
be an excellent solution to what has been a serious problem in surgery, namely ventral and incisional hernia disease. The future of the procedure rests upon the sound
judgment of the surgeons performing the procedure.
Surgeons must adhere to basic surgical principles and
always make the safety of the patient their priority. The
initial results of the procedure are encouraging, and
long-term follow up is essential to verify the long-term
benefit of the procedure.
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
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Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and
Gore-Tex to repair abdominal wall defects in the rat. Can J Surg
1989; 32: 2447.
Molloy RG, Moran KT, Walaron RP, et al. Massive incisional hernia:
abdominal wall replacement with Marlex mesh. Br J Surg 1991;
78: 2424.
McCarthy JD, Twiest MW. Intraperitoneal polypropylene
mesh support incisional herniorrhaphy. Am J Surg 1981;
142: 70711.
Bellon JM, Contreras LA, Sabeter C, Bujan J. Pathologic and clinical
aspects of repair of large incisional hernias after implant of PTFE
prosthesis. World J Surg 1997; 21: 4027.
Monaghan RA, Meban S. ePTFE patch in the hernia repair: a
review of clinical experience. Can J Surg 1991; 34: 5055.
Ambrosiani N, Harb J, Gavelli A, Huguet C. Echec de la cure des
eventrations et des hernies par plaque de PTFE (111 cas). Ann Chir
1994; 48: 91720.
Saiz AB, Willis IH, Paul DK, Sivina M. Laparoscopic ventral
hernia repair: a community hospital experience. Am Surg 1996;
5: 3368.
Ven der Lei B, Bleichrodt RP, Simmermacher RKJ, van Schilgaarde
R. Expanded polytetrafluoroethylene patch for the repair of large
abdominal wall defects. Br J Surg 1989; 76: 8035.
Gillion JF, Begin GF, Marecos C, Fourtanir G. Expanded
polytetrafluoroethylene patches used in the intraperitoneal or
extraperitoneal position for repair of incisional hernias of the
anterolateral abdominal wall. Am J Surg 1997; 174: 1617.
PART
Laparoscopic treatment of
diaphragmatic herniation
23
24
25
26
27
28
History
173
179
187
193
201
209
29 Etiology of recurrent gastroesophageal

reflux disease
30 Reoperation for recurrent gastroesophageal
reflux disease
31 Results of laparoscopic treatment of hiatal hernias
217
227
235
239
23
History
RAYMOND C. READ
Initial experience
Short esophagus
Phillip Allisons contribution
Rudolph Nissens contribution
173
173
174
175
Even though Barrett did not introduce the term reflux

oesophagitis until 1950,1 this entity is now considered
to be the most common chronic disease afflicting the
Western world. Forty per cent of the population complain
of occasional heartburn, and a third of these require longterm medical treatment. A significant minority progress
to Barretts metaplasia. Other complications include
esophagitis, ulceration, stricture, herniation and neoplasia, many of which require surgery. The purpose of this
chapter is to trace the evolution of such therapy.
INITIAL EXPERIENCE
Herniation of abdominal contents through the diaphragm
has been recognized for centuries. According to Reid, the
lesion was first documented by Sennertus in 1541 at postmortem examination.2 Boyle described the clinical findings in 1812.3 Successful repair was accomplished by
Potemski in 1889.4 Congenital diaphragmatic herniation
was reported in 1701 by Holt.5 Operative correction was
effected in 1902 by Heidenhain.6 Ambroise Pare in 1610,
quoted by Hedblom,7 described cases of hiatus herniation
and post-traumatic protrusion at autopsy, but it was
not until 1908 that the former, discovered fortuitously
at laparotomy, was dealt with in a living person. Even
Part of this review was presented at the third Annual Scientific Meeting
of the American Hernia Society, Toronto, 15 June 2000, and has been
published previously as Contribution of Allison and Nissen to laparoscopic hiatal herniorrhaphy in Hernia 2002; 5: 200203.
Laparoscopic approach
Conclusion
References
175
176
176
though diaphragmatic hernias were considered rare,

Hedblom reviewed almost 400 cases (19 at the Mayo
Clinic) operated upon worldwide by 1925. The following
year, Akerlund published his radiological studies;8 these
were performed with barium, the patient being placed in
the Trendelenburg position, as recommended by Soresi.9
Most surgeons operated only on large protrusions
(mainly para-esophageal) because of their known risk of
incarceration, volvulus and strangulation. Based on experience with external hernias, pain and dysphagia were
attributed to pinching of the stomach by the hernial ring.
Harrington considered diaphragmatic herniation to be the
great masquerader because it was frequently confused
(and associated) with the more commonly recognized
peptic ulcer disease or cholecystitis.10 Therefore, in contrast to most surgeons of his time, he preferred the
abdominal approach. Thoracotomy allowed phrenic nerve
crush, which was still being recommended in the 1950s
to facilitate return of the stomach to the abdomen.11
Gastropexy was used to limit recurrence and prevent
postoperative volvulus.12
SHORT ESOPHAGUS
Harrington10 and other surgeons in the period between
the two world wars encountered some patients, young
and old, whose stomachs could not be reduced below the
diaphragm because of shortening and narrowing of the
esophagus. Forceful taxis resulted in disruption. These
individuals were therefore not operated upon, being
managed instead by bougienage. Harrington, as pointed
174 Laparoscopic treatment of diaphragmatic herniation
out by Hayward,13 also deserves credit for being the first

to distinguish between really short esophagus and one
that is apparently so.14 He also separated para-esophageal
hiatus herniation from the sliding type, the latter, the more
common, having a higher incidence of stricture.
A seminal but ultimately malign contribution to our
understanding of these cases was made by Findlay and
Kelly in 1931.15 Their paper was entitled Congenital
shortening of the esophagus and the thoracic stomach
resulting therefrom. In this, they described nine infants
and children who presented with dysphagia from high
strictures of the esophagus. Distally, the remaining foregut
in the chest was shown by endoscopic biopsy to be lined by
gastric mucosa. This structure was therefore considered
to be the stomach. Since their youngest patient was only
five days old, its intrathoracic position was presumed to
have been present before birth; thus it was not a hernia
but a congenital misplacement. To support this concept,
Findlay and Kelly cited seven necropsies, mostly of elderly
men whose intrathoracic stomach had been thought previously to be herniation. Kelly later reported further
examples of congenital intrathoracic stomach, but he
did accept that in some patients herniation could occur
postnatally.16 The associated strictures were considered to
arise from esophagitis, spasm, and ascending fibrosis.
During barium studies on normal children, these authors
incidentally observed longitudinal muscular spasm producing hiatal herniation during deglutition. This was the
first evidence for the modern concept that hernia may follow rather than cause gastroesophageal reflux disease
(GERD).
PHILLIP ALLISONS CONTRIBUTION

This thoracic surgeon (190874) was born and educated
and, for most of his career, practiced in Yorkshire,
England. In the late 1930s, while at the University of Leeds,
he pioneered intrapericardial pneumonectomy. In 1954,
he was appointed Nuffield Professor of Surgery at Oxford
University. Unfortunately, because of petty parochialism
practiced by the Harley Street surgeons of London, his
achievements were appreciated more overseas than in
his native land. In 1943, he and his colleagues described
ten middle-aged or elderly men and women with short
esophagus and peptic ulceration. They had complained
for months or years of substernal pain, dysphagia and,
in half, occasional bleeding. Symptoms responded to dilation and antacids, and endoscopy demonstrated fibrotic
narrowing. Some patients also had gastric or duodenal
ulceration. Allison and colleagues conclusion was that the
deformity referred to as congenitally short esophagus may
be acquired and result from herniation of the stomach
with ulceration and scarring.17
Barrett in 1950 distinguished between peptic ulceration of the esophagus lined with squamous epithelium
and gastric ulceration distally in what he called thoracic
stomach, even though it had no serosal covering to go
along with its adenomatous mucosa.1 (Barretts rejoinder
to such quibblers was Neither does the cardia!) Three
years later, Allison and Johnstone, in a paper entitled The
esophagus lined with gastric mucous membrane, argued
that Barretts thoracic stomach was actually esophagus
with an abnormal mucosa.18 They conferred his name on
both the epithelium and ulcers arising therein. They also
noted the presence of sliding hiatus herniation with or
without a para-esophageal component in their patients,
all of whom demonstrated peptic esophagitis (Allisons
term) or Barretts reflux esophagitis. In over 100 patients
with peptic stricture of the esophagus, less than ten per cent
were in the gastric lining. Most occurred at the junction
of squamous and adenomatous epithelium. Their conclusion was that the gastric epithelium in the esophagus,
rather than being congenital in origin, might develop by
healing of reflux esophagitis with metaplasia. LortatJacob19 and Hayward13 concluded that all such cases were
acquired. Interestingly, the former, a Frenchman, introduced the term endo-brachy-oesophage, analogous to the
English short esophagus. Lortat-Jacob agreed with Allison
that reflux esophagitis could shorten the squamous-lined
esophagus when its inferior portion became lined with
gastric-type mucosa.
One of Allison and Johnstones patients developed a
cancer in the adenomatous lining of the esophagus.18 At
72 years of age, he had complained of hiccup, epigastric
pain, flatulence, and nocturnal regurgitation on and off
for his entire life. Increasing dysphagia had started eight
weeks before admission. Olsen and Harrington had previously reported on four such examples of malignancy
associated with short esophagus and hiatus herniation.20
In discussion, Sweet commented that 13 per cent of his
resections for cancer of the cardia at the Massachusetts
General Hospital had been in patients with the short
esophagushiatus hernia syndrome. Cases of the latter
presenting with perforation or massive hemorrhage had
ulcers arising in the adenomatous epithelium of the
esophagus (Barretts), not in the squamous lining above.
To prevent reflux esophagitis, Allison focused on
hiatus herniorrhaphy.21 Since there was, at the time, no
anatomical or physiological evidence for a sphincter at
the esophagogastric junction, he set out to re-establish
both the angle of His and the diaphragmatic pinchcock
formed by the right crus of the diaphragm and the
phreno-esophageal ligaments. The situation being considered analogous to that of the puborectalis sling around the
anorectal junction, Allison felt that a posterior rather than
the popular anterior repair was indicated. His herniorrhaphy was conducted through the chest, the diaphragm
being incised to expose the abdomen.
History 175
Unfortunately, Allisons repair, which was adopted

widely, proved unsatisfactory because a significant number of patients suffered symptomatic relapse. Collis cited
these results in recommending a return to anterior closure of the defect in the dome of the diaphragm.22 This
surgeon, who also worked in the UK (Birmingham), had
described in 1957 an operation for patients with hiatus
hernia and short esophagus that has stood the test of
time.23 This involved constructing a neo-esophagus from
the Magenstrasse of the stomach. Hiebert and Belsey provided an explanation for the failure of Allisons procedure
when they documented incompetence of the gastric cardia
in the absence of hiatal herniation.24 The problem was
primary incompetence of the intrinsic gastroesophageal
sphincter of Code and colleagues.25
RUDOLPH NISSENS CONTRIBUTION

This distinguished thoracic surgeon (18961981), the
son of a surgeon, was an assistant between 1921 and 1933
to Professor Sauerbruch of Munich and Berlin. Being
Jewish, Nissen was forced to emigrate to Turkey, from his
Fatherland despite being wounded in the lung during
World War I. In 1931, he performed the worlds first successful pneumonectomy on a 12-year-old girl with a torn
left mainstem bronchus. While in Istanbul, he undertook
a transthoracic gastroesophagectomy for benign ulceration of the cardia.26 He later learned that this was the second such resection to be accomplished successfully, the
first being performed by the Japanese in 1933. It is interesting that Sauerbruch pioneered the procedure experimentally in the dog in 1906. Since almost all previous
attempts had failed in humans because of anastomotic
leakage, Nissen buried the anastomosis of the transected
esophagus in the fundus of the stomach. He brought up
two folds in the manner of a Witzel gastrostomy.
Amazingly, while he was Chief of Surgery at Basel,
Switzerland, 17 years after this operation he obtained
follow-up information from a relative of the patient.
The patient was well and had no symptoms of reflux
esophagitis. Two years later, Nissen decided to perform
fundoplication alone for esophageal reflux disease. He
undertook this procedure in a man and a woman who
each had the signs and symptoms of reflux esophagitis
without evidence of hiatal herniation. Nissen reported
success in 1956.27 In agreement with modern thought,28
he believed that hiatus herniation was the result rather
than the cause of reflux esophagitis. Therefore, in cases of
symptomatic hiatus herniation, he paid no attention to
the hernial sac, considered closure of the defect unnecessary, and with short esophagus performed transthoracic
fundoplication. He always conducted the procedure over
a large-bore bougie to prevent postoperative dysphagia,
and stitched the fundoplication to the esophageal wall

to obviate slippage. He mobilized the lesser curvature of
the stomach, being careful to preserve the vagi and their
branches. The left gastric vasculature rather than the short
gastric vessels was divided. A nasogastric tube was left
postoperatively to prevent vomiting.
Initially, Nissen performed a partial wrap since he did
not mobilize the fundus by dividing its blood supply.
Later, he recommended 360-degree rotation, since he
ligated the short gastric vessels rather than branches of
the left gastric on the lesser curvature. Today, both partial
and complete fundoplications are performed, depending
on the emptying characteristics of the esophagus and
stomach. Whereas Nissen was not concerned about an
intrathoracic location of the fundoplication, either intraoperatively with short esophagus or, later, secondary to
herniation, surgeons have adopted Belseys recommendation that the intra-abdominal portion of the esophagus
should be restored and maintained by repair of any hiatal
herniation.24 Any shortening of the esophagus from
scarring, secondary to GERD, is eliminated by the use of
Collis procedure.23 To avoid gas bloat and dysphagia, the
length of the wrap, which is floppy, has been halved.
Nissen retired from surgical practice in 1967 and died in
1981. Despite modifications, his operation continues to
be the basis for the surgical relief of complications arising
from reflux esophagitis with or without hiatus herniation.
LAPAROSCOPIC APPROACH
This mini-invasive surgical technique evolved from
endoscopy,29 which began on the island of Kos with the
school of Hippocrates (460375 BC), who described the
rectal speculum. A three-bladed vaginal speculum was
recovered from the ruins of Pompeii. The earliest light
sources were mirrors, introduced by the Arabs before
1000 AD. In 1587, Aranzi described the use of the camera
obscura, popularized by Leonardo da Vinci in 1519. A
spherical glass flask filled with water was used to focus a
beam of sunlight into the nasal cavity. In the seventeenth
century, Borell employed a lantern.
Bozzini in 1806 initiated modern endoscopy by developing a complex tubular system to convey light from
a candle allowing observation of the bladder or cervix
through a second channel. Segal in 1826 used a similar
arrangement to fabricate a cystoscope without lenses.
Desormeaux in 1865 and Nitze in 1879 developed telescopic instruments. Originally, their light source was
an overheated, water-cooled platinum wire (described
by Bruck in 1867), but after the electric light bulb was
invented in 1880 by Edison, this was incorporated into
a gastroscope by Mickulicz in 1881 and into a cystoscope
by Newman in 1883. Later, the bulb was mounted distally,
an operating channel was added, and the lens was separated therefrom.
Laparoscopy began in 1901 when Ott reported on
culdoscopy and later (1909) on ventroscopy using a
speculum. Kelling in 1902 suggested that a better view
of the compressed viscera could be obtained by inducing
pneumoperitoneum, this having been performed earlier
in the treatment of tuberculosis. His first observations,
Koelioskopie, were made on animals but in 1910 Jacobeus
reported 17 lapothorakoskopies on patients with ascites
employing a Nitze cystoscope. Further developments
included the use of the Trendelenburg position and a
trocar endoscope by Nordentoeft in 1912. The automatic
spring insufflating needle was invented by Goetz in 1918.
Carbon dioxide, which is absorbed more rapidly than
air, was substituted for air by Zollikofer in 1924. Kalk in
1929 devised a new lens system that permitted oblique
(135-degree) viewing, along with a dual-trocar technique.
In the 1930s, laparoscopy was performed largely by
general surgeons and internists (e.g. Ruddock) for the
diagnosis and biopsy of visceral disease. The stomach,
bladder and rectosigmoid were sometimes transilluminated for better evaluation. The first operation using
laparoscopy, adhesiolysis, was carried out by Fervers in
1933. Boesch in 1936 used the procedure for sterilization,
coagulating the fallopian tubes. Palmer expanded its use
in gynecology. Advances in instrumentation enhanced its
popularity: cold light illumination (Foursestiere in 1943),
fiber-optics (Hopkins in 1952), and new instruments
(Frangenheim in 1954, Semm in 1963). Semm also introduced the automatic insufflator. Later, bipolar coagulation
(Frangenheim in 1972) and laser technology (Bruhat in
1979) were added. Nevertheless, the major breakthrough
was the invention of the computer-chip video camera in
1986. This enabled assistants and students to view the
progress of the operation.
In 1981, Semm performed laparoscopic appendectomy; cholecystectomy followed (Muhe in 1986, Mouret
in 1987). Despite initial censure, laparoscopic herniorrhaphy, hysterectomy, bowel resection, gastrectomy, nephrectomy, cystectomy, splenectomy, adrenalectomy, vagotomy
and esophagectomy followed rapidly. Thoracoscopy was
rejuvenated.
Laparoscopic fundoplication was introduced independently by Geagea and Dallemagne in 1991. Since then,
it has been adopted worldwide and has supplanted the
open Nissen procedure. Hospital stay is reduced along
with postoperative morbidity. Treatment costs are thereby
reduced. An increase in operating time can be eliminated
by experience. Follow-up studies, many of which are prolonged and randomized, show that results are as good as
those obtained by classical open procedures, except perhaps with esophageal shortening or giant para-esophageal
herniation. Here, restoration of the abdominal esophagus
or recurrence pose problems.
Whereas a 360-degree fundoplication is the most common procedure, partial wraps are favored by some surgeons, especially if emptying of the esophagus or stomach
is inadequate. The mini-invasive nature of laparoscopy
has made surgery more acceptable, and it has become
competitive with long-term medical treatment. Improved
outpatient pH monitoring and other diagnostic measures
have expanded the population known to be suffering
from GERD.
The success of laparoscopic fundoplication, complete
or partial, in both children and adults has extended this
technique to prosthetic repair of hiatal defects, the Collis
operation for short esophagus, and the management of
incarcerated para-esophageal herniation. Other diaphragmatic hernias protruding through the foramina of
Bochdalek and Morgagni have been dealt with similarly,
along with blunt or penetrating injuries seen early or
late. Heller cardiomyotomies have also been performed
for achalasia. Smaller ports, narrower instruments, and
joystick controls have facilitated these procedures.30
Robotics are now on emerging technology.
CONCLUSION
Our understanding of the common ailment, reflux
esophagitis, has been shown to be based largely on the pioneering efforts of European thoracic surgeons. By unraveling congenital misplacement, hiatus herniation, short
esophagus, stricture, ulceration, adenomatous hyperplasia, and its malignant transformation, they made
modern surgical therapy possible.
European surgeons again played a leading role in the
evolution of laparoscopy from endoscopy. The successful application of this technique to appendectomy and
cholecystectomy stimulated its use, a decade ago, in the
management of GERD. This approach has now supplanted open fundoplication. It has been adopted for
prosthetic repair of various diaphragmatic hernias,
Heller myotomy, Collis gastroplasty and, combined with
thoracoscopy, esophagectomy. Technical advances and
new instrumentation continue to improve patient outcome while reducing costs and hospitalization.
REFERENCES
1 Barrett NR. Chronic peptic ulcer of the oesophagus and oesophagitis.
Br J Surg 1950; 38: 17582.
2 Reid J. Case of diaphragmatic hernia produced by a penetrating
wound. Edinburgh Med J 1840; 53: 10412.
3 Boyle A. Case of wounded diaphragm. Edinburgh Med J 1812;
8: 424.
4 Potemski M. Nouvo processo operativo per la reduzione cruenta
della cruie diaframmatiche da trauma e per la sutura della ferite
del diaframma. Bull Reale Acad Med Roma 1889; 15: 191.
History 177
5
6
9
10
11
12
13
14
15
16
17
Holt C. Child that lived two months with congenital diaphragmatic

hernia. Philos Trans 1701; 22: 922.
Heidenhain L. Geschichte eines Fallas von chronischer
Incarceration des Magens in einer angeborenen Zwerch fellhernie
welcher durch Laparotomie geheilt wurde, mit anschliessen
den Bemerkungen ueber die Moglichkeit. Das Kardiocarcinom der
Speiserohre zu reseciren. Deutsch Ztschr Chir 1905; 76: 394403.
Hedblom CA. Diaphragmatic hernia: a study of three hundred and
seventy eight cases in which operation was performed.
JAMA 1925; 85: 94753.
Akerlund A. Hernia diaphragmatic Hiatusoesophagei vom
anatomischen und rontgenologischen Gesicfhtspunkt. Acta Radiol
1926; 6: 322.
Soresi AL. Diaphragmatic hernia, its unsuspected frequency: its
diagnosis, technique for radical cure. Ann Surg 1919; 69: 25470.
Harrington SW. Diagnosis and treatment of various types of
diaphragmatic hernia. Am J Surg 1940; 50: 377446.
Adams HD, Lobb AW. Esophagoaortal hiatus hernia. N Engl J Med
1954; 250: 1438.
Boeremia I, Germs R. Anterior geniculate gastropexy for hiatal
hernia of the diaphragm. Zentralbl Chir 1955; 80: 158593.
Hayward J. The treatment of fibrous stricture of the esophagus
associated with hiatal hernia. Thorax 1961; 16: 4564.
Harrington SW. The surgical treatment of the more common types
of diaphragmatic hernia. Ann Surg 1945; 122: 54668.
Findlay L, Kelly B. Congenital shortening of the esophagus and
the thoracic stomach resulting therefrom. J Laryngol Otol 1931;
46: 797816.
Kelly AB. Some oesophageal affections in young children.
J Laryngol Otol 1936; 51: 7899.
Allison PR, Johnstone AS, Royce GB. Short esophagus with simple
peptic ulceration. J Thorac Surg 1943; 12: 43257.
18
19
20
21
22
23
24
25
26
27
28
29
30
Allison PR, Johnstone AS. The esophagus lined with gastric

mucous membrane. Thorax 1953; 8: 87101.
Lortat-Jacob JL. Les malpositions cardia-tuberositaires.
Arch Mal App Dig 1953; 42: 75074.
Olsen AM, Harrington SW. Esophageal hiatal hernias of the
short esophagus type: etiologic and therapeutic considerations.
J Thorac Surg 1948; 17: 189209.
Allison PR. Reflux esophagitis, sliding hiatal hernia and the
anatomy of repair. Surg Gynecol Obstet 1951; 92: 41931.
Collis JL. Review of surgical results of hiatus hernia. Thorax 1961;
16: 11423.
Collis JL. An operation for hiatus hernia with short esophagus.
J Thoracic Surg 1957; 34: 76878.
Hiebert CA, Belsey RHR. Incompetency of the gastric cardia
without radiologic evidence of hiatal hernia, the diagnosis and
management of 71 cases. J Thorac Cardiovasc Surg 1961; 42:
35271.
Fyke FE, Code CF, Schlegel JF. The gastroesophageal
sphincter in healthy human beings. Gastroenterologia 1956;
86: 13547.
Nissen R. Die Transpleurale Resektion der Kardia. Deutsche Ztschr
Chir 1937; 249: 31116.
Nissen R. Gastropexy as the lone procedure in the surgical repair
of hiatus hernia. Am J Surg 1956; 92: 38992.
Dunne DP, Paterson WG. Acid-induced esophageal shortening
in humans: a cause of hiatus hernia? Can J Gastroenterol 2000;
10: 84750.
Lau WY, Leow CK, Li AKC. History of endoscopic and laparoscopic
surgery. World J Surg 1997; 21: 44453.
Awad ZT, Filipi CJ. Commentary: the short esophagus, pathogenesis,
diagnosis and current surgical options. Arch Surg 2001; 136:
11314.
24
MARK A. REINER
Anatomy
Physiology
Surgical considerations for diaphragmatic repair
in patients with gastroesophageal reflux disease
179
183
Conclusion
References
185
185
184
In an attempt to elucidate the etiological factors that

contribute to gastroesophageal reflux disease (GERD), it
is necessary to have a full understanding of normal diaphragmatic anatomy and physiology. Pathological reflux
occurs when there are anatomical and physiological
abnormalities at the gastroesophageal junction and crura.
These abnormalities are influenced by postural changes
and gradients between intra-abdominal and intrathoracic
pressures. Corrective surgery must include a proper
diaphragmatic repair in order to minimize the potential
for recurrence. Postoperative management must be
tailored to the patients age, the size of the hiatal defect,
and the patients lifestyle.
ANATOMY
The diaphragm separates the abdominal and thoracic cavities. It is composed of a non-contractile central tendon
and three peripheral or skeletal muscular components, the
sternal, costal, and lumbar or crural.1 The central tendon
connects all of the muscular components by acting as a
central focal point from which these three muscle groups
radiate. The sternal portion of the muscular component
originates from the undersurface of the sternum and may
be considered as an independent structure or as the medial
aspect of the costal segment.1,2 The costal portion originates from the undersurface of the lower six costochondral junctions, extending on to these ribs, and then ending
by interdigitating with the transversus abdominis muscles
bilaterally. The lumbar or crural segment originates from
the first three lumbar vertebrae.1 These segments have

four components: the medial and lateral lumbosacral
arches or internal and lateral arcuate ligaments, and the
right and left crura.1,3 The medial lumbosacral arch (internal arcuate ligament) drapes over the psoas muscle; it is
fixed to the transverse processes of the first and second
lumbar vertebra, and fuses into the lateral portion of the
contiguous crus. The lateral lumbosacral arch (external
arcuate ligament) covers the quadratus lumborum and
becomes fixed to the first lumbar vertebrae and twelfth
rib.1,3 The crura originate as tendons that are a direct
extension of the longitudinal ligament of the vertebral column and as such are attached to the lumbar vertebrae. The
tendon of the left crus is shorter and thinner than the right
crus. It originates from the ventral surface of the bodies
and intervertebral disks of L1 and L2. The right crus, the
stronger and longer of the two, originates from the ventral
surfaces and intervertebral cartilages of L1, L2 and L3. The
crura muscular fibers, originating from their respective
tendons, then merge and surround the esophageal hiatus
at the level of T10.1,3,4 Before doing this, the medial margins of the crura pass ventrally and then merge medially
near the midline to surround the anterior surface of the
aorta. The muscular fibers coming off the crural tendons
then integrate and connect into the central tendon. The
right crus muscular fibers split into two segments. The
medial segment completely surrounds the esophageal hiatus, while the lateral segment merges directly into the central tendon. The muscular fibers of the left crus enter
directly into the central tendon. Occasionally, muscle bundles will overlap and may be derived from both tendons
(Figure 24.1).1,3,5,6

Costal origin
Esophageal hiatus
Vena cava foramen

Lumbar crural
Right crus
Median arcuate ligament
Aortic hiatus
Left crus
Medial arcuate
ligament
Lateral arcuate
ligament
Quadratus lumborum
Lumbar vertebrae
Figure 24.1 Normal diaphragmatic

anatomy.
Central component
Right component
Left component
Figure 24.2 Central tendon.
The muscular components of the diaphragm merge

centrally into the central tendon. This structure is a
strong aponeurosis broken down into three components.
The largest is the right component, followed by the central and left components. The entire structure is slightly
off-center, being biased slightly anteriorly and to the
right.1 The tendon gets its considerable strength because
the fibers merge at different angles (Figure 24.2).
Anatomical rents in the diaphragm exist so that passage of structures can occur between the thoracic and
abdominal cavities. There are three main and five minor
defects or apertures in the diaphragm. The minor defects
serve for passage of small vessels, such as the superior
epigastric artery and vein anteriorly, and the hemiazygos
vein and splanchnic and sympathetic nerves posteriorly.
The three major apertures are for the vena cava, the
aorta, and the esophagus.
The innervation of the diaphragm is from the phrenic
nerves, which arise mainly from the fourth and to a lesser
degree the third and fifth cervical nerves. The blood
supply is from the inferior phrenic arteries. The right
phrenic artery is more lateral, while the left phrenic
artery is more medial. The right vessel passes anterior to
the inferior vena cava and along the right side of its hiatus. The vessel divides into a medial and lateral branch.
The medial branch angles further anteriorly and anastomoses with the same branch of the opposite side, as well
as the musculophrenic and pericardiophrenic vessels.
The lateral branch courses laterally to anastomose with
the posterior intercostal arteries.1 The left vessel is significantly more medial and runs anterior to the esophagus
and ventrally along the left side of the esophageal hiatus.1,4 It must be noted carefully at this site to prevent
inadvertent injury during anti-reflux procedures, especially when closing the diaphragmatic rent. Branches of
the inferior phrenic vessels and occasionally an arterial
branch off the left gastric artery will pass just anterior
to the ventral margin of the esophageal hiatus.5 These
vessels can be injured when mobilizing the left lateral
segment of the liver or when a probe is placed in the
hiatus for anterior displacement aiding visualization
during an anti-reflux procedure. If this vessel is near the
apex, I prefer to use a more flat or fan retractor to help
prevent injury.
The next integral anatomical component in preventing reflux disease is the phreno-esophageal ligament. This
Anotomy/physiology 181
Lower esophageal attachment

Gastrophrenic ligament attachment
Pars condesa attachment
Anterior cardial attachment
Figure 24.3 Phreno-esophageal ligament.
Elliptical hiatus
Figure 24.4 Normal esophageal hiatus.
is a misnomer, being not a true ligament but rather a continuation of the subperitoneal fascia. Its attachments are
the anterior portion of the cardia of the stomach, the
lower 4 cm of the esophagus, and the left and right sides
of the crura around the esophageal hiatus. It terminates
on the left by merging into the gastrophrenic ligament
and on the right into the pars condensa of the lesser
omentum (Figure 24.3).4,7 The phreno-esophageal ligament is the only structure that establishes a direct connection between the lower esophageal sphincter and the
crural diaphragm. This structure has been considered an
important factor in preventing reflux. It tends to be
stretched and distracted in hiatal hernias.710 When this
occurs, it minimizes or eliminates any positive effect
that a normal ligament will have on reflux prevention.
This stretching, when seen in conjunction with a hiatus
hernia, allows a segment of gastric cardia to herniate
through the hiatus into the mediastinum, shortening the
length of the abdominal esophagus. When this occurs in
the presence of a hypotensive or atonic lower-esophageal
sphincter (LES), the patient will experience the symptoms
of GERD. The etiology of this laxity remains obscure,

but it has been attributed to a variety of factors, including
atrophic changes as seen with age, chronic stretching
secondary to each peristaltic contraction,10 obesity, pregnancy, surgical destruction, and trauma. Since the physiological benefits of the phreno-esophageal ligament are
diminished in the presence of a hiatus hernia, wide
dissection of the ligament in anti-reflux surgery has
no detrimental effect. Adequate dissection of the crura,
proximal stomach, and lower esophagus are mandatory
in order to perform an adequate repair. This condition
is not present in patients having upper-esophageal surgery for conditions other then reflux disease, such as a
Heller myotony for achalasia. Minimal dissection of the
phreno-esophageal ligament in these cases may help
minimize postoperative GERD.
The structural anatomy of the normal esophageal
hiatus has a significant impact in preventing reflux disease.
In its normal form, it is elliptical in shape and present
in the muscular portion of the diaphragm (Figure 24.4).
The hiatus is located at the level of the tenth thoracic
Oval-shaped
Figure 24.5 Esophageal hiatal hernia.
Central tendon
Interlocking anterior muscle fibers
Figure 24.6 Muscle and tendon

borders of the esophageal hiatus.
vertebra,1 and its lateral borders are formed by a split in

the muscular fibers of the right crus with only minor reinforcement on the left side by the left crus. The anterior surface of the hiatus is supported by a sling of muscle fibers
and tendinous attachments merging into the junction
between the medial and lateral leaflets of the central tendon. The posterior segment of the esophageal hiatus is
supported only by a sling of muscular tissue that is comprised almost exclusively of fibers originating from the
right crus. The presence of a hiatus hernia reflects a breakdown in the anatomical structures of the hiatus. As the
hernia enlarges, the defect becomes more oval in shape
(Figure 24.5).9 Stress on the hiatus causes an enlarging
defect in the muscular boundaries. The anterior border is
more resilient, being supported by interlocking muscle
fibers reinforced by tendinous fibers of the central and left
leaflets of the central tendon (Figure 24.6). This area tends
to resist forces that would cause the hiatus to enlarge. The
lateral muscular fibers of the hiatal borders stretch, especially as the phreno-esophageal ligaments elongate. This
causes a circular deformity of the esophageal hiatus without significantly enlarging its cross-sectional diameter.
The weakest portion of the hiatus is formed at the triangular shaped merging of the right crus fibers posteriorly
(Figure 24.7).7,9 This is an inherent site of anatomical
weakness that cannot be overcome by the extra support
provided by the prevertebral fascia. Forces that influence
the development of a hiatal hernia cause the rounding or
separation of these V-shaped muscular fibers, with the
subsequent effect of increasing the size of the esophageal
hiatus. Since the majority of the defect seen in hiatal hernias occurs dorsally, repair should be performed posterior
to the esophagus in order to re-establish normal anatomy.
I prefer to do the repair in the presence of a 5660 French
dilator so that I do not inadvertently make the new hiatal
size too narrow. Care must be taken to avoid injury to the
Triangular shaped merging of

the right crus fibers posteriorly
Figure 24.7 Posterior border of the

esophageal hiatus.
Intrathoracic esophagus
Lower esophageal sphincter
Intra-abdominal stomach
aorta at this stage because of its proximity to the posterior

aspect of the defect.
PHYSIOLOGY
The physiology of diaphragmatic function has a direct
effect on the presence or absence of symptomatic reflux.
A brief review of the etiological factors causing GERD
is warranted before we consider how to integrate the diaphragmatic repair into the surgical treatment of reflux
disease. Reflux occurs when gastric contents are regurgitated into the esophagus. The normal stomach resides in
an area of higher pressure than the thoracic esophagus. In
order for reflux not to occur, a pressure barrier must exist
between these areas of low and high pressure. A segment
of esophagus approximately 2 cm long, of which at least
1 cm usually resides intra-abdominally, called the LES, is
the junction between the two different pressure zones
(Figure 24.8). The presence of pathological reflux is
dependent on failure of the LES. Three factors come into
Figure 24.8 Anatomy of the lower

esophageal sphincter.
play. The first two are the normal average pressure and
the length of the sphincter.11 The third component of
this anti-reflux triad is the lower esophageal position. The
adequate presence of all three components will prevent
GERD under the conditions of rest, changing body positions, ingestion of moderate amounts of food and drink,
and physical activity that results in significant increases in
intra-abdominal pressures. A functional change in any
one of these components, without a corresponding compensatory adjustment in another of the other components, will result in GERD. An example of this adjustment
can be demonstrated in a patient with a shortened LES
segment. Reflux would occur unless there was a compensatory rise in the LES pressure. There is, however, one
situation in which there is an alteration in the balance
between these three factors that is physiologically normal
and the most common cause of non-pathological reflux:
transient lower esophageal sphincter relaxation (tLESR).
This occurs when there is gastric distention secondary to
ingestion of excess food, air, or gas, such as is seen with
carbonated beverages. This is unrelated to swallowing or
esophageal peristalsis, and it may have a neuromuscular
component, a purely mechanical component, or combinations of both.1012

The presence of the LES is not defined by any specific
anatomical landmarks, but it is well demonstrated by
placing an intragastric pressure monitor and withdrawing it into the distal esophagus. A high-pressure zone will
exist in the lower esophagus as compared with the gastric
baseline.11 In normal individuals, this will fall only
during swallowing or when the gastric fundus overfills
with gas or food. This segment of elevated pressure is
partially dependent on the length of the distal esophagus
exposed to intra-abdominal pressure. This length can be
altered by gastric distention, resulting in tLESR, the
shortening of the intra-abdominal component in the
presence of a hiatal hernia, or a shortened esophagus as
seen in chronic reflux. Once the pressure of the highpressure zone falls below an average of 6 mmHg, an average intra-abdominal length of 2 cm or less and/or an
average length exposed to the positive intra-abdominal
pressure of 1 cm or less than the LES is permanently
destroyed.11 These patients require surgical intervention
when they cannot be controlled adequately by medical
management.
A number of explanations have been postulated in an
effort to explain the relationship between the diaphragm,
the lower esophageal pressure, and the intra-abdominal or
distal few centimeters of esophagus. Allison believed that
when the right crus of the diaphragm contracts during
inspiration, it compresses the esophagus together at the
same time increasing its angulation.6 This action combined with a normal phreno-esophageal ligament produces adequate intra-abdominal esophageal length, thus
allowing an acceptable LES pressure to be generated
to prevent reflux. Delattre and colleagues believe that
diaphragmatic contraction causes the changes in LES
pressures and should not be attributed solely to changes in
intra-abdominal pressure.5 Most authors, however, believe
that there is both an intrinsic and an extrinsic mechanism
to prevent esophageal relux.4,11,1315 The intrinsic component is made up of the smooth muscle of the distal
esophagus under a variety of neuro-hormonal controls.
This component is referred to as the LES. A variety of
pathophysiological conditions affect this non-anatomical
sphincter. These effects can be mostly asymptomatic and
normal, as found with physiological reflux associated with
tLESR. They can also be pathological, causing symptoms
of GERD, as demonstrated by patients with a hypotensive
or atonic LES. The extrinsic component is comprised of
the diaphragm, with its reaction to respiration, position,
varying intra-abdominal pressures, and the phrenoesophageal ligament. GERD is most often expressed as a
result of a combination of intrinsic and extrinsic components. The tLESRs are affected by diaphragmatic contractions and relaxations mediated partially by their mutual
attachments to the phreno-esophageal ligament.15 LES
pressures are also affected by the contraction of the

diaphragm. The presence of a large hiatal hernia, with the
subsequent stretching of the phreno-esophageal ligament,
will disrupt the angle of His and diminish the length of
intra-abdominal esophagus. This, in conjunction with
intrinsic LES factors, will affect the development of GERD.
The size of a hiatal hernia has been shown to affect the
severity of GERD.10,14,16 A larger defect will have a shorter
sphincter length and lower LES pressures. Not surprisingly, the amount of reflux will be greater, with decreased
efficiency of acid clearance and a higher degree of
esophagitis.
SURGICAL CONSIDERATIONS FOR

DIAPHRAGMATIC REPAIR IN PATIENTS
WITH GASTROESOPHAGEAL REFLUX
DISEASE
Patients with hiatal hernias and GERD have a large posterior diaphragmatic defect. In these patients, the phrenoesophageal ligament has lost its anatomical importance
due to stretching or laxity developed as a result of the
increasing size of the hiatus. In this condition, the lower
esophagus and stomach can herniate into the chest. This
will then alter the angle of His and diminish or eliminate
the incursion of the lower esophagus into the abdomen.
These anatomical changes reduce the LES pressure,
shorten the abdominal esophagus, and diminish the total
length of the LES. Reflux can occur and, if treated inadequately, can result in chronic esophagitis with extensive
fibrosis and total irreversible atony of the LES. Surgical
repair is directed at increasing the efficacy of the malfunctioning LES and re-establishing the presence of the
abdominal esophagus. The laparoscopic gold standard is
the Nissen fundoplication coupled with an adequate
crural repair. In their reviews of fundoplication failures,
Soper and Dunnegan17 and Hunter and coworkers18
showed that the most frequent anatomical cause for failure was transdiaphragmatic herniation. The correct surgical approach for diaphragmatic repair is mandatory in
order to minimize operative failures in the treatment of
reflux disease. The repair should be done posterior to the
esophagus, using a mattress suture of adequate strength
nonabsorbable suture material (Figure 24.9). Pledgets are
not usually needed, but in elderly patients or in exceptionally large defects their use may be warranted. The size
of the defect should be just large enough to easily fit a
5660 French dilator. To prevent crural disruption in the
immediate postoperative period, extubation should be
smooth to prevent bucking against the endotracheal tube.
Anti-emetics should be used generously to prevent violent postanesthesia retching. Delayed disruption can be
avoided if the patient refrains from strenuous competitive
Esophagus
Pledget
Crural closure
Figure 24.9 Posterior crural repair.
sports, where sudden abdominal impact could cause a

significant and rapid rise in intra-abdominal pressure.
Caution must also be given to weight-lifters, who possess
thicker and stronger muscular diaphragms, about lifting
practices that could disrupt the repair.
5
6
7
8
CONCLUSION
The surgical treatment of GERD can be addressed successfully and safely only after fully understanding the
normal anatomy and physiology of the diaphragm, the
lower esophageal forces that prevent and cause reflux, and
the abnormal anatomical defects found in patients with
hiatus hernias. Failures can be kept to a minimum by the
diligent performance of a meticulous posterior repair of
the diaphragm before completing the fundoplication.
REFERENCES
10
11
12
13
14
15
Goss CM, ed. Grays Anatomy, 28th edn. Philadelphia: Lea &
Febiger, 1966.
2 Poole DC, Sexton WL, Farkas GA, et al. Diaphragm structure and
function in health and disease. Med Sci Sports Exerc 1997; 29:
73854.
3 Agur AMR, Lee MJ, eds. Grants Atlas of Anatomy, 10th edn.
Philadelphia: Lippincott Williams & Wilkins, 1999.
4 Delattre JF, Aviss C, Marcus C, Flament JB. Functional anatomy of
the gastroesophageal junction. Surg Clin North Am 2000; 80:
24160.
16
17
18
Delattre JF, Palot JP, Ducasse A. The crura of the diaphragmatic

passage. Anat Clin 1985; 7: 271.
Allison PR. Reflux esophagitis, sliding hiatal hernia, and the
anatomy of repair. Surg Gynecol Obstet 1951; 92: 41931.
Postlethwait RW. Surgery of the Esophagus, 2nd edn. Norwalk, CT:
Appleton-Century-Crofts, 1986.
Eliska O. Phrenoesophageal membrane and its role in
the development of hiatal hernia. Acta Anat (Basel) 1973; 86:
13750.
Marchand P. A study of the forces productive of gastroesophageal
regurgitation and herniation through the diaphragmatic hiatus.
Thorax 1957; 12, 189202.
Kahrilas PJ. Suoraesophageal complications of reflux disease and
hiatal hernia. Am J Med 2001; 111: 51S5S.
DeMeester TR, Peters JH, Bremner CG, Chandrasoma P. Biology
of gastroesophageal reflux disease: pathology relating to
medical and surgical management. Annu Rev Med 1999; 50:
469506.
Richter J. Do we know the cause of reflux disease? Eur J
Gastroenterol Hepatol 1999; suppl 1: 839.
Cuomo R, Grasso R, Sarnelli G, et al. Role of diaphragmatic crura
and lower esophageal sphincter in gastroesophageal reflux
disease. Dig Dis Sci 2001; 45: 268794.
Kahrilas P. The role of hiatus hernia in GERD. Yale J Biol Med 1999;
72: 10111.
Orlando RC. Overview of the mechanisms of gastroesophageal
reflux. Am J Med 2001; suppl 8A: 174S7S.
Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size
affects lower esophageal sphincter function, esophageal acid
exposure, and the degree of mucosal injury. Am J Surg 1995;
171: 1826.
Soper NJ, Dunnegan D. Anatomic fundoplication failure
after laparoscopic antireflux surgery. Ann Surg 1999; 229:
66977.
Hunter JG, Smith CD, Branum GD, et al. Laparoscopic
fundoplication failures. Ann Surg 1999; 230: 595606.
25
MARCO G. PATTI AND PIERO M. FISICHELLA
Preoperative evaluation for anti-reflux surgery

Esophageal manometry
Ambulatory pH monitoring
187
188
189
Laparoscopic Nissen fundoplication is one of the operations performed most frequently by general surgeons
today. The past decade has seen a progressive increase in
the number of laparoscopic Nissen fundoplications performed throughout the USA due to the recognition that
although the laparoscopic approach gives results similar
to those obtained with the open approach (excellent control of symptoms in about 90 per cent of patients), it is
also associated with shorter hospital stay, less postoperative discomfort, and faster recovery time.15 The increased
number of patients referred for surgical treatment has
allowed us to improve the understanding of the pathophysiology of the disease and to define the technical elements that play a role in the performance of an effective
and durable fundoplication.2
Traditionally, gastroenterologists have referred patients
for surgery based on clinical evaluation and findings of
endoscopy, particularly if they had a poor response to acidreducing medication. Today, however, this approach is
unacceptable for the following reasons: (1) many patients
undergo surgery for control of symptoms in the absence of
esophagitis; (2) more patients are referred for treatment
of atypical symptoms of gastroesophageal reflux disease
(GERD) such as cough or chest pain;6,7 and (3) because of
the efficacy of proton-pump inhibitors, in patients who do
not respond to these medications a diagnosis other than
GERD should be sought.8,9 Therefore, a careful and complete preoperative evaluation is of key importance for the
success of the operation.
Evaluation for failed anti-reflux surgery

References
190
191
PREOPERATIVE EVALUATION FOR

ANTI-REFLUX SURGERY
All patients who are candidates for laparoscopic fundoplication should undergo the following preoperative evaluation in order to determine whether abnormal reflux is
present, whether the symptoms are caused by the reflux,
and whether complications of GERD, such as Barretts
esophagus, are present, and to define the anatomy and
pathophysiology of the disease in the individual patient.
Symptomatic evaluation
Patients are questioned regarding the presence of typical
and atypical symptoms (Table 25.1). The severity of the
symptoms is scored from 0 (asymptomatic) to four
(severely affecting quality of life). Symptoms alone, however, are not diagnostic of GERD. Unfortunately, many
clinicians are overly confident that a diagnosis of GERD
can be based firmly on the clinical findings, even though
it has been shown that symptoms are unreliable in diagnosing GERD.810 For instance, our group found that
among 822 consecutive patients referred for esophageal
function tests with a clinical diagnosis of GERD (based on
symptoms and endoscopic findings), 30 per cent had no
abnormal reflux by pH monitoring (GERD' patients).8
Heartburn and regurgitation were as frequent in
GERD% and GERD' patients, so symptoms alone could

Table 25.1 Symptoms of gastroesophageal reflux disease
Typical symptoms
Atypical symptoms
Heartburn
Regurgitation
Dysphagia
Cough
Wheezing
Chest pain
Hoarseness
Otitis media
Enamel problems
not distinguish between those with and those without

genuine reflux. Other studies have shown that heartburn
and regurgitation have a low sensitivity and specificity,
with positive predictive values of 59 and 66 per cent,
respectively.9
The response to proton-pump inhibitors is a better
predictor of the presence of abnormal reflux. For example,
in our study 75 per cent of GERD% patients but only
26 per cent of GERD' patients reported a good or excellent
response to these medications.8 Similarly, in a multivariate
analysis of factors predicting outcome of laparoscopic
fundoplication, Campos and colleagues found that a clinical response to acid-suppression therapy was one of three
factors predictive of a successful outcome, along with an
abnormal 24-hour pH score and the presence of a typical
primary symptom, such as heartburn or regurgitation.11
Barium swallow
This test provides information about the presence and
size of a hiatal hernia, the presence and length of a stricture, and the length of the esophagus. The test is not diagnostic of GERD, as a hiatal hernia or reflux of barium can
be present in patients who do not have GERD. However, it
has been shown that among patients with proven GERD,
a large hiatal hernia impairs the function of the loweresophageal sphincter (LES) and prolongs esophageal acid
clearance, producing more severe mucosal injury and
increasing the risk of pulmonary symptoms.12
247 patients with negative pH studies, 60

(25 per cent) had been found to have grade I or II
esophagitis.8
Major interobserver variation exists for esophageal
endoscopy, particularly for the low grades of
esophagitis.14
Therefore, we feel that the major value of endoscopy

is to exclude other pathology and to detect the presence
of Barretts esophagus, which occurs in about 12 per cent
of patients with GERD.15
ESOPHAGEAL MANOMETRY
This test provides information about the length and resting pressure of the LES and the quality of esophageal
peristalsis (amplitude, duration and velocity of the peristaltic waves). In most patients with GERD referred for
surgery, the LES is hypotensive. However, in some
patients, the resting pressure of the LES is normal, and it
is assumed that transient LES relaxations account for the
majority of reflux episodes.16 Regardless of the mechanism underlying the abnormal reflux, a fundoplication
restores the function of the LES by increasing the pressure and length of the sphincter13 or by decreasing the
frequency of episodes of transient LES relaxation.17 In
addition, esophageal manometry provides information
about esophageal peristalsis, which is the most important factor in acid clearance.18 Among 1006 consecutive
patients with GERD confirmed by pH monitoring, we
found that peristalsis was normal in 56 per cent of
patients, severely abnormal in 21 per cent of patients
(ineffective esophageal motility, IEM), and mildly abnormal in 23 per cent of patients (non-specific esophageal
motility disorder, NSEMD) (Figure 25.1). Patients with
Endoscopy
Endoscopy is usually the first test performed to confirm
a symptom-based diagnosis of GERD. However, the
approach has the following pitfalls:
Even though the goal of endoscopy is to assess the

mucosal damage due to reflux, mucosal changes are
absent in about half of patients who have GERD.13
For instance, in our study esophagitis was absent
in 54 per cent of the patients who had positive
pH-monitoring studies.8
The sensitivity of endoscopy is low, particularly for
low grades of esophagitis.9 In our study, among
23%
56%
21%
Normal
NSEMD
IEM
Figure 25.1 Esophageal peristalsis in 1006 patients with GERD.
Preoperative evaluation 189
IEM had more severe reflux, slower acid clearance, worse

mucosal injury, and more frequent respiratory symptoms.18 Thus, manometry (and pH monitoring) can help
in staging the severity of the disease, identifying patients
who might benefit most from surgical treatment.
Finally, esophageal manometry allows proper placement of the pH probe for ambulatory pH monitoring
(5 cm above the upper border of the LES), avoiding the
false positive and negative results that occur in about 75
per cent of patients when the probe is placed with the
step technique.19
AMBULATORY pH MONITORING
Ambulatory pH monitoring is the most reliable test in the
diagnosis of GERD, with a sensitivity and specificity of
about 92 per cent.20 The results of the test are reproducible,
and false positive or negative results are rare. Acidsuppressing medications are discontinued three days
(H2-blocking agents) or 14 days (proton-pump inhibitors)
before the study. Diet and activity are unrestricted during
the study in order to mimic a typical day in the patients
life. This test is of key importance for the following reasons:
It determines whether abnormal reflux is present.

In our study, 30 per cent of patients with a clinical
diagnosis of GERD had a normal pH-monitoring
test.8 Therefore, in these patients, the test avoided the
continuation of inappropriate and expensive drugs,
such as proton-pump inhibitors, or the performance
of a fundoplication. In addition, it prompted further
investigation that pointed to other diseases, such as
cholelithiasis, irritable bowel syndrome, or primary
esophageal motility disorders.
It establishes a correlation between symptoms and

episodes of reflux. This is particularly important
when atypical symptoms such as cough or wheezing
are present, as 50 per cent of these patients do not
experience heartburn and 50 per cent do not have
esophagitis on endoscopy.13 In these patients, we use
a pH probe with two antimony sensors spaced 15 cm
apart (5 and 20 cm above the upper border of the
manometrically determined LES) in order to
determine the proximal extent of the reflux.21 The
pH monitoring tracings need to be analyzed for a
temporal relationship between an episode of cough
and an episode of reflux (signified by a drop of the
pH to #4.0). An episode of coughing is induced by
reflux if it occurs within three minutes of an episode
of reflux in the distal or the distal/proximal
esophagus (Figure 25.2). In a study of the effect of
laparoscopic fundoplication on GERD-induced
respiratory symptoms, we found that pH monitoring
helped to identify the patients most likely to benefit
from anti-reflux surgery. Following surgery,
respiratory symptoms resolved in 83 per cent of
patients when a temporal correlation between cough
and reflux was found on pH monitoring, but in only
57 per cent when this correlation was absent.6
Ambulatory pH monitoring with symptom
correlation is also the single best test for evaluating
non-cardiac chest pain.22 In our experience, the test
helps in predicting the outcome of a fundoplication.
Following laparoscopic fundoplication, chest pain
improved in 85 per cent of patients when a temporal
correlation between chest pain and reflux was found
on pH monitoring (Figure 25.3), and specifically in
96 per cent of patients when a strong correlation
("40 per cent) was present.7
Figure 25.2 GERD and respiratory

symptoms. Dual-sensor pH
monitoring: red line, acid reflux 5 cm
above LES; green line: acid reflux
20 cm above lower esophageal
sphincter. The image shows the
correlation between cough and
reflux in the distal esophagus; and a
correlation between cough and reflux
in the distal and proximal esophagus;
(c) $cough.
Figure 25.3 GERD and chest pain:

correlation between chest pain and
reflux.
It stages the disease according to severity.

Ambulatory pH monitoring and esophageal
manometry allow us to stratify patients according to
the severity of the disease, identifying a subgroup
characterized by worse esophageal motor function
(defective LES, abnormal esophageal peristalsis),
more acid reflux in the distal and proximal
esophagus, and slower acid clearance. As a
consequence, these patients experience more
stricture formation and Barretts metaplasia.18 It is
very important to identify these patients, as they
should benefit from early anti-reflux surgery.
EVALUATION FOR FAILED

ANTI-REFLUX SURGERY
During the past five years, we have seen an increased
number of patients referred to our Swallowing Center
for evaluation and treatment of foregut symptoms after
laparoscopic anti-reflux surgery. In these patients, it is
essential to repeat the entire preoperative work-up while
trying to answer the following questions:
Are the symptoms due to persistent gastroesophageal

reflux?
Are the symptoms due to the fundoplication per se?
Can a cause of the failure be identified and corrected
by a second operation?
Barium swallow
A barium swallow is essential in order to define the
anatomy of the gastroesophageal junction. As shown by
Horgan and colleagues from the University of Washington,

three types of configuration are usually present:23
Type I hernia: the gastroesophageal junction is above

the diaphragm (type IA, both the gastroesophageal
junction and the wrap are above the diaphragm; type
IB, only the gastroesophageal junction is above the
diaphragm).
Type II hernia: para-esophageal configuration.
Type III hernia: the gastroesophageal junction is
below the diaphragm, there is no evidence of hernia,
but the body rather than the fundus of stomach has
been used to perform the wrap.
Endoscopy
This determines whether esophagitis is present and
whether there is distortion of the gastroesophageal
junction.
Esophageal manometry
This determines the length and pressure of the LES and
its ability to relax in response to swallowing. In addition,
it assesses eventual changes in peristalsis.
Ambulatory pH monitoring
It is often assumed that if a patient has heartburn after a
fundoplication, then this is due to a failed operation, so
acid-reducing medications are restarted. However, this
approach is wrong in the majority of patients, as postoperative pH monitoring is abnormal in only about 20 per
cent of patients.24 In addition, this test determines whether
Preoperative evaluation 191
a correlation exists between symptoms experienced by

the patient and episodes of reflux. If abnormal reflux is
present, then the choice is between medical therapy and
a second operation.
REFERENCES
11
12
13
14
1
5
6
10
DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for

gastroesophageal reflux disease: evaluation of primary repair in
100 consecutive patients. Ann Surg 1986: 204; 929.
Patti MG, Arcerito M, Feo CV, et al. An analysis of operations for
gastroesophageal reflux disease: identifying the important
technical elements. Arch Surg 1998; 133: 6006.
Peters JH, DeMeester TR, Crookes P, et al. The treatment of
gastroesophageal reflux disease with laparoscopic Nissen
fundoplication: prospective evaluation for 100 patients with
typical symptoms. Ann Surg 1998; 228: 4050.
Hunter JG, Smith DC, Branum GD, et al. Laparoscopic
fundoplication failures: patterns of failure and response to
fundoplication revision. Ann Surg 1999; 230: 595604.
Eubanks TR, Omelanczuk P, Richards C, et al. Outcomes of
laparoscopic antireflux procedures. Am J Surg 2000; 179: 3915.
Patti MG, Arcerito M, Tamburini A, et al. Effect of laparoscopic
fundoplication on gastroesophageal reflux disease-induced
respiratory symptoms. J Gastrointest Surg 2000; 4: 1439.
Patti MG, Molena D, Fisichella PM, et al. GERD and chest pain.
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Patti MG, Diener U, Tamburini A, et al. Role of esophageal function
tests in diagnosis of gastroesophageal reflux disease. Dig Dis Sci
2001; 46: 597602.
Johnsson F, Joelsson B, Gudmundsson K, Greiff L. Symptoms and
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disease. Scand J Gastroenterol 1987; 22: 71418.
Costantini M, Crookes PF, Bremner RM, et al. Value of physiologic
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15
16
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18
19
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21
22
23
24
Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis

of factors predicting outcome after laparoscopic Nissen
fundoplication. J Gastrointest Surg 1999; 3: 292300.
Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size affects
lower esophageal sphincter function, esophageal acid exposure,
and the degree of mucosal injury. Am J Surg 1996; 171: 1826.
Richter JE. Typical and atypical presentations of gastroesophageal
reflux disease. The role of esophageal testing in diagnosis and
management. Gastroenterol Clin North Am 1996; 25: 75102.
Bytzer P, Havelund T, Hansen JM. Inter-observer variation in the
endoscopic diagnosis of reflux esophagitis. Scand J Gatroenterol
1993; 28: 11925.
Patti MG, Arcerito M, Feo CV, et al. Barretts esophagus: a surgical
disease. J Gastrointest Surg 1999; 3: 397403.
Doods WJ, Dent J, Hogan WJ, et al. Mechanisms of
gastroesophageal reflux in patients with reflux esophagitis.
N Engl J Med 1982; 307: 15471552.
Ireland AC, Holloway RH, Toouli J, Dent J. Mechanisms underlying
the antireflux action of fundoplication. Gut 1993; 34: 3038.
Diener U, Patti MG, Molena D, et al. Esophageal dysmotility and
gastroesophageal reflux disease. J Gastrointest Surg 2001; 5: 2605.
Molena D, Patti MG, Diener U, Way LW. Esophageal manometry is
a prerequisite for pH monitoring. Gastroenterology 2000;
118: 715.
Fuchs KH, DeMeester TR, Albertucci M. Specificity and sensitivity
of objective diagnosis of gastroesophageal reflux disease. Surgery
1987; 102: 57580.
Patti MG, Debas HT, Pellegrini CA. Clinical and functional
characterization of high gastroesophageal reflux. Am J Surg 1993;
165: 1638.
Hewson GE, Sinclair JW, Dalton CB, et al. Twenty-four hour pH
monitoring: the most useful test for evaluating non-cardiac chest
pain. Am J Med 1991; 90: 57683.
Horgan S, Pohl D, Bogetti D, et al. Failed antireflux surgery. What
have we learned from reoperations? Arch Surg 1999;
134; 80915.
Lord RVN, Kaminski A, Oberg S, et al. Absence of gastroesophageal
reflux disease in a majority of patients taking acid suppression
medications after Nissen fundoplication. J Gastrointest Surg
2002; 6: 310.
26
J. BARRY McKERNAN AND CHARLES R. FINLEY
Treatment
Discussion
193
200
Over the past decade, there has been a significant shift in

the role of surgery for the treatment of gastroesophageal reflux disease (GERD). Anti-reflux surgery, once reserved for severe disease refractory to medical therapy, is
now considered appropriate for many patients without
mucosal complications. Several factors have contributed
to the growing acceptance of surgery for reflux disease.
One such factor is the appreciation that abnormal reflux
can result in serious esophageal complications, such as
ulcerations, strictures, and the development of Barretts
metaplasia. It is well recognized that many of the extraesophageal symptoms observed in patients with GERD,
including laryngitis, erosion of dental enamel, and pulmonary disorders (asthma, chronic cough, bronchitis),
are due to refluxed gastric material entering the oropharyngeal cavity and lungs. Although medical therapy with
proton-pump inhibitors is fairly effective in controlling
heartburn and esophagitis, it is less effective in controlling these extra-esophageal symptoms.
Current evidence suggests that treatments directed at
restoring normal competence to the lower esophageal
sphincter (LES) will be more effective than those aimed
at controlling acid secretion.1,2 The introduction of safe
and effective minimally invasive anti-reflux procedures
has contributed greatly to the shift in the role of surgery for treating GERD. Medical therapy is directed at
alleviating uncomfortable symptoms, whereas surgery is
directed towards repairing the functional defect. Laparoscopic anti-reflux procedures are comparable to their
open counterparts in terms of high rates of symptom
relief coupled with low rates of complications, but they
offer advantages in terms of shorter hospital stay, quicker
recovery, and cost-savings.35
For many patients, operative therapy has become an
alternative rather than a last resort to treat their abnormal
References
200
reflux and prevent the development of complications associated with GERD. The laparoscopic approach, as in cholecystectomy, adrenalectomy and splenectomy, has replaced
the open technique as a method of choice. Patients considered candidates for laparoscopic anti-reflux surgery are
those who have failed medical therapy, those who cannot
afford medical therapy, those who have recurrence of
symptoms, those with extra-esophageal manifestations or
strictures, and those with para-esophageal hernias. Previous
open abdominal surgery, either for reflux disease or for
other reasons, does not prevent the patient from having
a successful laparoscopic anti-reflux procedure.
TREATMENT
Non-surgical therapy
Although this chapter focuses primarily on the laparoscopic treatment of GERD, several other non-surgical
treatment modalities for GERD and related disorders
deserve mention. Patients are becoming more knowledgeable and inquisitive about their disease, in particular
through the use of the Internet. Two recent procedures
have caught the attention of patients with reflux disease
who are seeking non-surgical alternatives to the treatment of GERD. The first is the Stretta Procedure
(Curon Medical), which involves endoscopic delivery of
radiofrequency energy to the gastroesophageal junction.
Indicated in patients with minimally active esophagitis
and a hiatal hernia of less than 2 cm in size, one study
revealed a significantly improved quality of life and
esophageal acid exposure while eliminating the need for
antisecretory medication in the majority of patients
studied.6 Another recently studied modality for patients

with minimal esophagitis and hiatal hernia less than
2 cm in size is the use of an endoscopic suturing device
to perform endoscopic gastroplasty. The authors noted
an improvement in heartburn severity score and an
improvement in postoperative 24-hour pH monitoring.7
Surgical therapy
We employ a selective approach to treating GERD, tailoring the anti-reflux procedure to each patients underlying
anatomical and functional defect. The most commonly
performed procedures for GERD are Nissen fundoplication, modified Toupet fundoplication, and Collis gastroplasty combined with a fundoplication. Additionally, we
have chosen a team approach for the treatment of GERD,
utilizing an ambulatory surgical center focused on endoscopic surgery as well as a team of nursing staff and anesthesiologists intimately familiar with the perioperative
care of patients undergoing laparoscopic foregut surgery.
Patients are admitted to the outpatient surgery center
one hour before the induction of anesthesia. Liberal use
of metoclopramide and ondansetron perioperatively has
greatly reduced the incidence of postoperative nausea
and vomiting (PONV). Patients are given a single dose of
prophylactic antibiotics and pneumatic sequential compression hose to prevent deep venous thrombosis.8
primary surgeon and the assisting surgeon utilize a twohanded technique. This enhances exposure and speeds up
the operation. The patient is placed in the Trendelenburg
position, with the back elevated to approximately 30
degrees. The 10-mm, zero-degree laparoscope is then
replaced with a 45-degree laparoscope. An angled laparoscope is used on every case as it provides optimum
exposure to the areas of the gastroesophageal junction,
the splenic hilum, the posterior esophageal area, and the
posterior mediastinum. Initially, peritoneal attachments
between the fundus of the stomach and the diaphragm
are divided with the surgeons energy system of choice.
Liver retraction
Surgeon left hand
Surgeon right hand
15 cm
Assistant right hand

Assistant left hand
Operative techniques
Mobilization
Patients are placed on the operating table in the supine
position. Six trocars are utilized routinely, as shown in
Figure 26.1. Some surgeons prefer the semi-lithotomy
position. A 10-mm incision is made just to the left of the
midline (paramedian), approximately 15 cm below the
xiphoid process. A zero-degree laparoscope with a 10-mm
optically dilating trocar is used to gain entrance into the
peritoneal cavity. The use of the optically dilating trocar
cannot be overstated, as it has allowed access to the peritoneal cavity in many patients who have had previous
open and closed abdominal procedures. The trocar is
used in the following manner: after the skin incision is
made, the trocar is advanced slowly through sequential
layers of the abdominal wall, allowing each layer to be
identified. Upon arriving visually at the posterior sheath/
peritoneal layer, the scope is manipulated, which reveals
any adherent bowel, thereby preventing inadvertent
injury (see Chapter 3).9 The abdomen is then insufflated
with carbon dioxide. The remaining 5-mm trocars are
placed under direct vision.
A locking Allis clamp is attached to the diaphragm just
above the apex of the esophageal hiatus to allow for liver
retraction (Figure 26.2). It is very important that both the
10 mm
optical
trocar
5 mm trocar
Figure 26.1 Typical trocar placement for laparoscopic

fundoplication, with patient in supine position.
Figure 26.2 Locking Allis clamp through the epigastric port on

the diaphragm for liver retraction.
Gastroesophageal reflux disease 195
Attention is now turned to the lesser omentum, which

is opened over the caudate lobe of the liver. There is one
vascular anomaly that deserves mention. In approximately
ten per cent of cases, a large branch of the left hepatic
artery traverses the lesser omentum in this area. This vessel should be preserved if it is felt to be larger than 5 mm in
diameter. If there is any doubt about this vessels contribution to hepatic blood flow, then it may be occluded
temporarily with a grasper and any color change noted in
the liver. Next, the right crus of the diaphragm is identified, along with its peritoneal attachment, or the white line
of the right crus of the diaphragm. This dissection of the
right crus of the diaphragm is carried down to the point
at which the median arcuate ligament is identified. Now,
dissection proceeds along the left crus of the diaphragm
until a retro-esophageal window is created. A grasper is
passed behind the esophagus, and a blue silastic vessel loop
is grasped, encircling the esophagus and secured in place
with a chromic endo-loop. Occasionally, a branch of the
inferior phrenic artery is encountered, requiring cauterization. Also, a few cases of thoracic duct injury have been
reported, which presumably resulted from its location in
proximity to this portion of the dissection. The assistant
gently grasps the vessel loop providing traction and excellent exposure for the surgeon. Dissection is begun along
the right crus, dividing the phreno-esophageal ligament
circumferentially, until the esophagus is completely mobilized. Both anterior and posterior vagus nerves are identified at this point of the dissection. It should also be noted
that in nearly all cases, the esophageal dissection is performed bluntly without the use of cautery for fear of
esophageal, vagal or pleural injury (Figure 26.3).
Care must be taken to adequately mobilize the esophagus in such a way that the fundoplication will be placed
Figure 26.3 Complete mobilization of the distal esophagus,

with blue silastic vessel loop for gentle anterior retraction. The
right and left crus and the vagus nerve are visualized.
at the level of the LES. Intraoperative esophagogastroduodenoscopy (EGD) is performed in all redo fundoplications, in patients with para-esophageal hernias, and in
any cases in which there is uncertainty as to the location
of the LES at the time of surgery. EGD is also carried out
after the performance of a Collis gastroplasty to verify
that there are no leaks at the site of the staple lines.
Furthermore, intraoperative EGD is performed following all cases of esophageal myotomy.
Once the esophagus has been mobilized, the short
gastric vessels are divided. Various methods of division
and ligation have been utilized, including clips, the harmonic scalpel, vascular staplers, and bipolar cautery forceps. The use of bipolar cautery forceps with monopolar
division seems to be the most efficient method, with both
surgeons using the two-handed technique. Routine division of the short gastric vessels ensures a loose, floppy
fundus. A recent prospective, double-blind, randomized
trial with five-year follow-up showed no improvement in
any measured clinical outcome by division of the short
gastric vessels at the time of laparoscopic Nissen fundoplication.10 If the surgeon chooses not to divide the
short gastric vessels, then adequate mobilization of the
posterior surface of the fundus should include division
of congenital adhesions, adhesions encountered in
patients with prior pancreatitis, and the occasional vascular anomaly in which there is a direct branch from the
splenic artery to the posterior fundus of the stomach.
Crural closure
We routinely measure the size of the crural opening with an
endoscopic ruler. This has significance with respect to
recurrence rate, as those with openings greater than 5 cm
have a higher rate of recurrence. Simple crural closure is
accomplished with interrupted 0-Ethibond (Ethicon, Inc.)
sutures tied extracorporally. Several options are available
for the difficult hiatal closure. Materials such as expanded
polytetrafluoroethylene (ePTFE) and bovine pericardium
have been used successfully. These are secured in place with
either a hernia stapler or sutures. Recently, we have utilized
Surgisis Gold(Cook Surgical), a biodegradable mesh,
secured with sutures or the hernia stapler. Regardless of the
material used, it is important to remember that the area of
the gastroesophageal junction is mobile. Care should be
taken to avoid direct contact between the materials and the
esophagus itself, the obvious concern being erosion of the
prosthetic material into the esophagus.
In some cases, a relaxing incision is made in the
diaphragm, just medial to the right crus of the diaphragm (Figures 26.4 and 26.5). The angled laparoscope
provides visualization into the chest, just above and
to the right of the right crus of the diaphragm. The incision is then made with the harmonic scalpel over the
liver. The crura of the diaphragm are then approximated
Figure 26.4 Location of relaxing incision in the diaphragm for

a very large hiatal hernia.
Figure 26.6 Buttressed closure of the relaxing incision in the

diaphragm. Sutures or staples (surgeons preference) for mesh
fixation.
passes the fundus through the retro-esophageal window.

An appropriate area of the fundus, usually near the recently
divided short gastric vessels, is then grasped. The anesthesiologist then passes a number 50 French bougie dilator as he
or she watches its progression into the stomach on the
monitor. The planned fundoplication is then calibrated
over the dilator in order to perform a loose fundoplication.
The fundus is sutured to the esophagus at the upper border
of the LES. Three sutures of 0-Ethibond are used most frequently, the middle suture incorporating only fundus to
fundus. Care is taken to avoid the anterior vagus nerve
while suturing, as it passes from the esophagus towards the
lesser curvature of the stomach.
Modified Toupet fundoplication
Figure 26.5 Relaxing incision in the diaphragm performed with

harmonic scalpel and closure of the hiatus. Crural sutures are
rarely placed anteriorly.
with Ethibond sutures and the relaxing incision can be

buttressed with one of the above-mentioned prosthetic
materials (Figure 26.6).11
Nissen fundoplication
Up to this point in the operation, no bougie dilator has
been placed during the procedure. The assistant gently
Esophageal motility is performed in all patients preoperatively. A careful history of any difficulty in swallowing
is also elicited. A modified Toupet fundoplication is utilized
in patients with poor esophageal motility, as demonstrated
by esophageal manometrics or in patients with significant
difficulty in swallowing. The classic Toupet fundoplication
did not involve crural closure. Furthermore, the fundus
was sutured to the crura laterally and posteriorly and to the
esophagus anteriorly, creating a 180-degree fundoplication.
Theoretically, this caused an unusual degree of tension
and mobility between the esophageal and fundic suture
lines, which resulted in a high incidence of recurrence. The
modified Toupet fundoplication requires only crural
closure, and the two most cephalad sutures anchor the
esophagus to the fundus and the crura. In the event that a
Fundus
Right crus
Esophagus
Left crus
Figure 26.9 The 1 oclock anchoring suture, incorporating the

left crus, fundus and esophagus (mirroring the previously placed
11 oclock suture).
Figure 26.7 Posterior suture in modified Toupet fundoplication,
incorporating the fundus to the left crus. This anchors the
fundus to the left crus posteriorly. E, esophagus; F, fundus; LC,
left crus; RC, right crus.
Figure 26.8 The 11 oclock suture. The needle is shown after

passing through the esophagus. The esophagus will then be
sutured to the fundus (directly inferior to the needle in the
photograph) and then to the right crus (just to the left of the
fundus in the photograph).
modified Toupet fundoplication is indicated, a grasper is

placed behind the esophagus and the fundus is grasped and
retracted medially behind the esophagus, such that a 270degree wrap can be performed. The first suture in the modified Toupet fundoplication is placed through the fundus
posteriorly and through the left crus using a 0-Ethibond
suture (Figure 26.7). A second suture is placed through the
wrap posteriorly and through the right crus. Next, the
esophagus is anchored to the right crus of the diaphragm
by passing the suture through the esophagus at 11 oclock,
then through the fundus, and finally through the crus
(Figure 26.8). Additional sutures are then placed caudad
Figure 26.10 Completion of the modified Toupet

fundoplication.
to this suture between the esophagus and the fundus.

Attention is then turned laterally, and a number 38 French
bougie dilator is advanced into the stomach. At the
1 oclock position, approximately 23 cm from the esophagus, a suture is passed through the fundus, through the
left crus of the diaphragm, and finally though the esophagus, thus anchoring the wrap laterally (Figure 26.9).12
Additional sutures are then placed between the fundus and
the esophagus, thus completing the left side of the fundoplication (Figure 26.10). Usually, three sutures incorporate
fundus to crura, two sutures anchor esophagus to fundus to
crura at 11 and 1 oclock, and there are two sutures on each
side between fundus and esophagus.
Collis gastroplasty
Esophagomytomy
The true occurrence of shortened esophagus is debatable.

In our experience, it occurs in one to two per cent of cases.
Adequate esophageal mobilization well into the chest will
usually allow the creation of an intra-abdominal fundoplication without the need for a Collis gastroplasty. If there is
any doubt as to the location of the gastroesophageal junction, then intraoperative esophagoscopy is performed. If
the LES, after maximal retroperitoneal mobilization, cannot be brought below the planned crural closure, then a
Collis gastroplasty may be indicated. The Collis gastroplasty is performed prior to closure of the hiatal hernia. A
number 50 French bougie dilator is placed along the lesser
curve of the stomach to be used as a stent in the formation
of the neo-esophagus. An additional 10-mm trocar is then
placed just below the subcostal margin in the left midclavicular line. The fundus is splayed out laterally, and the
angled linear cutter is introduced into the recently placed
10-mm trocar. The linear cutter is then angled medially to
transect the stomach from a point along the greater curvature to a point approximately 34 cm below the crural
opening (Figure 26.11). This usually requires more than
one firing of the stapler. The goal is to have at least 45 cm
of neo-esophagus below the crural opening. Then the
angled linear cutter is placed parallel to the bougie and
fired cephalad (this may require more than one firing),
thus creating the neo-esophagus and in the process
removing a small triangular portion of the fundus of the
stomach (Figure 26.12). The remaining stapled lateral fundus is invaginated into a Nissen repair or, if the patient had
significant preoperative dysphagia, into a modified Toupet
repair (Figure 26.13). We usually perform a highly selective vagotomy in the neo-esophagus to prevent gastritis.
Achalasia is secondary to a loss of ganglion cells in

the lower esophagus, resulting in failure of relaxation
of the LES with subsequent hypertrophy of the muscle
and aperistalsis of the esophageal body. The diagnosis of
achalasia is made primarily utilizing esophageal manometry along with the typical radiographic findings on barium
esophagogram of the bird-beak appearance of the esophagus. The surgeon generally sees these patients after the failure of standard medical therapy, esophageal dilation, and
possibly botulinum toxin injection. Surgical treatment
Figure 26.12 Creation of the neo-esophagus.
5 cm
Figure 26.11 Initial application of linear cutting device.
Figure 26.13 Remaining fundus utilized for either modified

Toupet or Nissen fundoplication.
involves esophagomyotomy and an anti-reflux procedure,

typically a modified Toupet fundoplication or Dor anterior fundoplication.
Spastic disorders of the esophagus include nutcracker
esophagus, diffuse esophageal spasm (DES), and hypertensive LES. DES and nutcracker esophagus primarily
involve the lower third of the esophagus. Nutcracker
esophagus is typified by significant chest pain and, to a
lesser extent, dysphagia. Esophageal manometry generally shows slightly elevated resting LES pressures and
normal relaxation, combined with average esophageal
pressures of greater than 180 mmHg. Nutcracker esophagus is usually identified easily on standard manometry,
as it is a fairly continuous disorder. Diffuse esophageal
spasm, on the other hand, may not be identified on standard or ambulatory esophageal manometry, due to its
episodic nature. DES is characterized by simultaneous,
mostly high-amplitude esophageal contractions. Each
case should be treated on an individual basis, and
patients should be selected carefully for surgical therapy.
We usually perform a laparoscopic esophagomyotomy
combined with an anti-reflux procedure (either a Nissen
or a modified Toupet fundoplication).
Hypertensive LES, less common than the other spastic
disorders of the esophagus, is characterized by high resting LES pressures ("40 mmHg or more than two standard deviations above normal) and normal relaxation of
the LES, combined with relatively normal esophageal
body motility. Reflux does occur in this population,
presumably as a result of transient relaxation of the LES
with subsequent delayed esophageal clearing of the
refluxed acid. Considerable controversy surrounds the
appropriate management of this condition. The various
treatment options include pharmacological agents to
decrease LES pressure, esophageal dilation, and surgery.
Only a small number of these patients require surgery.
We most commonly perform an esophageal myotomy
and modified Toupet fundoplication when treating this
group of patients surgically.
Technique
Once esophageal and fundic mobilization has been completed, and before closure of the esophageal hiatus, the
anterior esophagus is exposed between 11 and 12 oclock.
This area avoids the anterior vagus nerve. Beginning
approximately 2 cm above the gastroesophageal junction, the longitudinal fibers in the first muscular layer of
the esophagus are sharply dissected and separated with
scissors. We use disposable endoscopic scissors with no
cautery, since we find that cautery is needed only rarely
on the small vessels in the esophagus. Once the longitudinal fibers have been bluntly separated, the circular
fibers become exposed. These are divided under direct
visualization. The assistant uses a suction irrigator to
keep the field clear for dissection. Once the circular fibers
are divided down to the mucosa, the mucosa can be
pushed bluntly inferiorly, and the dissection can proceed
in a cephalad direction. The total length of the myotomy
will depend on the indication for the procedure. For a
primary motility disorder such as achalasia, nutcracker
esophagus, or diffuse esophageal spasm, a length of
68 cm is usually sufficient. For a hypertensive LES, typically only a 4-cm myotomy is needed (length of the LES)
to relieve the obstruction.
Once the proximal portion of the myotomy is completed, the more distal segment, which involves the gastroesophageal junction, is approached. Dissection is carried
inferiorly until it impinges upon the decussating fibers of
the stomach wall and the presumed location of the gastroesophageal junction. It is our practice, in patients undergoing esophageal myotomy, to perform an intraoperative
EGD to determine accurately the location of the gastroesophageal junction. The intraoperative EGD serves two
purposes: it ensures that the myotomy extends beyond
the gastroesophageal junction to totally relieve any distal
obstruction, and it ensures that there is no iatrogenic perforation of the mucosa prior to closure. Once the myotomy
is complete, the muscular layer is swept laterally to expose
approximately 1.5 cm of mucosa. The site is inspected for
bleeding and the fundoplication is performed. When performing a myotomy with a modified Toupet fundoplication, the fundus is sutured to the divided muscular edges
of the esophageal myotomy, taking care not to injure the
bulging mucosa.
Pyloroplasty
Approximately 1050 per cent of patients with GERD
have delayed gastric emptying. This frequently manifests
itself in the form of recurrent reflux symptoms after a successful anti-reflux procedure. The patients history, EGD,
upper gastrointestinal radiological studies, and a nuclear
medicine gastric-emptying scan are all helpful in making
the diagnosis of delayed gastric emptying. Once the diagnosis is made, the patient is treated initially with endoscopic pneumatic dilation of the pylorus. If the patient
responds favorably to this treatment, then the definitive
treatment by laparoscopic pyloroplasty can be offered.
Trocars are placed similarly as for laparoscopic fundoplication, although usually in a more caudad position on
the abdominal wall. The duodenum is then mobilized
(Kocher maneuver) utilizing the harmonic scalpel and
blunt dissection. The pylorus is identified, and a longitudinal incision is made on the anterior surface of the
duodenum, through the pylorus and then on to the stomach. This longitudinal incision is now closed transversely
in one layer utilizing 0-Ethibond sutures. Following the
completion of the pyloroplasty, intraoperative EGD is
performed to check for air leaks, and additional sutures
are placed as necessary. The EGD is also valuable in determining the adequacy and patency of the pyloroplasty.
DISCUSSION
The technical steps presented in this chapter represent
the authors preferred methods of performing anti-reflux
procedure. It should be emphasized that each patient
should be treated individually. As surgeons, we love to
adhere to rules, but we often forget the true intent of
such rules. For example, the intent of dividing the short
gastric vessels was to allow adequate mobilization of the
fundus of the stomach. We now know that the fundus
can be mobilized adequately and the patient can obtain a
good result without division of the short gastric vessels,
as discussed earlier. Certainly, one can mobilize the fundus posteriorly by dividing the posterior gastric attachments. What is important is that minimal tension be
placed on the fundoplication.
Much has been said about the results of preoperative
esophageal motility. Again, by individualizing each
patient, the history of possible dysphagia is much more
important to us than the fact that they can generate a
pressure of 30 mmHg in the body of the esophagus, as it
relates to the decision to perform a complete or partial
fundoplication.
Lastly, our tendency as surgeons often to adhere
rigidly to tradition has made the question of performing
the above procedures in an ambulatory surgical center a
controversial issue. However, the outpatient setting is our
preference in performing anti-reflux procedures (including redos, para-esophageal hernias and Collis gastroplasties). Available data support the fact that this can be
done with similar morbidity and mortality, as compared
with the inpatient setting. We feel strongly that a dedicated team approach is the single most important factor
to the success of any advanced laparoscopic procedure.
The team must be composed of individuals who are both
expertly trained and self-motivated in their respective
roles. Additionally, good-quality and well-maintained

equipment makes for a better experience for the physician. The patient ultimately reaps the benefit from the
smaller, more patient- and physician-friendly setting.
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1
8
9
10
11
12
Orlando RC. The pathogenesis of gastroesophageal reflux

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gastroesophageal reflux disease: role of the lower esophageal
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duodenogastric reflux. Ann Surg 1992; 216: 3543.
Bowry, DJ, Peters JH. Current state, techniques, and results of
laparoscopic antireflux surgery. Semin Laparosc Surg 1996; 6:
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Spechler SJ. Veterans Affairs Gastroesophageal Reflux Disease
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27
HUGO BONATTI, BEATE NEUHAUSER AND RONALD A. HINDER
Treatment of para-esophageal hernias

Surgical procedure
201
202
203
Hiatal hernias are common disorders in the western population.1 The overall incidence of hiatal hernias has been
reported to lie between ten and over 20 per cent.2 Hiatal
hernias are categorized into four groups, as determined
by Hill and Tobias in 1968.3 Type I hiatal hernias, also
known as sliding hiatal hernias, account for the most
common group ("80 per cent) and are characterized by
a sliding herniation of the gastroesophageal junction
through the hiatus into the chest. Para-esophageal hernias (PEHs) account for the remaining three groups:
type II represent a herniation of the fundus of the
stomach through the hiatus with a fixed gastroesophageal junction in the normal position; type III are the
most common PEHs, and represent a combination of
type I and type II with a displaced gastroesophageal junction as well as herniation of parts of the stomach into the
chest; type IV are composed of a large PEH combined
with a large hiatal defect containing not only the stomach
but also other intra-abdominal organs, such as colon or
spleen. PEHs are observed more commonly in the elderly
population. In our series of 117 patients undergoing
laparoscopic PEH repair, the median age was 68 years
(range 3995); 12 patients were over the age of 80 years.
Sixty per cent of patients were female.
TREATMENT OF PARA-ESOPHAGEAL
HERNIAS
The only curative treatment available for PEH is surgery.
The principles are complete reduction of the hernia from
the chest, repair of the hiatal defect, and fundoplication.
Conclusion
References
207
208
208
Indications for surgical repair

PEH may occur with or without symptoms. PEH can
remain asymptomatic for long periods, but these patients
require close observation.4 On closer examination, the
patient may eventually report distinct symptoms, such as
coughing, chest pain or epigastric pain, which the patient
may relate to other causes.5 The more common complaints associated with symptomatic PEH are dysphagia,
gastroesophageal reflux (GER), epigastric pain, chest pain,
regurgitation and vomiting, shortness of breath, and
coughing; there is also chronic anemia in up to 38 per cent
of patients with PEH.6,7 Symptomatic PEH is always an
indication for elective surgical repair in order to avoid the
potentially serious complications, such as acute strangulation, volvulus, massive hemorrhage, and perforation.8,9
Contraindications to surgical repair

Patients with PEH are usually of an older age than
patients with type I hiatal hernias. A meticulous cardiopulmonary investigation is necessary in most cases. One
must bear in mind that symptoms consistent with PEH
in this population could also originate from cardiac or
pulmonary disease.10 If these latter etiologies are
excluded and the patient is fit for laparoscopy, then we do
not see any major contraindications for the procedure,
regardless of age. It has been shown that laparoscopic
anti-reflux procedures can be performed safely in elderly
patients.11 We recently published a series of 30 octo- and
nonagenarian patients undergoing laparoscopic fundoplication, with zero mortality.12 Although considered by
some to be a contraindication to the procedure, we do

not hesitate to use a laparoscopic approach for recurrent
PEH or in patients with a history of previous abdominal
surgery.13
Laparoscopic versus open approach

A variety of studies have shown that the laparoscopic
approach is as effective as the open approach in terms of
recurrence rate and perioperative complications, if an
experienced laparoscopic surgeon carries out the procedure.1416 However, hospitalization was shorter after
laparoscopy and patients experienced less pain.17 Recent
studies based on symptomatic outcomes analyses have
shown that the laparoscopic repair of large PEHs is safe,
successful, and equivalent to open repair.18 A disturbingly
high (42 per cent) prevalence of recurrent herniation following laparoscopic repair of type III hiatal hernias has
been reported recently in a single study.19 However, more
than half of such recurrences had few, if any, symptoms,
and recurrence rates in other series were considerably
lower.20 In our own series, we observed a recurrence rate
of 15 per cent; there was no mortality.2 Other authors
have also concluded that the laparoscopic approach is
superior to a transthoracic approach due to less pain
and shorter hospitalization.2,17 Gastrostomy or gastropexy,
although suggested for high-risk patients, cannot provide
results comparable to surgical PEH repair.21
(a)
Anatomy/pathology
Whereas GER symptoms are present in most patients
with type I hiatal hernias, the presence of reflux in type II
PEH is variable and dependent on the esophageal length
and function. Type III hernias are usually accompanied
by GER. The presence of dysphagia can be explained by
the fact that the PEH tends to rotate along the long axis
of the stomach, resulting in gastric volvulus, which can
cause obstruction at the esophagogastric or gastroduodenal junction. In patients with a large type IV PEH, the
likelihood of pulmonary symptoms is greatest. Coughing,
shortness of breath, asthma-like symptoms, and lowerrespiratory-tract infections result not only from recurrent
aspiration but also from compression of the lung by the
intrathoracic mass.
A substantial number of PEHs are diagnosed incidentally
on thoracic radiography (Figure 27.1a). Usually, a gas
bubble within the mediastinum in most cases on
the left side can be observed. Preoperative evaluation
includes a barium esophagogram (Figure 27.1b), upperintestinal endoscopy, esophageal manometry, and sometimes 24-hour ambulatory pH monitoring. The lower
(b)
Figure 27.1 (a) Thoracic radiograph showing gas bubble within the chest as a result of a giant PEH. (b) Barium esophagogram
showing large PEH (type III). The fundus of the stomach and the gastroesophageal junction are positioned above the diaphragm.
Para-esophageal hernias 203
Figure 27.2 On CT scan, the PEH is seen in the posterior

mediastinum anterior to the spine and to the right of the aorta.
esophageal sphincter (LES) is considered incompetent if

any of the following criteria are met:
Figure 27.3 Trocar placement for laparoscopic PEH repair.
resting pressure less than 6 mmHg;

overall sphincter length less than 2 cm;
intra-abdominal sphincter length less than 1 cm.
A computerized tomography (CT) scan can be of

value in some cases in order to obtain optimal imaging of
the hernia (Figure 27.2).
SURGICAL PROCEDURE
Operating room set-up
The patient is placed supine in the lithotomy position in
the steep reversed Trendelenburg position. Full muscle
relaxation is of major importance in order to create a
good intra-abdominal working space. The laparoscopic
procedure is performed using 511-mm ports in similar
positions to those used for Nissen fundoplication (Figure
27.3). Instrumentation includes a zero-degree laparoscope, atraumatic graspers, a liver retractor, a small hook
attached to the electrocautery, the harmonic scalpel, and
two needle-holders. A nasogastric tube is inserted only if
there is excessive gas within the stomach.
Operative technique
A transverse 1-cm incision is made above the umbilicus in
the midline, the Veress needle is introduced, and a pneumoperitoneum is created. After placement of the other
ports, the abdomen is inspected. The first step of PEH
Figure 27.4 After the ports are placed, the stomach is retracted
to the left, exposing the large hiatal defect.
repair is to completely reduce the hernia contents (Figure

27.4). Dissection is commenced by dividing the gastrohepatic ligament at its flaccid part. The right crus is visualized, and the hernia sac is divided along the free edge of the
hiatus. This is extended on to the left crus, ensuring that
the sac is freed far posteriorly on the left (Figure 27.5).
Thereafter, the peritoneum is completely mobilized within
the mediastinum and the sac is pulled caudally (Figures
27.6 and 27.7). This can usually be achieved easily without
the need to divide any adhesions within the mediastinum.
Once the sac is reduced from the chest, it remains adherent
to the anterior surface of the stomach. Dissection in this
Figure 27.5 The peritoneum along the edge of the right crus is
divided.
Figure 27.6 The incision of the peritoneum along the crural

edge allows access to adipose tissue in the posterior
mediastinum, and the sac can be dissected easily out of the
mediastinum.
Figure 27.7 The peritoneal incision is continued far posterior

on the left crus. This allows access to the connective tissue
behind the lower esophagus.
Figure 27.8 This dissection is continued from the right side

behind the esophagus but inferior to the left crus of the
diaphragm.
Figure 27.9 A window is created behind the esophagus, firstly

inferior to the left crus and then superior to the left crus. This
allows the esophagus to be separated completely from all of its
crural attachments.
region should be carried out cautiously in order to avoid

injury to the gastric or esophageal wall, blood vessels, or
the left vagus nerve. The peritoneal sac may, however, be
trimmed if it is very bulky.
The esophagus can now be observed and elevated on a
closed instrument (Figures 27.8 and 27.9). This allows for
the creation of a window posterior to the esophagus, which
can be freed further from its attachments in the mediastinum to achieve adequate length. Once there is sufficient
esophageal length, the hiatus is reconstructed using two to
ten interrupted nonabsorbable stitches, such as 0-Ethibond
or Prolene (Ethicon, Inc.), depending on the size of the
defect (Figure 27.10). The first stitch should be placed
immediately above the point where the two crura join.
Sufficient tissue should be included in the stitches to avoid
Figure 27.10 The hiatal defect is closed using interrupted

nonabsorbable sutures.
Figure 27.12 Fundic wrap being created using Prolene Ustitch with Teflon pledgets.
Figure 27.11 The hiatal closure is continued posterior to the

esophagus until an adequate defect remains to easily
accommodate the esophagus and its contents.
tearing the muscle. A tension-free reconstruction should be

achieved. Stenosis of the hiatus around the esophagus must
be avoided (Figure 27.11). The hiatal defect can be reinforced with mesh, such as polypropylene, Marlex
(BARD), Gore-TexDualMesh (W.L. Gore & Associates),
or denatured animal tissue (Surgisis ES
, Cook Surgical
Inc.) fixed to the diaphragm using metallic staples or
stitches. The mesh measures about 4 ! 5 cm; it is cut with
a keyhole to enclose the esophagus and is overlapped posteriorly. The mesh is placed on the hiatal musculature. We
prefer to use Surgisis, which is absorbable and soft. It is less
desirable to use a nonabsorbable material adjacent to the
esophagus, which has the potential for erosion into the
lumen or stricture formation. Following repair of the hiatal
defect, the short gastric vessels are divided using the harmonic scalpel (Ethicon Endosurgery, Inc.). The procedure
is completed by a fundoplication, which can be performed
as a 360-degree Nissen or a 270-degree Toupet procedure
Figure 27.13 The completed fundoplication with an additional

silk suture placed inferior to the U-stitch to secure it in position.
(Figures 27.12 and 27.13). The decision as to which procedure to perform is based on preoperative esophageal motility. If a severe motility disorder was diagnosed, then a
Toupet fundoplication is indicated. With the Nissen repair,
the fundoplication should be tacked to the diaphragm
on either side to prevent recurrence of a sliding hernia.
Gastrophrenic anchorage can be added by suturing the
peritoneum of the hernia sac to the diaphragm.
Operative pitfalls
Para-esophageal hernia repair in patients with
previous abdominal surgery
An increasing number of PEHs are seen in patients
who have undergone previous surgery. As in other
laparoscopic procedures, insertion of ports can be difficult, and placement at non-standard sites might be necessary. If a previous midline incision is present, then the
Veress needle can usually be placed safely in the left subcostal area. After division of adhesions between the parietal peritoneum and intra-abdominal organs, placement
of the other trocars can be achieved. Occasionally, patients
must undergo PEH repair following an unsuccessful antireflux operation. Dissection of the left liver lobe from the
stomach and diaphragm can be particularly difficult in
these cases. Nevertheless, in redo operations, conversion
to laparotomy is required rarely.22,23
Left accessory or replaced hepatic artery
These arteries originate from the left gastric artery and
are found in up to 25 per cent of patients. Some accessory
arteries are small and can be divided without consequence; however, large vessels suggest that there is complete replacement of the arterial blood supply to the left
lateral liver segments. If this is suspected, the vessel
should be preserved intact in order to avoid ischemic
damage of the biliary tree.24
Large defects at the hiatus

In some patients, the defect at the hiatus is too large to be
closed primarily. This occurs most frequently in type IV
hernias. In other cases, the fibrous tissue at the hiatus in
this elderly patient population is not compliant and cannot
be approximated adequately. This can result in large dissecting tears in the crura, which must be managed by the
use of mesh (Figures 27.1427.16). These patches should
be cut with a keyhole defect and positioned to lie circumferentially around the esophagus. The keyhole technique
allows for overlapping of the mesh posteriorly. There is
the risk of erosion of the mesh into the esophagus if nonabsorbable materials are used. They must be attached to
the diaphragm using staples or interrupted sutures. Some
authors suggest the universal use of such patches to allow
for tension-free repair.25 Diaphragmatic stitches placed
anterior to the esophagus have been suggested to close
large defects; however, tension is usually even greater in
this area. Others have used a relaxing incision made lateral
Tearing and perforation of stomach and esophagus

This is best avoided by gentle handling of tissues in these
elderly patients. However, surrounding tissues can be
rather fibrotic and sharp dissection might be necessary.
Small serosal tears can be oversewn and should be included
in the fundoplication site whenever possible. Transmural
injuries of the esophagus and stomach can be repaired
laparoscopically using a stapling device. Intraoperative
endoscopy can be helpful to make sure that the defect is
closed completely.
Type IV hernias
These hernias can contain colon or the spleen. Injuries to
the spleen may result in major hemorrhage. Closure of
the defect can be particularly difficult in these patients.
Postoperative use of incentive spirometry is of importance to avoid atelectasis and pneumonia.
Figure 27.14 Giant hiatal defect with a tear in the right crus
after failed primary closure.
Pneumothorax
This occurs more frequently on the left side and can
result in a symptomatic pneumothorax. When this
occurs, the intra-abdominal gas pressure should be
decreased to avoid a tension pneumothorax. Should
the latter occur, conversion to an open procedure may be
necessary. A chest tube can be used to alleviate the tension in the pneumothorax if necessary. Generally, however, most cases do not require a chest tube, as the gas in
the pleural space may be expelled by forceful lung inflation at the time of release of the pneumoperitoneum.
Figure 27.15 Closure of the large defect using a Gore-Tex patch.
to the esophageal hiatus with primary closure of the hiatus

and mesh repair of the relieving incision.
Hernia sac
Some controversy exists as to whether to excise the sac or
mobilize it fully with complete excision.26 We feel that a
remnant of the sac in the mediastinum might cause an
effusion or lead to recurrent herniation. We always mobilize the sac completely from the mediastinum. On dissection, care must be taken not to injure the esophagus,
stomach, vagus nerve, or blood vessels. The sac is left
anterior and to the left of the cardia and can be used as a
plug to help avoid recurrent herniation of the stomach.
Division of short gastric vessels
It is our preference that the short gastric vessels are
divided along the upper 10 cm of the greater curvature of
the stomach to allow for a tension-free wrap. In most
cases, these vessels have been stretched by the gastric
herniation, allowing the fundus to be brought behind
the esophagus easily and without tension.
Possible kinking of the esophagus
Following the posterior approximation of the crura, the
esophagus might be forced anteriorly, causing kinking
and obstruction as it rides up and into the hiatus. This
has been observed occasionally as a kink on a barium
esophagogram, but there are seldom any observed symptoms related to such a kink in the follow-up of our
patients.
Short esophagus
In type III hernias, insufficient intra-abdominal length of
the esophagus has been reported following attempted
Figure 27.16 Closure of a large defect using a polypropylene

mesh.
mobilization.6 In most cases, dissection of the esophagus

far up into the mediastinum allows for adequate mobilization. Dissection can be performed as high as the
bronchial bifurcation. If adequate intra-abdominal
length of the esophagus without tension cannot be
obtained, then an esophageal-lengthening procedure,
such as Collis gastroplasty, followed by a fundoplication
should be performed. This can be achieved laparoscopically, but in our opinion the best approach for this procedure is through the chest. Hashemi and colleagues have
reported the need for thoracotomy in over 33 per cent of
cases.27 A novel approach for esophagus lengthening has
been suggested by Champion and coworkers (personal
communication, 2002): they laparoscopically flap the
fundus of the stomach to the right and then carry out a
stapled fundectomy to a point 3 cm inferior to the angle
of His. This is then stapled off along the left side of the
esophagus, achieving a Collis gastroplasty (see Chapter 26).
Para-esophageal hernia repair in obese patients
In obese patients there may be excessive fat in the operative field, and/or the left lateral liver segments may be
very large. This might hinder retraction of the liver. Such
fatty livers are rigid and the capsule can be injured easily,
resulting in hemorrhage. Local appliance of argon-beam
coagulation or electrocautery may be used, followed by
insertion of a collagen plug to control such hemorrhage.
In general, we do not place a nasogastric tube. For the
majority of patients, this represents an unnecessary inconvenience and is tolerated poorly. Patients are encouraged
to ambulate early and to use incentive spirometry. A gastrografin esophagogram is performed only if the dissection was difficult and in the presence of symptoms such
as excessive pain, vomiting or fever. During the first
24 hours after surgery, pain control is achieved satisfactorily using oral analgesics. We prefer to use paracetamol
(acetaminophen) elixir; however, any synthetic opioid,
tramadol or non-steroidal anti-inflammatory drug can
be used. Metoclopramide or ondansetron are our preferred antiemetic drugs. Retching and vomiting must be
suppressed in order to avoid stress on the repaired hiatus
and the fundoplication. Patients are started on a liquid diet
on the night following surgery and advanced to a pureed
diet, as tolerated. Fresh bread and meat should be avoided
for about three weeks. A normal diet is usually achieved
within six weeks following surgery. We have now completed 120 laparoscopic repairs of large PEH with zero
mortality and a 15 per cent recurrence rate. These recurrences are usually asymptomatic type I hernias. Others
reported higher rates of mortality (three per cent28) and
morbidity (30 per cent29). Dahlberg and colleagues28 and

Trus and colleagues29 also report the need for conversion
to an open procedure in 1.35.4 per cent of cases. We feel,
however, that with adequate experience, these rates of
morbidity and mortality should be reduced.
CONCLUSION
10
Currently, the only effective treatment available for PEH

is surgery. This is successful in most cases if appropriate
principles of operative therapy are followed. Surgical
reduction of the hernia results in the relief of dysphagia
in 91 per cent of patients. The principles of PEH repair
include reducing the stomach, mobilizing the hernia
sac from the mediastinum, effectively closing the hiatus,
and achieving a sufficient gastropexy. Open repair using
laparotomy or thoracotomy was the standard procedure a
decade ago. The development of laparoscopic anti-reflux
surgery has stimulated interest in laparoscopic paraesophageal hiatal hernia repair. Minimally invasive techniques today offer a better treatment option with lower
risk. Laparoscopic repair of PEH is safe, technically feasible, and well tolerated, with rapid relief of symptoms. The
laparoscopic approach allows for excellent visualization
of the hiatus and superior esophageal mobilization, with
significantly less surgical insult to this often aged and
debilitated patient population. PEH repair remains a
challenging surgical procedure. We feel that an anti-reflux
procedure is necessary because the LES is mobilized
extensively during the dissection and is likely to be
incompetent as a result. This does not add significantly to
the time required for this operation, and it provides an
excellent anchoring mechanism for the stomach on to the
diaphragm. We consider laparoscopic PEH repair with
Nissen fundoplication to be the procedure of choice in
appropriately selected patients with PEH.
REFERENCES
1
Ilves R. Hiatus hernia. The condition. Chest Surg Clin N Am 1998;

8: 4019.
2 Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophageal
hernia repair. Arch Surg 1997; 132: 5869, 5901.
3 Hill LD, Tobias JA. Paraesophageal hernia. Arch Surg 1968; 96:
73544.
4 Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic
stomach. Presentation and results of operation. J Thorac
Cardiovasc Surg 1993; 105: 2538, 2589.
5 Akdemir I, Davutoglu V, Aktaran S. Giant hiatal hernia presenting
with stable angina pectoris and syncope a case report. Angiology
2001; 52: 8635.
6 Hashemi M, Sillin LF, Peters JH. Current concepts in the
management of paraesophageal hiatal hernia. J Clin Gastroenterol
1999; 29: 813.
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
Moskovitz M, Fadden R, Min T, et al. Large hiatal hernias, anemia,

and linear gastric erosion: studies of etiology and medical therapy.
Am J Gastroenterol 1992; 87: 6226.
Maruyama T, Fukue M, Imamura F, Nozue M. Incarcerated
paraesophageal hernia associated with perforation of the
fundus of the stomach: report of a case. Surg Today 2001; 31:
4547.
Nattakom T, Schuerer D, Batra S, et al. Emergency
laparoscopic repair of a paraesophageal hernia. Surg Endosc 1999;
13: 756.
Richter JE. Noncardiac (unexplained) chest pain. Curr Treat Options
Gastroenterol 2000; 3: 32934.
Kamolz T, Bammer T, Granderath FA, et al. Quality of life and
surgical outcome after laparoscopic antireflux surgery in the
elderly gastroesophageal reflux disease patient. Scand J
Gastroenterol 2001; 36: 11620.
Bammer T, Hinder RA, Klaus A, et al. Safety and long term
outcome of laparoscopic antireflux surgery in patients in their
eighties and older. Surg Endosc 2002; 16: 4042.
Neuhauser B, Hinder RA. Laparoscopic reoperation after failed
antireflux surgery. Semin Laparosc Surg 2001; 8: 2816.
Freeman ME, Hinder RA. Laparoscopic paraesophageal hernia
repair. Semin Laparosc Surg 2001; 8: 2405.
Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000;
80: 124352.
Buenaventura PO, Schauer PR, Keenan RJ, Luketich JD.
Laparoscopic repair of giant paraesophageal hernia. Semin Thorac
Cardiovasc Surg 2000; 12: 17985.
Oelschlager BK, Pellegrini CA. Paraesophageal hernias: open,
laparoscopic, or thoracic repair? Chest Surg Clin North Am 2001;
11: 589603.
Basso N, Rosato P, De Leo A, et al. Tension-free hiatoplasty,
gastrophrenic anchorage, and 360 degrees fundoplication in the
laparoscopic treatment of paraesophageal hernia. Surg Laparosc
Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of
large type III hiatal hernia: objective followup reveals high
recurrence rate. J Am Coll Surg 2000; 190: 55360, 5601.
Edye MB, Canin-Endres J, Gattorno F, Salky BA. Durability of
laparoscopic repair of paraesophageal hernia. Ann Surg 1998;
228: 52835.
Kercher KW, Matthews BD, Ponsky JL, et al. Minimally invasive
management of paraesophageal herniation in the high-risk
surgical patient. Am J Surg 2001; 182: 51014.
Seelig MH, Hinder RA, Klingler PJ, et al. Paraesophageal herniation
as a complication following laparoscopic antireflux surgery.
J Gastrointest Surg 1999; 3: 959.
Floch NR, Hinder RA, Klingler PJ, et al. Is laparoscopic reoperation
for failed antireflux surgery feasible? Arch Surg 1999;
134: 7337.
Edoga JK, Willekes CL. Laparoscopic fundoplication and the
aberrant left hepatic artery. Arch Surg 1997; 132: 4489.
Hui TT, David T, Spyrou M, Phillips EH. Mesh crural repair of large
paraesophageal hiatal hernias. Am Surg 2001; 67: 11704.
Athanasakis H, Tzortzinis A, Tsiaoussis J, et al. Laparoscopic repair
of paraesophageal hernia. Endoscopy 2001; 33: 5904.
large type III hiatal hernia: objective follow-up reveals high
recurrence rate. J Am Coll Surg 2000; 190: 55360.
Dahlberg PS, Deschamps C, Miller DL, et al. Laparoscopic repair of
large paraesophageal hiatal hernia. Ann Thorac Surg 2001; 72:
11259.
Trus TL, Bax T, Richardson WS, et al. Complications of
laparoscopic paraesophageal hernia repair. J Gastrointest Surg
1997; 1: 2218.
28
SERGIO G. SUSMALLIAN AND ILAN CHARUZI
Diaphragmatic injuries
Acute diaphragmatic herniation
Surgical treatment of acute diaphragmatic injuries
Chronic diaphragmatic hernia
209
210
211
212
The diaphragm is a thin muscle with a full-time job. It

is innervated by the ipsilateral phrenic nerve and has
an abundant blood supply.1 The anatomical role of the
diaphragm consists of dividing the two large cavities of
the human body and maintaining its different pressures.2
Its presence separates and contains the viscera of the
abdominal and thoracic cavities. The symptoms related
to diaphragmatic injuries are caused by the incapacity to
contain the abdominal viscera in the cavity favored by
the pressure gradient.1
During inspiration, the diaphragm contracts physiologically, acquiring a flat shape. During expiration, it
relaxes passively and acquires a dome shape. This concept is important for understanding and diagnosing
diaphragmatic injury in the various chest and abdominal
levels of penetrating trauma.
Diaphragmatic injury is not common, but its incidence has increased over the past few years, probably
because of the increased frequency of high-speed motorvehicle accidents.35 Additionally, early recognition has
become more feasible with the diagnostic procedures that
are now available. It is also conceivable that early recognition of signs and symptoms of a possible diaphragmatic
injury can result in the correct treatment being given, so
avoiding chronic injuries. The diagnosis of diaphragmatic
injury is influenced strongly by the severity of the associated lesions.68
Sennertus in 1541 was the first to report a diaphragmatic injury, in a postmortem examination.9 He described
a strangulated stomach herniated through a left diaphragmatic defect seven months after a stab wound. In 1579, Par
described the consequences of diaphragmatic herniation in
blunt and penetrating injuries.10 He found a strangulated
Surgical treatment of chronic diaphragmatic injuries

Conclusion
References
213
214
215
colon through a small defect in the diaphragm. In 1853,

Bowditch became the first physician to diagnose a posttraumatic diaphragmatic hernia in vivo.11 In 1886, Riolfi
performed the first repair of a diaphragmatic herniation
after a stab wound,12 while Walker in 1900 was the first surgeon to repair a diaphragmatic hernia after blunt trauma.13
The aim of this chapter is to provide a clear concept of
the various diaphragmatic lesions and the approaches for
successful diagnosis and treatment.
DIAPHRAGMATIC INJURIES
Injuries of the diaphragm can be classified into two
groups: acute and chronic. Acute injuries (from blunt or
penetrating trauma) detected in the first 24 hours are
called early diagnosed; after the first 24 hours, they are
called delayed diagnosed. If the diaphragmatic lesion
was missed in the acute phase, then the second latent
phase occurs. In this variable time (months to years), the
injury may be asymptomatic. The chronic phase begins
with the appearance of symptoms related to the herniation of the abdominal viscera into the thoracic cavity.
This, in turn, will affect respiratory patterns or cardiovascular performance or cause digestive symptoms,
such as gastric distention, gastric or colonic obstruction,
volvulus, and perforation.1417 Each of the three phases
of diaphragmatic injury has a relevant importance in the
operative strategy decision.
The early-diagnosed acute phase accounts for about
90 per cent of diaphragmatic injuries. These patients will
typically have associated injuries and are treated by the
open approach.18 Delayed-diagnosed acute injuries differ

from early-diagnosed injuries in that patients with the
former are generally more stable and have fewer severely
associated injuries. In this subgroup of acute patients,
laparoscopic approach and repair can be achieved.1921
Laparoscopic treatment for chronic diaphragmatic herniation is quickly becoming widely accepted and performed.
ACUTE DIAPHRAGMATIC HERNIATION

The etiology of diaphragmatic injuries can be classified
as penetrating or blunt trauma. Diaphragmatic injury
in trauma patients is not uncommon: its incidence
is 0.8 per cent of all trauma patients admitted, 5 per cent
of all blunt abdominal traumatic admissions, and 9.5
per cent of all thoracoabdominal penetrating trauma
admissions.8,22,23
Penetrating diaphragmatic hernia during thoracoabdominal trauma, such as in shotgun wounds, has a
different incidence of severity. This massive destructive
effect requires laparotomy or thoracotomy and laparotomy
to repair visceral or vascular damage. Stab wounds and
iatrogenic diaphragmatic injuries are usually less severe,
and if vascular penetration is ruled out laparoscopic repair
is feasible. Blunt trauma is more common in motor-vehicle
accidents, especially during high-speed impact.7,24
The physiological pressure of the abdominal cavity
varies from 4 to 20 cm of water, and it can climb to
100 cm of water during a forced inspiration. Elevation of
the abdominal pressure up to 400 cm of water occurring
during motor-vehicle accidents can explain the rupture
of the diaphragm and the herniation of the viscera into
the thorax, which has a negative pressure ('2 to '10 cm
of water). Blunt diaphragmatic injury is seen more frequently after motor-vehicle accidents than after pedestrian or motorcycle accidents or falls from great heights.
During blunt trauma, the rupture of the diaphragm can
occur in the right, left or both sides, the central tendinous
area (opening into the pericardium), or into the posterior
area, thereby compromising the hiatus. Diaphragmatic
injury is an indicator of an impact with high-energy
transmission.
Each of the affected areas demonstrates differing characteristic features. In 80 per cent of cases the trauma results in
herniation through the left side of the diaphragm, 15 per
cent affect the right side, and in five per cent both sides are
affected.18 Rupture of the diaphragm is effected, generally,
by an impact that occurs on the ipsilateral side of the
injury.25 An associated injury has been reported in 90 per
cent of patients with diaphragmatic tear. Mortality varies
between three and 30 per cent, and depends upon the severity of the trauma and associated injuries. The differences
between right and left side on admission were well defined
in the literature.2628
Abdominal contents were found to invade the thorax

in 58 per cent of patients with a left-sided diaphragmatic
tear and in 19 per cent with a right-sided defect. These
findings can be explained by the presence of the liver in
the upper right abdominal cavity, thereby protecting the
passage of the viscera. Because of this anatomical difference, patients with a right-sided tear are generally injured
more severely than those with a tear on the left side.18
Boulanger and colleagues showed that the mean Glasgow
Coma Scale was 8 for patients with right diaphragmatic
tear compared with 11 for those with left diaphragmatic
tear.18 Patients with a right diaphragmatic injury had
more significant amounts of blood loss than patients with
injuries elsewhere in the diaphragm.
The injuries associated with blunt diaphragmatic
trauma are shown in Table 28.1.2931 The figures shown in
this table indicate that hemothorax occurs in 78.5 per cent
of patients with blunt trauma. Table 28.2 outlines the overall rate of abdominal injuries associated with blunt trauma.
The overall mortality rate in the blunt diaphragmatic
injuries group of patients is 1620 per cent, depending on
the associated injuries. Bilateral rupture of the diaphragm
is associated with the highest rate of mortality, followed
by traumatic rupture of the right hemidiaphragm.
Intrapericardial diaphragmatic rupture is a rare condition
that can mimic cardiac tamponade during the acute diagnosed phase of herniation; most commonly, it is the stomach that protrudes into the pericardium.3234
Posterior rupture of the diaphragm is an infrequent
lesion that can compromise the crura and the hiatus.35
Recently, we had the opportunity to treat a patient with a
known hiatal hernia after a motor-vehicle accident. He
presented with a posterior transverse rupture of the
Table 28.1 Injuries associated with blunt trauma
Injury
Percentage
Hemothorax
Rib fracture
Pelvic fracture
Extremity fracture
Pneumothorax
Spinal fracture
Thoracic aortic tear
78.5
51
46
40
28
16.5
7
Table 28.2 Overall rate of abdominal injuries in blunt trauma

Abdominal injury
Percentage
Liver
Spleen
Hollow viscus
Kidney
Bladder
Pancreas
63.5
51
25.5
11
9
6.5
Traumatic and unusual herniation 211
diaphragm, which included a total avulsion of the right

crura. A primary repair by open approach was performed, and the crura was sutured with non-absorbable
sutures. In these cases, esophageal perforation must be
ruled out either before (with preoperative testing) or
during operation by irrigation with saline solution or
methylene blue solution through a nasogastric tube.
Manifestations of diaphragmatic injury during the
acute phase depend upon the severity of pulmonary
compromise and the associated clinical manifestations.
The symptoms of thoracic pain referred to the scapula,
dyspnea, and decreased breath sounds are present in
more than 70 per cent of these patients. Specific symptoms of diaphragmatic rupture may be absent in 2537
per cent of the patients.36 Abdominal tenderness, distension and rebound can also be present. Almost half of
the victims are admitted to the emergency room with
symptoms of shock.
Following historical and physical examination, the
initial assessment of a trauma patient with suspected
diaphragmatic injury should be a chest radiograph.
However, the ability of the chest X-ray to demonstrate
a diaphragmatic injury varies from 37 to 50 per cent.37
Direct signs of diaphragmatic rupture on chest X-ray are
visceral herniation, indistinct diaphragmatic lines, elevation of the diaphragm, and position of a nasogastric tube
within the thorax (Figure 28.1). Indirect signs of diaphragmatic injury on chest X-ray are rib fractures, sternal
fracture, pneumothorax, hemothorax, lung contusion,
atelectasis, gastric dilation, and subcutaneous air.
Ultrasonography can demonstrate diaphragmatic
rupture by the presence of fluids above and below the
diaphragm and discontinuity of the diaphragmatic edge.

On the right side, ultrasonography can be sensitive to
detection of diaphragmatic rupture with liver herniation.
Spiral computerized tomography (CT) and magnetic resonance imaging (MRI) are the most accurate diagnostic
methods for finding diaphragmatic ruptures.38,39 Diagnostic peritoneal lavage (DPL) is a controversial tool for
diagnosing diaphragmatic injury.1 DPL in the presence of
isolated diaphragmatic injury may be falsely negative, and
the positive results depend upon the status of the abdominal viscera.
Laparoscopy and thoracoscopy are the best invasive
techniques for diagnosing diaphragmatic lesions and
eventual treatment of the rupture.4042 However, the diagnosis and treatment of this problem can also be accomplished with the use of a thoracotomy and/or laparotomy
when necessary.
SURGICAL TREATMENT OF ACUTE

When diaphragmatic injuries are diagnosed, repair is
mandatory. If, during the acute phase, early diagnosis is
confirmed, then the approach to the repair must be dictated by any associated injuries. Generally in this case,
laparotomy will be the preferred method to treat additional visceral injuries. The repair of the diaphragm will
usually be accomplished with simple suturing of the
defect with nonabsorbable sutures in one or two layers.43
If the diaphragmatic injury is isolated or the associated
damages allow a laparoscopic approach, then the repair
can be performed easily with the advantage of good visualization, even in the posterior areas.
Operative technique
Figure 28.1 Chest X-ray, showing nasogastric tube in the left

thorax after trauma.
The patient is placed in lithotomy and Fowlers position.

Some surgeons prefer to stand on the right side of the
patient, with the patient supine. In the former approach,
the surgeon stands between the legs of the patient. The
first assistant is positioned on the left side of the patient
and the second assistant is on the right of the patient.
A pneumoperitoneum using carbon dioxide is obtained
by introducing a Veress needle in the left subcostal midclavicular line at low pressure, such as 12 mmHg. The
use of high-pressure insufflation (15 mmHg or higher)
must be avoided in trauma patients. High abdominal
pressure can reduce the venous return by 30 per cent, and
the patient could became hemodynamically unstable.
One 10-mm trocar is introduced supraumbilically
where a 30-degree laparoscope is placed. It is important to
remember that in obese patients, this first trocar must be
introduced in a slightly higher position between the
10 mm trocar
5 mm trocar
Figure 28.2 Schematic position of trocars for laparoscopic

treatment of diaphragmatic herniation.
umbilicus and the xiphoid process. Another 11- or 12-mm

trocar is introduced in the left upper quadrant, higher than
the first one, in the midclavicular line, with direct visualization with the laparoscope. A third trocar (5 mm) is
placed in the left upper quadrant subcostally. The placement of two more trocars is optional, one for liver retraction in the subxiphoid area and one in the left flank for
retraction (Figure 28.2). The herniated abdominal viscera
are returned gently into the abdominal cavity using atraumatic graspers. Any devitalized tissue that is found along
the edge of the laceration should be debrided. The defect
is then sutured with endo-stitches. These can be made
free-hand or placed with a device designed to suture
laparoscopically.
If the defect is greater than 4 cm in diameter, then a
reinforcement of the suture line can be done with an onlay
of absorbable mesh, such as braided Dexon(U.S. Surgical
Corp.) or Vicrylknitted mesh (Ethicon, Inc.), fixing it
to the diaphragm with endo-staplers. We believe that the
placement of such prostheses can help to relieve any excessive tension on the suture line if the patient develops high
abdominal pressure or abdominal compartment syndrome
in the immediate postoperative period.
Treatment of diaphragmatic rupture when diagnosis
is delayed (more than 24 hours) differs from treatment
during the early diagnosis phase because of the greater
possibility of failure of primary repair due to tension
on the suture line. In this condition, the fibers of the
diaphragm are contracted. Primary suture of the defect
will be performed under tension, thereby increasing the
possibility of recurrence.
We prefer to treat these defects with nonabsorbable
material, such as an expanded polytetrafluoroethylene
(ePTFE) prosthetic biomaterial. Polypropylene mesh can

also be used to close these defects, but severe adhesions to
the adjacent viscera can develop, especially to the splenic
flexure of the colon. Additionally, polypropylene mesh
should be used carefully when it is fixed in the proximity
of the esophagus due to the possibility of erosion. If contaminated fluids are found in the abdominal cavity, then
the use of nonabsorbable material is not advised. In these
cases, an absorbable material such as Dexon or Vicryl
mesh is preferred.
Another unusual type of diaphragmatic injury is that
of posterior rupture, which can compromise the hiatus.
We recommend that this injury is repaired with a procedure that restores the normal anatomy, such as restoration
of the crura by nonabsorbable sutures. The area of repair
is then reinforced by placing an ePTFE mesh around the
esophagus in either a U- or O-shape, depending on the
size of the defect. The ePTFE patch is then attached to the
diaphragm with titanium spiral tacks posterior to the
esophagus and to the crura (using special care not to
injure the aorta). Lateral and anterior to the esophagus,
the fixation of biomaterial should be performed with
sutures or an endo-stapler. Regardless of the method of
choice, one must be careful in the tendinous area to avoid
penetration of the myocardium. In our experience, we
have demonstrated by echocardiogram one case of pericardial effusion after laparoscopic repair of a diaphragmatic hernia induced by a stapler in the pericardial area.
Intrapericardial rupture of the diaphragm is rare,
with fewer than 60 cases having been reported in the
literature.3234 Generally, these were long, transverse
wounds that occurred during blunt abdominal trauma.
CT and echocardiography were used for diagnosis.44
Primary suture is recommended in these cases. The
myocardium must be protected from injury, which could
occur at the time of repair.
CHRONIC DIAPHRAGMATIC HERNIA

Diaphragmatic injury represents one of the most commonly missed pathologies in trauma patients.1 Undetected
acute diaphragmatic injuries begin as small lacerations
without associated serious damage. During the posttraumatic phase, the positive abdominal pressure causes
the viscera to herniate into the pleural space, resulting in an
increase in the size of the diaphragmatic defect.6,45,46
Because of a delay in diagnosis, only ten per cent
of diaphragmatic hernias are diagnosed in the acute
phase. Consequently, 90 per cent of these injuries become
chronic.47 The time interval to diagnosis varies from
months to years and depends upon the appearance of
symptoms after the latent phase. The size of the original
disruption, localization (left, right, central or posterior),
and content can influence the development of pulmonary
Figure 28.3 Left chronic diaphragmatic hernia after stab

wound three years previously.
Figure 28.4 Right chronic hernia: the entire liver, stomach and
hepatic flexure of the colon were reduced from the right thorax.
or abdominal symptoms. An acute presentation with signs

and symptoms of incarceration or obstruction can be the
initiating event for the patient (Figure 28.3).17,48
Perforation or necrosis are serious complications that
make the emergency repair of these diaphragmatic
hernias a life-saving procedure. In such cases, two-stage
repairs should be considered. Work-up should include a
simple chest X-ray, which can make a diagnosis in 73 per
cent of cases with chronic herniation on the left side.
Spiral CT is most useful for diagnosis of right-sided herniation in which an indirect sign of herniation can be
identified by an abnormal position of the liver. CT can
also help to identify the content of the herniation. MRI is
the preferred and the most sensitive diagnostic method
for identifying missed diaphragmatic injuries.49
SURGICAL TREATMENT OF CHRONIC

The diaphragm is a muscle, and its insertions are around
the inferior chest wall. Physiologically, the injured muscle
experiences eccentric retraction, with a tendency to
increase the diameter of the edges. The muscle can also
undergo atrophy. Therefore, primary repair in chronic
defects has a high index of failure, with subsequent
recurrence of the hernia. Additionally, the diaphragmatic
hernia does not have a sac, unlike the classical concept of
the more commonly seen hernias (Figures 28.4 and 28.5).
The choice between the two methods of repair, thoracoscopic or laparoscopic, is the object of debate.5053 We
strongly recommend an abdominal approach, which provides for better management of the adhesions and abdominal viscera. The technique includes placing the patient in
the lithotomy position and carrying out abdominal insufflation through a Veress needle with carbon dioxide at a
Figure 28.5 Diaphragmatic hernia repair with ePTFE mesh by

laparoscopy.
pressure of 15 mmHg. Some surgeons prefer a lateral position of the surgeon and the use of one of the optical viewing trocars.
A supraumbilical trocar is inserted for the introduction of a 30-degree scope (5- or 10-mm). One 11-mm
trocar is then inserted in the left upper quadrant at the
lateral border of the rectus abdominis muscle under
vision to avoid injury to the epigastric vessels. Two more
5-mm trocars are used, one on the right abdominal side
subcostally, and one in the left flank for the assistant. One
more 5-mm trocar can be inserted in the epigastrium for
liver retraction if this is necessary.
Meticulous adhesiolysis is the first step in the repair,
avoiding injury to any viscus. Careful reduction of the
hernia contents from the pleural space to the abdominal
cavity is performed during this dissection. A complication, such as a perforation, during these procedures can
can be performed using ePTFE mesh fixed by nonabsorbable sutures alone to avoid injury to the myocardium.
The complicated diaphragmatic hernia is an emergency and is associated with high mortality and morbidity
rates. The herniorrhaphy can be a life-saving procedure.
Complicated cases, such as those associated with bowel
injury or severe bleeding in an unstable patient, can be
treated in relation with the affected viscous, such as primary suture or exteriorization of the injured bowel, and
the definitive repair delayed. Contamination is a contraindication for definitive repair. Treatment during an acute
presentation consists of the management of the compromised viscera (reduction, resection, colostomy, etc.). The
defect in the diaphragm is closed by primary suture if possible or (in our experience) with absorbable mesh if there
is a devitalized area of the diaphragm. In the latter case,
definitive treatment is delayed for three months and then
performed laparoscopically.
Figure 28.6 Chronic diaphragmatic hernia, showing part of the
stomach in the left chest. The presentation of this patient was
incarceration of the stomach.
contaminate the operative field. The retracted edges of

the laceration must be identified and cleared from the
adhesions. The definitive repair is then performed with
nonabsorbable mesh materials.
We use either ePTFE mesh as the sole prosthesis or
polypropylene mesh placed on to the diaphragm, which
is then covered by an ePTFE mesh to avoid contact
between the polypropylene and the viscera (Figure 28.6).
We recommend an overlap of the mesh size of at least
3 cm. The mesh is folded into a cylindrical shape and
introduced into the abdominal cavity through the lumen
of the 11-mm trocar.
After unfolding the mesh in the abdominal cavity, fixation commences in the posterior muscular diaphragm
with titanium spiral tacks. In the lateral, central and
anterior portions, we use several interrupted nonabsorbable sutures and EMS staples. For a posterior laceration mimicking a para-esophageal hernia, the repair
consists of a total reduction of the stomach and dissection of the crura. In these cases, a sac may be present if
the patient had a hiatal hernia before the injury; removal
of the sac, if present, is recommended. The hiatus is
repaired by closure of the crura posterior to the esophagus with endoscopic sutures.
After completion of the sutured repair, we reinforce
the site with mesh. In the proximity of the esophagus, the
use of ePTFE mesh is recommended. Because a repair in
this area of the diaphragm must include the esophagus,
the ePTFE mesh must be cut into either an O- or a
U-shape. If an intrapericardial hernia is present in the
tendinous area of the diaphragm, then a meticulous repair
CONCLUSION
Traumatic diaphragmatic hernia is an indicator of the
severity of injury in blunt trauma patients, who have high
rates of mortality and morbidity. Penetrating trauma of
the diaphragm is generally a smaller injury of the
diaphragm but is usually associated with injury of vital
organs of the chest and abdomen. During blunt trauma of
the diaphragm, the injury is a long tear caused by the high
pressure of the forces originated. Preoperative diagnosis
of diaphragmatic injuries in trauma patients is low
(39 per cent) and missed injuries are seen in ten per cent.
Acute repair can be performed by laparoscopy in stable
patients without severe associated injuries. The technique
includes primary repair with separate stitches using a
nonabsorbable material.
Delayed diagnosis (more than 24 hours) and chronic
diaphragmatic hernias require prosthetic repair with nonabsorbable mesh, fixed to the diaphragm with titanium
spiral tacks, sutures and/or EMS staples. If incarceration is
present without contamination and the reduction can be
performed without complication, then the repair will be
similar to that seen in chronic diaphragmatic hernia.
During strangulation, life-saving procedures must be
performed, such as resection, colostomy, or feeding tubes.
In this situation, absorbable materials are recommended
as a means to effect a temporary repair until definitive
repair is possible.
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29
Etiology of recurrent gastroesophageal
reflux disease
ZIAD T. AWAD AND CHARLES J. FILIPI
Clinical presentation
Mechanisms of failure
Wrong operation
217
219
221
Gastroesophageal reflux disease (GERD) is a common

disease that accounts for approximately 75 per cent of the
pathology of the esophagus. Forty per cent of the adults in
the USA have occasional heartburn, and ten per cent experience heartburn daily.1,2 It is estimated that 20 per cent of
patients with GERD develop serious complications, such
as ulceration, stricture, and Barretts metaplasia. Although
medical therapy may be effective, it is often required for a
protracted period of time. In addition, prolonged therapy
often requires escalated dosages, and discontinuation of
medications may result in an early recurrence of symptoms. Surgery has improved because of a better understanding of the underlying pathophysiology of GERD and
technical refinements of operative techniques.3,4 A controlled, randomized trial showed superiority of surgical
therapy for the treatment of severe GERD, with less frequent side effects than with non-surgical management.5
Other investigators have provided evidence to favor antireflux surgery over medical treatment.6,7
The advent of minimally invasive surgery has revolutionized the surgical treatment of GERD, leading to a significant increase in the number of cases performed. Studies
have shown that the functional results of laparoscopic
anti-reflux procedures are equal to those of open surgery,
but with significantly less postoperative morbidity and
a shorter hospital stay.810 The surgical management of
GERD sometimes fails, whether performed open or
laparoscopically, and may require reoperation for optimal
results. Failure of open fundoplication occurs in 930 per
cent of patients,3,11,12 whereas published failure rates of
laparoscopic Nissen fundoplication are 217 per cent.6,1316
The lower published rates for laparoscopic surgery probably
Wrong diagnosis
Discussion
References
221
222
224
reflect the fact that laparoscopic fundoplication is a relatively new technique rather than it being intrinsically better. However, the early adopters of the laparoscopic
approach were usually more skillful individuals who were
likely to be quite compulsive in the indications and techniques of these operations. Therefore, it is hoped that with
longer follow-up this procedure will reveal its superiority.
Reoperations for failed or recurrent GERD are technically more demanding due to adhesions from previous surgery and obscured anatomy. The relatively fragile walls of
the esophagus, gastric cardia, and fundus are easily damaged or breached, leading to postoperative leak with potentially lethal complications. In addition, the recognized and
repaired injury may impair the precise reconstruction
required to obtain a good functional result. Reoperative
anti-reflux surgery has a morbidity and mortality of 440
per cent and 04.9 per cent, respectively.17 The overall clinical results after reoperation even those obtained by experienced surgeons are significantly less favorable than
outcomes for first-time repairs. The incidence of unsatisfactory results is at least doubled after reoperation.
Furthermore, the greater the number of previous failed
repairs, the greater the incidence of poor results.
CLINICAL PRESENTATION
Dysphagia
Approximately 3040 per cent of patients suffer from
some form of dysphagia in the early postoperative
period. This, however, decreases to approximately five
per cent at long-term follow-up. It is believed that early

short-term dysphagia is due to distal esophageal edema
and transient esophageal dysmotility. We generally recommend that the patient stays on a liquid diet for two
days after surgery and then maintains a soft diet for three
weeks following surgery. If the patient has difficulty
in swallowing liquids and/or there is significant weight
loss, then intervention may be necessary. This includes
esophageal dilation and, in extreme cases, placement of a
gastrointestinal feeding tube. Postoperative gastrografin
or barium esophagogram helps to define acute postoperative events, such as para-esophageal herniation of the
stomach producing obstruction at the lower esophagus.
This finding warrants emergency surgical intervention.
Patients with dysphagia that persists past three months
represent a complex problem that warrants careful analysis
and interpretation. Common causes include slipped
fundoplication, para-esophageal hernia formation, tight or
fibrotic fundoplication, hiatal stenosis, twisted fundoplication, missed tumors at the gastroesophageal junction, lowamplitude esophageal waves, incomplete propagation of
contractile waves, and undiagnosed achalasia. A barium
esophagram with a 12.5-mm barium pill will differentiate
anatomical abnormalities at the gastroesophageal junction
(slipped or para-esophageal hernia) from other causes
of dysphagia, such as esophageal dysmotility. The latter
diagnosis is confirmed by an esophageal motility study.
Patients who are still confined to liquids at three months
postoperatively, and patients who are losing weight because
of dysphagia, should be offered reoperation. If the solid
dysphagia is mild or moderate with few dietary restrictions,
and there is little or no weight loss, then conservative
management is a viable option.
Recurrent reflux
This occurs in up to eight to ten per cent of patients followed for ten years after the open procedure.3 Common
causes of recurrent reflux are slipped fundoplication,
intrathoracic fundoplication with partial disruption, and
fundoplication that is too loose. Barium esophagogram,
esophageal manometry, endoscopy, and 24-hour pH
monitoring studies are valuable adjuncts in the evaluation of these patients.
Abdominal bloating
This frequent entity is believed to be due to the trapping
of swallowed air, which may not be belched easily in the
presence of a competent fundoplication. Many patients
after anti-reflux surgery complain of increased epigastric
discomfort and flatulence.18 It is likely that patients who
undergo anti-reflux surgery habitually swallow air to
clear the esophagus of refluxed acid. This habit continues
after the anti-reflux surgery, resulting in the so-called

gas-bloat syndrome. The symptoms can be treated with
gas-binding agents or prokinetics. Very rarely, it is necessary to take down the fundoplication or convert it to a
partial fundoplication.
Pain
Some patients complain of pain, mainly in the lower thoracic region, the epigastrium or the left shoulder, following fundoplication. This is believed to be due to suture
placement in the diaphragmatic hiatus, producing referred
pain; it may also be the result of esophageal muscle
spasm. These symptoms can be treated expectantly, and
occasionally they respond to a calcium-channel blocker
such as nifedipine or diltiazem.
Diarrhea
After fundoplication, approximately eight per cent of
patients have diarrhea. The reason for this may be
increased gastric emptying, excessive liquid intake, or a
post-vagotomy effect. In those cases in which the cause is
not clear, gastric-emptying studies or, for completeness
of vagotomy, a sham feeding pancreatic polypeptide test
may help to resolve the question.19 A pyloroplasty is
appropriate when the gastric-emptying study has a halftime of more than 150 minutes. Most patients can be
treated effectively with anti-diarrhea medication; only
rarely is surgical intervention, such as the reversal of a
10-cm jejunal loop, necessary.
Alkaline reflux gastritis

Some patients complain of epigastric discomfort in conjunction with their preoperative complaints of heartburn and acid regurgitation. Careful evaluation of these
patients may identify excessive bile in the stomach at
endoscopy and on testing with the Bilitec probe. Twentyfour-hour gastric pH monitoring and hepatobiliary
scanning with technetium 99 m-labeled derivatives of
iminodiacetic acid to show the presence of radioactive
material in the stomach help to define the problem further. In carefully selected patients, bile-diversion surgery
is useful. The duodenal switch consists of division of the
duodenum at the juncture of the first and second portion
with a roux-en-Y jejunal loop anastomosed to the proximal duodenum in addition to a highly selective vagotomy. Medical management using a prokinetic and a
binding agent such as cholestyramine, however, usually
suffices. It is important that the patient is advised
preoperatively of the probability of continued gastric
symptoms after fundoplication.
Etiology of recurrent gastroesophageal reflux disease 219
MECHANISMS OF FAILURE
Failed repairs requiring reoperation may be the result of
technical errors, selection of the wrong operation, or
incorrect primary diagnosis. Technical failure undoubtedly relates to the inexperience of the individual surgeon.
The restoration of a functional acid barrier while avoiding dysphagia and side effects, such as diarrhea and
gastroparesis, requires precise surgical technique and
careful preoperative assessment.
Crural disruption
This disorder results in an intrathoracic migration of
the wrap or a para-esophageal hernia and is particularly
common after laparoscopic anti-reflux procedures for
large hiatal hernias.20,21 Contributing factors, in theory,
include operator inexperience, short esophagus, inadequate mobilization of the esophagus, and physiological
factors that would increase pressure or tension at the
diaphragmatic hiatus.21 This is particularly true if the
patient vomits or retches during the early postoperative period or encounters excessive intra-abdominal pressure secondary to a fall, heavy lifting, or a car accident. We
advise inclusion of the overlying crural peritoneum when
closing the hiatus. The subdiaphragmatic fascia, which is
identified easily on the left limb of the right crus, is
included in our crural repair. Although some surgeons
advocate an anterior crural closure and others recommend a prosthetic reinforcement,22,23 we prefer to place
deep 0-Ethibond sutures 1 cm apart that include the peritoneum and subdiaphragmatic fascia. A concerted effort
is made to preserve the fascia and avoid a muscle-to-muscle closure. In addition, patients are placed on an antiemetic regimen intraoperatively, which is continued
during the first 48 postoperative hours. Restricted activity
and lifelong avoidance of weight-lifting are advised.
Missed short esophagus

Pathological acid reflux initially produces an inflammatory reaction and edema in the lamina propria. However,
in long-standing cases, it results in destruction of the
muscularis mucosae, forming a stricture down to and
including the circular muscle level. Eventually, transmural
inflammation causes fibrosis of the outer longitudinal
muscle, creating a shortening effect and, in some cases, an
inability to reduce the gastroesophageal junction to its normal subdiaphragmatic position. A foreshortened esophagus may also be found in patients with a failed anti-reflux
procedure and in those with type III (mixed) hiatal hernias. Between three and 14 per cent of patients undergoing
anti-reflux surgery have the so-called short esophagus.24,25
Preoperative diagnosis of the short esophagus,

although not standardized, is currently based on demonstrating a non-reducing 5-cm or larger hiatal hernia on
an upright barium esophagram, endoscopic demonstration of stricture formation or Barrett esophagus, or short
esophageal length as measured by manometry. Awad and
colleagues showed that neither a single preoperative test
nor any combination of tests was completely accurate.26
When each of the preoperative tests was evaluated individually, endoscopy had the highest sensitivity (61 per
cent) and a positive predictability rate of 26.6 per cent;
manometric length measurement had the highest specificity rate (78 per cent) and a positive predictability rate
of 36.3 per cent. The combination of two or more tests
resulted in a specificity ranging from 63 to 100 per cent
but a low sensitivity (2842 per cent).
The only reliable way to confirm or exclude esophageal
shortening is to demonstrate intraoperatively that the
gastroesophageal junction rests in the abdominal environment allowing for a tension-free repair. If this precaution is not observed, then an anti-reflux repair has
a failure rate of approximately 25 per cent.27 The most
effective treatment for the shortened esophagus is a
lengthening procedure using a Collis gastroplasty. This
operation can be done by an open transthoracic approach;
alternatively, a totally laparoscopic or a combined laparoscopic and thoracoscopically assisted approach can be
used. Currently, the primary problem with laparoscopic
esophageal mobilization is exposure, as only 68 cm of
distal esophagus can be freed easily when using the
laparoscopic approach. The use of longer instruments, an
incision of the arch of the diaphragm to allow a mediastinal retractor, and division of the vagal branches to the left
lung aid in circumferential esophageal dissection up to
the aortic arch.
All patients with a possible short esophagus undergo
circumferential esophageal mobilization followed by intraoperative endoscopic evaluation of the distance between
the gastroesophageal junction and the arch of the crus.
Initially, we required a 2-cm intra-abdominal segment of
the esophagus without tension, but after experiencing one
recurrent slipped Nissen we subsequently have used a 3-cm
intraperitoneal length requirement.
Two-compartment stomach
A partitioned stomach is unique to laparoscopic antireflux surgery and occurs when a point too low on the
anterior greater curvature of the stomach is used as
the anterior wing or a point too distal on the posterior
wing of the fundoplication is selected. This creates a
pouch of fundus that is isolated from the corpus, created
by a partitioning line of tension. There is a characteristic
X-ray picture at esophagography (Figure 29.1) and
Twisted fundoplication
This disorder may be associated with the NissenRosseti
repair and results from failure to mobilize the greater
curvature of the stomach from the spleen, diaphragm
and pancreas. A lead point on the anterior wall of the
stomach is used for the posterior wing and is sutured to
another level of the anterior stomach wall. If the proximal distal axis lead point levels are sufficiently different,
then a twist results and a spiral-type deformity is seen on
retroflexion at endoscopy. This deformity is associated
with dysphagia; a manometric evaluation will show a
hypertensive and, sometimes, poorly relaxing fundoplication. The twisted fundoplication is often resistant to
esophageal dilation and requires reoperation.
Hiatal stenosis
Figure 29.1 The proximal compartment is filled with barium

and the distal compartment is filled with air.
This phenomenon is associated only with laparoscopic

Nissen fundoplication. It has been reported infrequently
and must be differentiated from an excessively tight
closure. Hiatal stenosis is due to excessive scar formation, which in turn constricts the esophagus at the hiatal
level. It is easily recognized at reoperation by intraoperative endoscopy, after taking down the gastric-hepatic
adhesions. It can be corrected by incising the hiatus anteriorly. We also inject the hiatoplasty with dexamethasone. The cause may be due to cautery dissection of the
right crura.
Missed neoplasm
A small submucosal tumor causing dysphagia may go
unnoticed at endoscopy. Endoscopic ultrasound is a useful adjunct in these circumstances, especially in patients
who exhibit weight loss and are suspected to have a
benign disorder. All patients with Barretts esophagus
should undergo a biopsy protocol before operation. At
laparoscopic reoperation, one should suspect a malignancy if the dissection is difficult and the tissue is
excessively hard.
Figure 29.2 A retroflexed view of the stomach with two
compartments separated by a fold/partition of tissue.
the endoscopy is diagnostic (Figure 29.2). Patients with

this deformity often have dysphagia, and manometric
evaluation shows a hypertensive fundoplication with
incomplete relaxation. The gastric body does not relax
with swallowing, thus dysphagia results when the gastric
body is used for the fundoplication. Reoperation is
required.
Slipped Nissen
This well-known problem occurs after protrusion of the
gastric fundus through the fundoplication. It may be the
result of esophageal foreshortening, failure to anchor the
fundoplication to the esophagus, or incorrect positioning of the fundoplication on to the stomach rather than
the lower esophagus. Esophageal mobilization to achieve
a sufficient intra-abdominal length of esophagus allowing for a tension-free repair is essential to minimize the
occurrence of this complication.
Vagal-nerve disruption
Fundoplication disruption
Injury to both vagus nerves can lead to a marked delay in

gastric emptying, which in turn may in turn require a
pyloroplasty. Familiarity with the anatomy and careful
dissection of the arch of the right crus will minimize the
risk of anterior nerve injury. Posterior nerve injury is
probably more common when the nerve is displaced
from the posterior esophagus and is unrecognized as
such. Single-nerve injury or excessive nerve stretching to
make an ample window behind the gastroesophageal
junction may create transient gastroparesis. A gastricemptying study should be performed; our criteria for
pyloroplasty is a half-time of more than 150 minutes for
solids or liquids. Vagal-nerve injury is the reason for legal
consultation and action more frequently than any other
post-Nissen problem.
This is the Achilles heal of Nissen fundoplication and

may not be avoidable. Disruption may be the incorrect
term in many instances. Clearly, the fundoplication folds
and tucks are lost with time in some patients and
recurrent reflux disease occurs, but this is based on the
retroflexed endoscopic view. In fact, at reoperation many
patients have a seemingly intact fundoplication with
sutures still holding the right and the left wing serosal
surfaces in continuity. Apparently, the suture has pulled
out of the full thickness of the stomach wall in one or
both of the wings, and an effective barrier has been lost.
Tissue attenuation may also be responsible for this phenomenon. Consequently, Tom DeMeester has recommended
a pledgeted repair, which the main author (CJF) of this
chapter incorporates with every Nissen fundoplication
he performs.
Too loose, too tight, or too long

fundoplication
If the wrap is too floppy, then the pressure created in the
distal esophagus is low, favoring recurrent reflux symptoms. Conversely, if the fundoplication is too tight, dysphagia may occur. Calibration of the fundoplication has
been standardized and shown to prevent long-term dysphagia.3 A 60F bougie should be introduced, and the
right and left wing lead points should be chosen with the
dilator in place. We prefer to overlap the lead points by
3 cm to create a floppy Nissen fundoplication (Figure 29.3).
Posterior
Anterior
3 cm
WRONG OPERATION
Selection of the optimal operation may be influenced by
the presence of esophageal foreshortening, defective
esophageal motility, or gastric-outlet or duodenal obstruction. The acquired short esophagus is an indication for an
esophageal-lengthening procedure to reduce undue tension on the repair. Significant impairment of esophageal
peristaltic amplitude of contraction, propagation, or
abnormal peristaltic waves necessitates a floppy Nissen
fundoplication to avoid the complication of dysphagia
from a functional obstruction. Gastric-outlet obstruction
warrants a gastric resection, while an obstructing duodenal stricture is best treated by gastrojejunostomy and
vagotomy.
WRONG DIAGNOSIS
Anterior
Posterior
Figure 29.3 An end-on view of the gastric fundus wings

overlapped to assure a floppy Nissen fundoplication.
Failure to identify an underlying primary motor disorder,

such as achalasia or diffuse esophageal spasm, results in a
repair that inevitably fails to relieve and may exacerbate
the clinical problem. In such cases, dismantling the fundoplication and adding myotomy is required. Preoperative
manometry is imperative in this case but is often forgotten
by the casual esophageal surgeon.
Esophageal cancer or a malignancy at the gastroesophageal junction can be missed at endoscopy. Care in
obtaining a good retroflexed view of the squamocolumnar junction is necessary. This may be difficult if the
patient is unable to hold the air in the stomach. A smaller
scope, however, can almost always be placed in the hiatal
hernia to obtain the view needed. Any suspicion of a neoplasm warrants biopsy. If the patient is combative when
the endoscope is retroflexed within the hernia, then

esophageal perforation can occur. Improved sedation or
repeat endoscopy at another session is warranted. We
have discovered four patients with malignancy who had
been endoscoped recently by an experienced physician
and referred for anti-reflux surgery. Endoscopy by the
operating surgeon is a must in our opinion.
DISCUSSION
The reasons for poorer outcomes after repeat surgery are
hypothetical and perhaps uncorrectable (Table 29.1). A
specific classification of mechanisms of failure has not
been agreed upon, and the best method of correction for
each mechanism has yet to be determined. Many failures
are the result of technical errors, whereas others result
from deteriorating foregut motility or wear and tear on
the fundoplication.
The best approach for reoperative anti-reflux surgery
is debatable. Currently, we prefer the transthoracic
approach for patients with two or more failed anti-reflux
procedures, for any patient with an irreducible hiatal
hernia more than 2 cm in size, and for patients with a
suspected short esophagus (short esophageal manometric length, stricture formation, or Barretts esophagus).
The left transthoracic approach provides maximum
exposure of the hiatus and makes dissection of the
esophagus from the surrounding tissues safer; with a circumlinear incision of the diaphragm near its rib attachment, excellent exposure of the abdominal contents is
possible. More importantly, the esophagus can be mobilized up to the aortic arch and a lengthening procedure,
if needed, can be performed easily.
A disrupted fundoplication, a repair that is too tight,
or a patient with crus closure failure and an intrathoracic
fundoplication more than 2 cm above the diaphragmatic
crus and without additional risk factors for a short
esophagus are our primary indications for laparoscopic
reoperative surgery. The patients symptoms must be
uncontrollable despite aggressive medical therapy (including dilations) to warrant reoperative surgery. Satisfactory
results have been shown with laparoscopic reoperative
surgery (Table 29.2).
Detractors of the laparoscopic approach for reoperative surgery are concerned primarily about incomplete
dismantling of the fundoplication. This can be difficult, as
the posterior wing is often densely adherent to the crural
closure and retroperitoneum. Safe dissection in this area
is not possible for inexperienced surgeons. However,
after mobilization, an intraoperative endoscopy with full
insufflation and the J-maneuver can prove or disprove
complete dismantling. If blood is seen within the lumen,
one should check carefully for a perforation. Obviously, if
the stomach cannot be inflated fully then a larger perforation may be present.
Vagal-nerve injury is also a concern, as the nerve
is not palpated so easily during laparoscopic surgery.
Attention to detail and sharp dissection immediately
adjacent to identifiable structures will usually prevent
this complication. If there is suspicion of a vagal nerve
injury, then percutaneous endoscopic gastrostomy placement is appropriate at the end of the operation.
Table 29.1 Reported series of reoperations with more than 30 cases

Reference
Cases
(n)
More than one

prior repair
Skinner (1967)28
Orringer (1972)29
43
45
0
0
Hill (1971)30
Polk (1980)31
63
36
12
28
Henderson and Marryatt (1981)32

Maher et al. (1984)33
Little et al. (1986)34
Stirling and Orringer35
121
55
61
87
0
6
27
25
Pearson et al. (1987)36

Low et al. (1989)37
Siewert et al. (1995)38
Stein et al. (1996)39
Ellis et al. (1996)40
Deschamps et al. (1997)41
118
116
50
71
101
185
22
9
11
43
Mortality
(%)
3
0
3
4
0
0
4
5
3
0
0
3
2
1
1
0.5
Good/excellenta
(%)
Satisfactoryb
(%)
73
85
81
80
50
94
80
72
67
76
80
86
70
86
80
88
Combined total of excellent and good results; bcombined total of excellent, good and fair results; fair results imply significant symptoms.
Table 29.2 All published series of laparoscopic reoperation anti-reflux repairs

Reference
Repairs
(n)
DePaula et al. (1995)17
19
9
8
0
25
Watson et al. (1999)43
27
22
Alexander et al. (1996)44

Croce et al. (1997)45
Schauer et al. (1999)46
2
5
22
0
20
4.5
Gastric strangulation preventing safe

mobilization of the distal esophagus
Dense adhesions between left lobe of

liver and stomach
Intra-abdominal adhesions,
perihiatal adhesions
Intrathoracic cuff and short esophagus

Not mentioned
Curet et al. (1999)47
27
3.7
Poor visualization, gastric perforation
Soper et al. (1999)21

Floch et al. (1999)48
6
46
16.6
20
Szwerc et al.(1999)49
15
Pointner et al. (1999)50
30
Hunter et al. (1999)51
75
Awad et al. (2001)52
38
13
Serafini et al. (2001)53
28
Frantzides and Carlson (1997)8

OReilly et al. (1997)42
PEH, para-esophageal hernia.
Conversion
(%)
Cause
Dense mediastinal adhesions

Adhesions, bleeding, perforation,
tension pneumothorax
Bleeding from the spleen,

gastric perforation
Adhesion, gastric perforation
Adhesions, bleeding, big PEH,
calcified Angelchik prosthesis
Dense adhesions
Complications
(%)
Results
(%)
Follow-up
(months)
Intraoperative, 15.8;
postoperative, 21
Postoperative, 100
Intraoperative, 33;
postoperative, 16.6
0
Excellent (84.3)
Mean 13 (range 126)
Excellent (100)
Excellent (100)
Range 414
Range 1242
Good (92.6)
Median 12 (range 348)
Excellent (100)
Excellent (100)
Excellent (73); fair (27)
Not clear
Range 620
Mean 5.7 (range 014)
Excellent (96); fair (4)
Mean 22 (range 160)
Excellent (75); poor (25)

Significant improvement
in wellbeing score
in symptom score
in quality of life
Excellent/good (87);
fair/poor (13)
Excellent (65);
fair (21.5); poor (13.5)
Excellent (89);
fair (11)
Not mentioned
17.1 ( 11.8
0
0
postoperative, 4.5
postoperative, 44.4
0
postoperative, 20
0
Intraoperative, 18
postoperative, 5
Intraoperative, 16;
postoperative, 38
Intraoperative, 46;
postoperative, 21
"3
Median 29 (range 1245)
Not clear
Mean 26.5 (range 4101)
Mean 20 ( 14
As more series of reoperative laparoscopic surgery

become available for review, a consensus concerning
treatment for the various mechanisms of failure should
result. Until that time, careful attention to preoperative
evaluation, intraoperative technical detail, and postoperative care are necessary to minimize the morbidity
of anti-reflux surgery.
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30
Reoperation for recurrent gastroesophageal
reflux disease
THOMAS R. EUBANKS
Characterizing failure
Patient selection
Operative strategy
227
230
230
Successful reoperative anti-reflux procedures are based

on three principles: precise characterization of the original procedures failure, appropriate patient selection, and
operative intervention capable of repairing the failure.
More than 30 000 anti-reflux procedures were performed in the USA in 1998, with the number expected
to go well above 50 000 annually in the early 2000s.
Symptomatic failure rates of operative intervention range
between seven and 15 per cent. Reoperation is required in
13.5 per cent of patients,13 thus 5001750 patients will
undergo reoperative anti-reflux surgery each year.
Symptoms of failed anti-reflux procedures can be
divided into three categories: those that are too tight,
those that are too loose, and those that are malpositioned. The first are characterized by dysphagia and
regurgitation of undigested material, the second by
recurrent heartburn and regurgitation, and the third by
chest pain, abdominal pain and, occasionally, dysphagia.
Although symptoms provide a clue to the etiology of the
failed initial procedure, objective assessment is required
before planning any further operative intervention.
Conclusion
References
234
234
Esophagitis confirms uncontrolled acid reflux. A tortuous path of the distal esophagus implies abnormalities
of fundoplication position. In some cases, a large paraesophageal hernia can be documented (Figure 30.1).
CHARACTERIZING FAILURE
The objective assessment of a patient being considered
for reoperative treatment should include endoscopy,
esophagography, esophageal physiological studies, and,
when indicated, solid-phase gastric-emptying studies.
Endoscopy is useful to assess the state of the esophageal
mucosa and the orientation of the fundoplication.
Figure 30.1 Retroflexed view of the gastroesophageal junction

at endoscopy. The lesser curve is at the bottom of the photograph.
The bulging mucosa above the crus is caused by extrinsic
compression of the heart on the herniated stomach. This is a
large para-esophageal hernia after an anti-reflux operation.
However, a twisted fundoplication or two-compartment

stomach can also be identified as causes for failure
during endoscopy.3
Contrast esophagography is undoubtedly the most
valuable anatomical study for evaluating symptoms
after anti-reflux surgery. This study shows the positional
Figure 30.2 Early phase of an esophagogram in the same

patient as in Figure 30.1. The contrast is flowing through
the esophagus, which is slightly distorted by the large
para-esophageal hernia. Air in the herniated stomach can be
seen in the mediastinum. Note the location of the diaphragm.
The gastroesophageal junction appears to be in the abdomen.
relationships between the esophagus, hiatus, stomach

and fundoplication. Figure 30.2 shows early images of
contrast flowing past the cardia of the stomach and
into the body. An air-filled fundus can be seen in the posterior mediastinum, well above the hiatus. Figure 30.3
demonstrates later images of the same study with
contrast in the fundus, confirming its position in the
mediastinum. The most common reasons for failure
of anti-reflux procedures can be identified on contrast
Figure 30.3 Later images in the study shown in Figure 30.2.

The contrast has been cleared from the esophagus and is now
present in the herniated portion of the stomach. The compression
of the stomach caused by the hiatus is evident.
Figure 30.4 Esophageal manometry

tracing, demonstrating normal
propagation of peristalsis along the
esophageal body. The patient had
occasional decreased amplitudes in
the distal esophagus (#60 mmHg).
Reoperation for recurrent gastroesophageal reflux disease 229
esophagography: transdiaphragmatic herniation, slipped

fundoplication, twisted fundoplication, and tight fundoplication. The addition of a marshmallow swallowed
during the study also gives a good impression of lower
esophageal relaxation.
Esophageal manometry is essential in all patients
being evaluated for postoperative symptoms. In patients
with dysphagia and chest pain, manometry identifies
motility (physiological) abnormalities. Manometry will
also help in planning the operative strategy to correct
the failed procedure. A patient with poor motility may
not be a candidate for a redo 360-degree fundoplication.
Figure 30.4 shows a typical esophageal body tracing,
with occasional decreased amplitudes of peristalsis in
the distal esophagus, but confirms the presence of peristalsis, a feature required to proceed with an anti-reflux
procedure.
The lower esophageal sphincter (LES) pressure also

provides helpful information. A defective sphincter supports the diagnosis of a loose fundoplication in patients
with symptoms of recurrent reflux. A non-relaxing
sphincter or a sphincter with extremely high pressures
confirms a fundoplication that is too tight. Figure 30.5
demonstrates normal LES pressure and relaxation in a
patient with symptoms of chest pain after a fundoplication, but no symptoms of reflux.
Twenty-four-hour pH monitoring is important in all
patients (Figure 30.6). Although the symptom of heartburn would seem to be an accurate predictor of postoperative acid exposure, 50 per cent of patients who
complain of heartburn after a fundoplication will have
normal acid exposure on pH testing.4 Half of the patients
who complain of heartburn but have normal acid exposure will have other etiologies identified as a cause of
Figure 30.5 Manometry tracing

showing a normal LES pressure
(1718 mmHg) with complete
relaxation during deglutition.
Figure 30.6 Twenty-four-hour pH

testing, showing normal amounts of
acid reflux in both proximal and
distal channels.
their symptoms (esophageal motility abnormalities,

cardiac dysrhythmia, irritable bowel syndrome). In those
patients who do not complain of heartburn, the study is
useful in documenting subclinical, abnormal acid exposure, which can be present in 20 per cent of cases.4
Solid-phase gastric-emptying studies are helpful in
patients who complain of bloating. These studies do not
document vagal injury at the previous operation but they
do raise the suspicion of this. Many surgeons will add a
pyloroplasty to the reoperation if the study is abnormal;
however, dumping syndrome may occur in up 30 per cent
of patients.5 If the stomach is atonic, then the patient
may not be amenable to reoperative anti-reflux surgery
but instead may require gastrectomy.
Objective testing helps to confirm the clinical suspicion
of failure of the previous operation and can influence the
strategy of the planned corrective procedure. The objective findings should support the clinical suspicion. A
patient with symptoms of reflux (heart burn and regurgitation) will have different objective findings compared
with a patient with dysphagia and postprandial chest pain.
PATIENT SELECTION
Laparoscopic revision of anti-reflux procedures is becoming more common, regardless of whether the original procedure was performed via laparotomy or laparoscopy.13,6,7
The surgeon should be comfortable with the laparoscopic
approach in its use for the initial anti-reflux procedures
before proceeding with redo operations.
The selection process in a case with an obvious
anatomical defect is straightforward. With such distorted
anatomy, the patient and surgeon can be confident that
the repair of the defect will improve symptoms. Less
subtle defects, such as a small posterior herniation, are
unlikely to be the cause of significant symptoms, and
reoperation is indicated rarely in these cases.
In patients with recurrent symptoms of reflux and a
fundoplication that is too loose, the decision to reoperate
is difficult. Symptom control after reoperative therapy is
significantly less than after the initial operation.7 Furthermore, reoperative anti-reflux surgery normalizes acid
exposure in 74 per cent of patients compared with 83 per
cent in primary operations.4 The medical management
of such a patient is often successful and obviates the need
for operative intervention.
Patients with obstructive symptoms caused by a tight
fundoplication (not malposition) may benefit from
endoscopic dilation. Early dilation (two to six weeks
postoperatively) can reduce the need for operative intervention when symptoms are severe. Up to four per cent
of all patients undergoing anti-reflux procedures will
require endoscopic dilation, but only one per cent will
need operative revision for dysphagia alone.7
Regardless of the reason for reoperation, the complication rates are significantly higher for redo procedures.
Major operative complications, such as visceral injury,
and postoperative problems, such as dysphagia requiring
dilation, occur twice as often during or following reoperations compared with primary procedures.8
OPERATIVE STRATEGY
The patient is placed in the low lithotomy position. The
surgeon stands between the patients legs. The assistant
stands on the patients left. A static liver retractor (endoscope holder) is attached to the right side of the operating table. A single monitor may be placed at the right
shoulder of the patient. Electrocautery (thin avascular
tissues) and ultrasonic (thick vascular tissues) dissection
capabilities are required.
Five laparoscopic ports are used. The equipment
available dictates the size of the ports. If a high-quality,
5-mm laparoscope, a flexible 5-mm liver retractor, and a
5-mm ultrasonic dissector are available, then all five
ports may be 5 mm in size; otherwise, several of the ports
may need to be larger.
Although each case is unique, the operative strategy is
based on complete restoration of the anatomy prior to the
repair of the hernia. The procedure can be divided into
three steps: initial dissection, unwrapping, and rewrapping.
Initial dissection
The first objective is to free the viscera from the hiatus.
Often, this requires mobilization of the inferior aspect of
the left lobe of the liver from the fundoplication. The two
most common planes encountered during this dissection
are the subcapsular plane of the liver and the subserosal
plane of the stomach. Neither is desired, and both are
characterized by the presence of unexpected bleeding.
Anterior traction of the liver edge and counter traction
on the stomach facilitate the dissection. Infusing saline
irrigant under modest pressure (hydrodissection) can
help to develop the proper plane.
After the liver is freed, the next move is to separate the
crura from the fundus/esophagus complex. The dissection
can be initiated at any point in which the anatomy is discernable. In Figure 30.7, the intraoperative view demonstrates a large para-esophageal hernia with relatively few
adhesions to the liver. The left crus and omental attachments to the greater curve could be discerned easily. The
adhesions between the omentum and proximal greater
curve are divided with electrocautery. Since the short
gastric vessels were divided at the original operation, this
plane was avascular (Figure 30.8). The para-esophageal
hernia allowed a clear view of the anterior aspect of the
Figure 30.7 Initial intraoperative view of the esophageal

hiatus, demonstrating the large para-esophageal hernia. The
liver is out of view to the left, the spleen to the right. Note the
adhesions to the pericardium at the top of the photograph,
which correspond with the endoscopy images in Figure 30.1.
Figure 30.9 Dissection of right crus. The lesser omentum has

already been divided (caudate lobe is visible) and adhesions of
subhiatal fat and greater omentum are being freed.
mobilization of the esophagus allows identification of

the anterior and posterior vagii. If the esophagus is
difficult to identify due to adhesions, then a lighted bougie
may be passed into the lumen via the mouth. With the
anterior esophageal wall exposed in the mediastinum
and the anterior surface of the stomach identified, the
surgeon can visualize the relative depth of the dissection
required to undo the fundoplication.
Unwrapping
Figure 30.8 Division of the adhesions between the omentum

and the greater curve of the stomach. This plane is usually
avascular if the short gastric vessels are divided at the original
operation.
crural arch, thus the dissection is carried out from left to

right. The plane between the right crus and the portion of
herniated stomach is shown in Figure 30.9. In paraesophageal hernias occurring after previous anti-reflux
surgery, no hernia sac will be encountered.
Freeing the fundoplication/esophageal complex from
the crura is an extremely important step for two reasons:
it provides visual confirmation of the course of the
esophagus as it travels into the fundoplication and it is
a safe step, as the fundoplication provides a buffer for
errant dissection and thus aids in the avoidance of
esophageal injury.
Once the fundoplication/esophageal complex is
circumscribed by surgical tubing, further mediastinal
The anterior portion of the fundoplication can usually

be elevated from the body of the stomach lateral to the
sutures forming the fundoplication. The surgeon then
locates the inferior extent of the fundoplication and
places traction on the right portion of the fundus while
the assistant places traction on the left. A bougie placed
in the esophagus provides a detectable firmness to the
esophagus. The surgeon and the assistant elevate their
respective aspects of the fundus anteriorly and inferiorly.
Electrocautery, ultrasonic or sharp dissection is then
carried out from the inferior aspect of the fundoplication
to the superior aspect. This plane is avascular and the
sutures used to construct the prior fundoplication are
encountered (Figure 30.10). Esophageal and vagal injury
can be avoided at this step if the surgeon and assistant
focus on proper traction upon the fundoplication.
When the sutures have been divided and the dissection plane is continued to the previously dissected mediastinal esophagus, the fundus should be freed from the
cardioesophageal junction. With the bougie still in place,
the surgeon elevates the right aspect of the fundoplication while the assistant provides counter-traction on the
cardia and the anterior vagus. The right portion of the
(a)
Figure 30.10 Close view of the sutures used to create the

fundoplication at the original operation. The grasper is used to
retract the suture while it is dissected. Encountering sutures is
reassuring during this part of the dissection as it confirms the
proper dissection plane.
(b)
Figure 30.11 Mobilization of the right portion of the

fundoplication. This is an essential step required to restore the
original anatomy. The anterior vagus is at risk during this portion
of the operation.
(c)
fundus is freed from the anterior aspect of the cardia and

esophagus, preserving the anterior vagus (Figure 30.11).
This dissection is carried as far posteriorly as possible.
The ideal dissection would extend just to the left of the
posterior vagus. As the right aspect of the fundus is
passed from right to left, through the retro-esophageal
space, the entire fundus and gastric body are freed from
the hiatal defect (Figure 30.12).
Dissection of the left aspect of the fundoplication does
not involve as much work as the right aspect, but it is just
as important. The assistant provides the traction on the
fundus and the surgeon provides the traction on the
Figure 30.12 Series of photographs demonstrating the extent

of stomach herniation. The grasper in (a) remains attached to
the same portion of stomach throughout the series. The hiatal
defect can be appreciated in (c).
cardia. Once the fundus is restored to its anatomical position, the cardiac notch should be clearly identifiable, as
should the smooth transition from the right edge of the
esophagus to the lesser curve of the stomach. Hopefully,
the anterior and posterior vagii are visible and intact.
With traction applied to the esophagus using surgical
tubing, the esophagus is mobilized from its mediastinal
Figure 30.13 The esophagus has been mobilized from the

mediastinum until 3 cm of intra-abdominal esophagus rests in
the abdomen without tension.
Figure 30.14 Closure of the hiatal defect. The first suture has
been placed and is about to be cut.
attachments (Figure 30.13). This allows the gastroesophageal junction to return to an intra-abdominal position.
Although it is often tempting to avoid complete dissection of the esophagus and stomach during a redo operation, the surgeon should recall that the best opportunity
for success lies in the first redo procedure. Subsequent
procedures have lower success rates and higher complication rates.
Rewrapping
The redo fundoplication is performed similarly to a
primary operation. Techniques to prevent recurrent
herniation should be emphasized. These include adequate
esophageal mobilization, hiatal closure, and anchoring
the fundoplication to the crura.
The crura are re-approximated to decrease the hiatal
opening (Figure 30.14). The fundoplication is re-created
by passing the posterior aspect of the fundus from left
to right through the retro-esophageal space and approximating it to the anterior aspect of the fundus (Figure
30.15). Figure 30.16 shows the completed fundoplication, which is 3 cm long.
The fundoplication is then anchored to the hiatus to
help prevent recurrent herniation (Figure 30.17). Figure
30.18 shows the completed fundoplication with the crural
closure sutures, fundoplication sutures, and anchoring
sutures visible. Intraoperative endoscopy showed an intact
flap valve, a symmetric fundoplication, and the absence of
the para-esophageal hernia (Figure 30.19). The anchoring
sutures help to secure the fundoplication to the hiatus.
Since herniation is the most common cause of reoperative hiatal hernia surgery, these sutures may also be important for initial operations. Four to six sutures are placed
between the fundoplication and the crura. The extreme
Figure 30.15 Re-creating the fundoplication using the

posterior (left) and anterior (right) portions of the fundus. The
esophagus and subhiatal fat are in the center, encircled by the
surgical tubing.
Figure 30.16 The fundoplication is complete. Four sutures placed

1 cm apart are shown securing the right and left portions of the
fundoplication.
Figure 30.17 The left portion of the fundoplication is being

anchored to the anterior portion of the left crus.
Figure 30.19 Intraoperative endoscopy shows the corrected
flap valve and the repaired para-esophageal hernia.
consisting of liquids the first week and advancing to

regular food by the fourth week is prescribed.
CONCLUSION
Effective reoperative anti-reflux surgery can be expected
if the reason for failure of the previous operation is
known, if it correlates with the patients symptoms, and if
it is correctable.
Figure 30.18 Completed procedure. This view demonstrates
the hiatal closure sutures, several of the anchor sutures
(fundoplication to hiatus), and the fundoplication sutures.
REFERENCES
1
right and left sutures can incorporate the muscular wall of

the esophagus if it is not too ragged from the previous
dissection. The anterior and posterior sutures should not
incorporate the esophagus, to avoid injuring the vagii.
Postoperative care for reoperative anti-reflux procedures is the same as that for patients undergoing primary repairs. Gastric decompression tubes are not used.
Patients are allowed liquids by mouth on the day of the
operation. Pharmacological agents are used to suppress
nausea and emesis. Once the patient is ambulating and
oral elixirs are controlling postoperative pain, the patient
is discharged from hospital.
Patients are instructed to limit exertion (lifting #7 kg)
to minimize intra-abdominal pressure. A graduated diet
2
3
4
5
6
7
Horgan S, Pohl D, Bogetti, D, et al. Failed anti-reflux surgery: what

have we learned from reoperations? Arch Surg 1999; 134: 80917.
laparoscopic anti-reflux surgery. Ann Surg 1999; 229: 66977.
Hunter JG, Smith D, Branum GD, et al. Laparoscopic fundoplication
failures: patterns of failure and response to fundoplication revision.
Ann Surg 1999; 230: 595606.
Eubanks TR, Omelanczuk P, Richards C, et al. Outcomes of
laparoscopic anti-reflux procedures. Am J Surg 2000; 179: 3915.
Rieger NA, Jamieson GG, Britten-Jones R, Tew S. Reoperation after
failed anti-reflux surgery. Br J Surg 1994; 81: 115961.
Watson DI, Jamieson GG, Game PA, et al. Laparoscopic reoperation
following failed anti-reflux surgery. Br J Surg 1999; 86: 98101.
Hinder RA, Klingler PJ, Perdikis G, Smith SL. Management of the
failed anti-reflux operation. Surg Clin North Am 1997; 77:
10831098.
Pohl D, Eubanks TR, Omelanczuk PE, Pellegrini CA. Management and
outcome of complications after laparoscopic anti-reflux operations.
Arch Surg 2001; 136: 399404.
31
Results of laparoscopic treatment
of hiatal hernias
PATRICK R. REARDON AND STIRLING E. CRAIG
Type I hiatal hernia repair

Types II, III and IV hiatal hernia repair
235
236
Four types of hiatal hernias exist. With type I or sliding

hiatal hernias, the most common type, the gastroesophageal junction is displaced cranially into the chest. Type II
and type III hiatal hernias are para-esophageal hernias. In
type II hiatal hernias, the gastroesophageal junction is in its
native position, inferior to the diaphragm. The fundus, and
sometimes the body and antrum of the stomach, have rolled
cranially into the mediastinum. Type III hiatal hernias are
mixed para-esophageal hernias. In these hiatal hernias,
both the gastroesophageal junction and a large portion of
the stomach have rolled into the mediastinum. Type IV
hiatal hernias include the spleen, the colon, or some other
intra-abdominal organ within the hernia.
When discussing outcomes for laparoscopic repair of
hiatal hernias, the results should focus on two groups of
patients. The first group comprises patients with type I
hiatal hernias, which account for 9095 per cent of all
hiatal hernias. These hernias are generally asymptomatic
and do not require repair. They are repaired primarily as
part of a fundoplication to treat gastroesophageal reflux
disease. Most surgeons mobilize the distal esophagus in
order to achieve intra-abdominal esophageal length. This
process destroys the phreno-esophageal ligament. At this
point, the anatomy resembles the anatomy in the repair of
a small type I hiatal hernia. Therefore, the outcomes for
the repair of these hernias are essentially the same as outcomes for laparoscopic 360-degree fundoplication. The
second group comprises patients with types II, III or IV
hiatal hernias. These tend to be larger hernias occurring
in an older patient population and have different outcomes. In an online PubMed literature search using the
keywords hiatal hernia and laparoscopic, 220 citations
References
237
were returned. There were no results that dealt specifically

with type I hiatal hernias. There were multiple articles on
type II, type III, and giant hiatal hernias.
TYPE I HIATAL HERNIA REPAIR

Intraoperative complications reported during laparoscopic
360-degree fundoplication include esophageal perforation,13 gastric perforation,1,2 pneumothorax,2 bleeding,2
and conversion to open procedure.24 These complications
should not be affected by small hiatal hernias. The intraoperative complications of type I hiatal hernia repair are
outlined in Table 31.1. Postoperative complications include
atelectasis, gastric perforations,4 dysphagia,3,4 substernal
chest pain,3,4 heartburn,3,4 regurgitation,3,4 early satiety,3
death,2 and recurrent hiatal hernia.4 The likelihood of a
recurrent hiatal hernia following a laparoscopic 360-degree
fundoplication with a small hiatal hernia or no hiatal
hernia is affected by whether the crura are closed. Crural
closure has been documented to reduce the occurrence of
recurrent hiatal hernias.47 Larger hiatal hernias are also
Table 31.1 Type I laparoscopic hiatal hernia repair
Percentage
Esophageal perforation
Gastric perforations
Pneumothorax
Bleeding
0.23.03,1
1.61
?2
?,2 1.030
Superscript figures indicate references.

? $ reported without a percentage.

Table 31.2 Type I laparoscopic hiatal hernia repair
Postoperative complications
Percentage
Gastric perforation
Dysphagia
Substernal chest pain
Heartburn
Regurgitation
Early satiety
Atelectasis
Pneumothorax
Wound infection
Postoperative herniation
Death
0.3,4 1.06
7.2,4 4.9,6 4.8,3 9.031
16.9,4 8.0,3 22.031
5.2,4 2.8,3 12.031
3.5,4 5.43
15.63
?31
16
130
6.2,4 1.0,6 3.4,31, 5.030
0.31

? $ reported without a percentage.
associated with an increased likelihood of recurrent hiatal

hernia.5 Most larger hiatal hernias, however, are type II, III
or IV. The postoperative complications of type I hiatal
hernia repair are outlined in Table 31.2.
TYPES II, III AND IV HIATAL HERNIA REPAIR

Laparoscopic repair of a large para-esophageal hernia is a
technically difficult operation and should be performed
only by a surgeon with significant experience of performing standard laparoscopic 360-degree fundoplications in patients with no or small type I hiatal hernias.
Large hiatal hernias tend to occur in older patients with
significant associated comorbidities, which make them
higher operative risks. In addition, because of the rotation
of the stomach up into the mediastinum, identification of
the anatomy is difficult. The larger hernia sacs may obscure
the location of the esophagus and vagus nerves, and these
structures are injured more easily in the repair of large or
para-esophageal hernias.
The intraoperative complications of types II, III and IV
hiatal hernias are outlined in Table 31.3. Intraoperative
complications include esophageal perforations,812 enterotomy,8 gastric perforations,8,9,1315 pneumothorax,9,13
hypercarbia,13 vagus nerve injury,13 bleeding,11 tearing of
the right crus,15 gastric leak,16 myocardial infarction,8
cardiac arrest, pulmonary embolism,8 and death due to
pulmonary embolism. When recognized and repaired
intraoperatively, perforations of the esophagus, stomach
and intestine add very little morbidity.5 Delayed recognition of a perforation of a hollow viscus is associated with
significant morbidity and a prolonged hospital stay.1,2
Most cases of pneumothorax do not involve an actual lung
injury. Most are due to inadvertent injuries to the mediastinal pleura during dissection in the chest. Most contain
only carbon dioxide. Whenever possible, a recognized
pleural injury should be oversewn. Positive-pressure ventilation using a positive end expiratory pressure (PEEP)
Table 31.3 Types II, III and IV laparoscopic hiatal hernia repair
Intraoperative
complications
Enterotomy
Pneumothorax
Hypercarbia
Vagus nerve injury
Bleeding
Tear of the right crus
Cardiac arrest
Death (due to a
pulmonary embolism)
Percentage
4.0,32 1.9,8 5.0,9 2.3,10 8.3,11 0.512
1.6,32 10.0,14 1.8,13 3.09
3.88
3.6,13 4.0,9
0.832
1.813
1.8,13 1.210
2.715
0.832
1.813
valve during the operation and high-volume ventilation

during desufflation of the abdomen will usually obviate
the need for any treatment. Hypercarbia is more common
in the repair of these large hiatal hernias due to the
extensive dissection within the mediastinum leading to
increased absorption of carbon dioxide. The problem may
be exacerbated by the frequent occurrence of emphysema
or chronic obstructive pulmonary disease in these elderly
patients. During dissection of the large sac associated with
these hernias, bleeding may occur.5,11 Vagus nerve injuries
may occur secondary to failure to recognize the esophagus
and vagus nerves within the sac.13 Cardiac arrest, and
death due to pulmonary embolism or other causes are rare
occurrences intraoperatively.13
Numerous postoperative complications have been
reported following laparoscopic repair of para-esophageal
hernias. Some of these complications are minor, but many
of them are severe. Many of these complications are related
to the fact that these patients present in the sixth and
seventh decades of life. Frequently, the patients are frail and
present with significant other diseases. Some of the complications may be related to failure to perform an anti-reflux
procedure at the time of the hernia repair. The postoperative complications are outlined in Table 31.4. The need to
perform anti-reflux procedures at the same time remains
a controversial issue. Some of the most common symptoms reported after these procedures, such as dysphagia,
are related directly to the performance of an anti-reflux
procedure. Hernia recurrence remains a problem in laparoscopic hiatal hernia repair. Symptomatic hernias represent
only a fraction of the total number of recurrences,5,17,18
and therefore, recurrences in many series may be underreported. Hernia recurrence is more common in paraesophageal hernias than in type I hernias. The larger the
hernia, the more likely is the recurrence.4 Factors associated
with increased recurrence include a failure to excise the
hernia sac,10,15,19 breakdown of the crural repair,20 shortened esophagus, and large hiatal defects with an inability to
Results of laparoscopic traeatment of hiatal hernias 237

Table 31.4 Types II, III and IV laparoscopic hiatal
hernia repair
Postoperative complication
Percentage
Esophageal stricture
Gastric obstruction
Acute gastric dilation
Delayed gastric emptying
Prolonged gastric atony
Mesh erosion into stomach
Prolonged ileus
Small-bowel obstruction
Dysphagia
1.333
0.8,32 1.98
2.633
1.210
1.3,33 8.337
1.813
2.6,33 16.737
2.321
1.0,9 2.715
1.536
3.6,13 20.0,14 6.0,8 21.0,10
8.3,11 1.612
1.8,13 20.0,14 10.0,8 41.7,11
3.712
19.08
1.112
29.08
10.014
37.5,39 48.834
8.337
3.210
10.0,24 8.3,37 10.0,38
3.718
3.5,10 8.311
1.09
0.8,32 4.09
1.813
2.0,9 1.210
1.8,13 1.9,8 3.0,9 1.210
1.6,32 1.9,8 1.09
6.0,9 16.711
1.813
1.3,33 1.836
3.718
1.09
1.09
3.718
8.311
3.718
0.512
1.8,36 2.923
1.09
7.4,18 2.321
0.8,32 0.512
2.0,9 0.512
4.621
1.09
1.333
2.715
3.6,13 10.0,14 8.0,8 1.0,9
3.5,10 1.112
2.4,32 0.512
GERD symptoms
Early satiety
Gas bloat
Hyperflatulence
Mediastinal seroma
Transient cervical emphysema
Breast mastalgia
Pneumothorax
Atelectasis
Pneumonia
ARDS
Pleural effusion
Respiratory failure
Deep vein thrombosis
Pulmonary embolus
Myocardial infarction
Atrial fibrillation
Cardiac arrhythmia
Congestive heart failure
Cardiac tamponade
Stroke
Hematoma
Hemothorax
Bleeding
Retroperitoneal bleeding
Need for transfusion
Urinary retention
Transient renal failure
Urinary-tract infection
Mediastinal abscess
Intra-abdominal abscess
Wound infection
Clostridium difficile colitis
Fever of unknown origin
Incisional hernia
Postoperative herniation
Death
achieve a tension-free repair. Recently, there have been

increasing reports in the literature of the use of mesh in an
attempt to decrease the recurrence rate following repairs of
hiatal hernias.16,2028 The mesh may be placed centrally as a
bolster to an already closed hiatus.16,23,26,28 The mesh may
be used to span the hiatal defect to create a truly tensionfree repair.16,20,29 The mesh may also be used to close a
relaxing incision placed laterally in the tendinous
diaphragm.
Overall, the surgical literature supports the belief that
the laparoscopic repair of para-esophageal and hiatal
hernias is technically feasible, safe and effective. Given
the age and condition of the patients, the morbidity and
mortality rates are acceptably low. However, the recurrence rates in some series have been unacceptably high.18
Recent reports utilizing mesh to reduce the recurrence
rate are promising and may help reduce the relatively
high recurrence rate that has been the Achilles heel of
laparoscopic hiatal hernia repair.
REFERENCES
1
2
3
4
5
6
10
11
12
13
14
Schauer PR, Meyers WC, Eubanks S, et al. Mechanisms of gastric

and esophageal perforations during laparoscopic Nissen
fundoplication. Ann Surg 1996; 223: 4352.
Bowrey DJ, Peters JH. Laparoscopic esophageal surgery. Surg Clin
North Am 2000; 80: 121342, vii.
Granderath FA, Kamolz T, Schweiger UM, et al. Long-term results
of laparoscopic antireflux surgery. Surg Endosc 2002; 16: 7537.
laparoscopic antireflux surgery. Ann Surg 1999; 229: 66976, 6767.
Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000;
80: 124352.
Watson DI, Jamieson GG, Devitt PG, et al. A prospective randomized
trial of laparoscopic Nissen fundoplication with anterior vs
posterior hiatal repair. Arch Surg 2001; 136: 74551.
Seelig MH, Hinder RA, Klingler PJ, et al. Paraesophageal herniation
as a complication following laparoscopic antireflux surgery.
J Gastrointest Surg 1999; 3: 959.
Swanstrom LL, Jobe BA, Kinzie LR, Horvath KD. Esophageal motility
and outcomes following laparoscopic paraesophageal hernia repair
and fundoplication. Am J Surg 1999; 177: 35963.
Luketich JD, Raja S, Fernando HC, et al. Laparoscopic repair of giant
paraesophageal hernia: 100 consecutive cases. Ann Surg 2000;
232: 60818.
Watson DI, Davies N, Devitt PG, Jamieson GG. Importance of
dissection of the hernial sac in laparoscopic surgery for large
hiatal hernias. Arch Surg 1999; 134: 106973.
Behrns KE, Schlinkert RT. Laparoscopic management of
paraesophageal hernia: early results. J Laparoendosc Surg 1996;
6: 31117.
Livingston CD, Jones HL, Jr, Askew RE, Jr, et al. Laparoscopic hiatal
hernia repair in patients with poor esophageal motility or
paraesophageal herniation. Am Surg 2001; 67: 98791.
Gantert WA, Patti MG, Arcerito M, et al. Laparoscopic repair of
paraesophageal hiatal hernias. J Am Coll Surg 1998; 186: 42832,
4323.
Oddsdottir M, Franco AL, Laycock WS, et al. Laparoscopic repair of
paraesophageal hernia. New access, old technique. Surg Endosc
1995; 9: 1648.

15
16
17
18
19
20
21
22
23
Wu JS, Dunnegan DL, Soper NJ. Clinical and radiologic assessment

of laparoscopic paraesophageal hernia repair. Surg Endosc 1999;
13: 497502.
Hui TT, Thoman DS, Spyrou M, et al. Mesh crural repair of large
paraesophageal hiatal hernias. Am Surg 2001; 67: 117074.
Velanovich V, Karmy-Jones R. Surgical management of
paraesophageal hernias: outcome and quality of life analysis. Dig
Surg 2001; 18: 4327.
large type III hiatal hernia: objective followup reveals high
recurrence rate. J Am Coll Surg 2000; 190: 55360, 56061.
Edye M, Salky B, Posner A, Fierer A. Sac excision is essential to
adequate laparoscopic repair of paraesophageal hernia. Surg Endosc
1998; 12: 125963.
Basso N, Rosato P, De Leo A, et al. Tension-free hiatoplasty,
gastrophrenic anchorage, and 360 degrees fundoplication in the
laparoscopic treatment of paraesophageal hernia. Surg Laparosc
Carlson MA, Richards CG, Frantzides CT. Laparoscopic prosthetic
reinforcement of hiatal herniorrhaphy. Dig Surg 1999; 16: 40710.
Huntington TR. Laparoscopic mesh repair of the esophageal hiatus.
J Am Coll Surg 1997; 184: 399400.
Frantzides CT, Richards CG, Carlson MA. Laparoscopic repair of large
hiatal hernia with polytetrafluoroethylene. Surg Endosc 1999; 13:
9068.
24
25
26
27
28
29
30
31
32
Athanasakis H, Tzortzinis A, Tsiaoussis J, et al. Laparoscopic repair

of paraesophageal hernia. Endoscopy 2001; 33: 5904.
Casaccia M, Torelli P, Panaro F, et al. Laparoscopic physiological
hiatoplasty for hiatal hernia: new composite A-shaped mesh. Surg
Endosc 2002; 27: 27.
Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior
cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc
1997; 11: 76971.
Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP.
A prospective, randomized trial of laparoscopic
polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty
for large hiatal hernia. Arch Surg 2002; 137: 64952.
Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic
antireflux surgery with routine mesh-hiatoplasty in the treatment of
gastroesophageal reflux disease. J Gastrointest Surg 2002; 6: 34753.
Paul MG, DeRosa RP, Petrucci PE, et al. Laparoscopic tension-free
repair of large paraesophageal hernias. Surg Endosc 1997; 11: 3037.
Zornig C, Strate U, Fibbe C, et al. Nissen vs Toupet laparoscopic
fundoplication. Surg Endosc 2002; 16: 75866.
Hunter JG, Smith CD, Branum GD, et al. Laparoscopic fundoplication
failures: patterns of failure and response to fundoplication revision.
Ann Surg 1999; 230: 595604, 595604.
Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome of
laparoscopic repair of paraesophageal hernia. Surg Endosc 2002;
16: 7459.
32
SANTIAGO HORGAN AND ROBERT BERGER
Postoperative complications
239
243
Numerous reports detail the benefits of laparoscopic fundoplication, including decreased pain, quicker return to
normal daily activities, and shorter hospital stay. However,
there are also complications related to the treatment of
gastroesophageal reflux disease (GERD). Mortality reports
range from zero to two per cent for initial repairs, increasing to five per cent for second operations.1,2 The morbidity, and likewise failure, of laparoscopic fundoplication is
dependent on its definition and length of follow-up. Most
large, single-institution studies report morbidities of two
to 26 per cent, with specific identification of failed surgery
occurring in four to eight per cent.24 Table 32.1 displays
the reported causes and frequencies of these failures (see
also Chapter 29). This chapter discusses the more common intraoperative and postoperative complications associated with laparoscopic fundoplication, their prevention,
the appropriate work-up for their diagnosis, and the
appropriate course of action. In addition, any reoperation,
whether laparoscopic or open, is known to have a higher
incidence of complications as well as a higher risk of
recurrence.57 It should be stressed that conversion from a
laparoscopic to open surgery for patient safety should not
be considered a complication if performed at the appropriate time.
INTRAOPERATIVE COMPLICATIONS
The ability to adequately visualize and identify the anatomy
required for performance of a Nissen fundoplication
cannot be overemphasized. These concepts are discussed
elsewhere and will not be re-addressed here. It is prudent,
however, to state that our typical fundoplication is performed using a left crus approach, as described by Horgan
Conclusion
References
247
247
and Pellegrini.8 The left crus is initially identified, and the

short gastric vessels are divided using an ultrasonic shears.
A no-touch technique for esophageal dissection is used to
minimize traumatic manipulation of the esophagus. This
requires the crura to be separated from the esophagus, and
not vice versa. After visualizing the right crura, circumferential dissection of the esophagus proceeds cephalad while
using a Penrose drain to manipulate the esophagus.
The posterior crura should be re-approximated with interrupted, nonabsorbable sutures to create a snug fit over a
56 French Maloney bougie placed within the esophagus.
A short, floppy, 2-cm fundoplication with three sutures is
created and secured to the esophagus but not to the crura
or diaphragm.
Table 32.1 Commonly reported complications and various case
reports following laparoscopic Nissen fundoplication
Complication
Incidence
(%)
Case report
Failed Nissen
Para-esophageal
hernia
Reoperation
Dysphagia
Heartburn/reflux
Pneumothorax
48
07
Pneumomediastinum
Pulmonary embolism
26
17
15
#2
Gastric perforation
1.5
Delayed gastric
emptying
Splenectomy
Mesenteric thrombosis
Hiatal stenosis
Bowel perforation
Delayed gastric
perforation
Cardiac
laceration/tamponade
Injury to major vessels
#1
Hemorrhage
0.5
Late diaphragmatic
rupture
Necrotizing fasciitis
Possible intraoperative complications are discussed

below. This is followed by a discussion on ways to avoid
encountering these problems initially and what to do if
they are encountered.
Posterior esophageal dissection

Factors causing increasingly difficult dissection of the
esophagus include prior foregut surgery, extensive history
of Barretts esophagus causing peri-esophagitis, and prior
dilation treatments (in which microperforations may
have occurred). Meticulous dissection and use of the
Penrose drain will help to minimize this complication. In
addition, the use of an angled scope (30 or 45 degrees)
will assist in visualizing the posterior aspect of the esophagus. The ultrasonic shears are well suited for the lysis
of adhesions, whereas monopolar cautery devices can
allow for lateral thermal injury and potential delayed
esophageal perforation. In addition, obese patients often
have significant adipose tissue along the greater curve of
the stomach. In these instances, it is best to place the
patient in a steep reverse Trendelenburg position and
place a 4 ! 4 gauze within the abdomen, just medial to
the superior tip of the spleen (Figure 32.1). This will assist
in lateral retraction of the adipose for improved exposure
of the left lateral and posterior aspects of the esophagus.
Should perforation of the esophagus be suspected, then
the anesthesiologist should be asked to place an orogastric
or nasogastric tube and instill 60 cc of methylene blue to
help localize any injury. If the surgeon cannot visualize
the posterior esophagus adequately, a clean 4 ! 4 gauze
may be placed behind the esophagus before the instillation of the methylene blue. The gauze is then withdrawn
and inspected for any evidence suggestive of a leak. If
methylene blue is not available, then the patient could be
placed in a level position while the upper abdomen is
Figure 32.1 Placing a gauze sponge at the superior splenic

pole assists in exposure.
filled with saline. The esophagus should then be insufflated with air while observing for bubbles as evidence of
a perforation.
Bougie perforation
Perforation with a bougie or dilator is a feared complication. The best safeguard is to ensure active communication
between the person passing the bougie and the surgeon
observing the process. This alone will not guarantee elimination of the risk of perforation, but it will diminish the
risk when both parties involved actively assist each other.
If any resistance is encountered with the passage of the
bougie, then force should not be applied. Either a more
experienced person should attempt to pass the bougie
and/or re-examination within the abdominal cavity via
the laparoscope should occur. First, verify that the appropriate bougie size is being used (4860 French are most
common, depending on the patients body habitus and
any history of prior dilations or strictures), and ensure
adequate lubrication of the bougie with a water-soluble
jelly. The Penrose drain, typically used to manipulate the
gastroesophageal junction, should not be manipulated in
any way while advancing the bougie. It is critical that no
tension is placed on the gastroesophageal junction to
ensure a straight and unobstructed path from the esophagus into the stomach. Using a blunt grasper, palpation
along the greater curve of the stomach and anterior gastric
wall will inform the surgeon when the bougie has entered
the stomach. The surgeon also needs to be attentive to an
overly aggressive and easy passage of the bougie to ensure
it does not pass too far distally, creating a perforation
along the greater curve or near the pylorus. Infrequently,
the use of the bougie is impossible because it cannot be
passed easily. It is safer to avoid the use of force for
advancement than to do so and produce a perforation.
With experience, the looseness of the wrap and the crural
closure will rarely result in postoperative dysphagia.
If perforation of either the intrathoracic or intraabdominal esophageal occurs, it is critical to recognize
and treat the injury early. If recognized immediately, the
injury may usually be treated with primary closure using
interrupted sutures with placement of the fundoplication over the injury to reinforce the repair. It is also considered safe to place a closed suction drain at the level of
the injury for postoperative monitoring. A drain is not
mandatory but is dependent on the level of comfort of
the surgeon with repairing this type of injury. The drain
is removed easily once the patient has shown no significant morbidity after adequate time to heal and there is
no evidence of leakage. We recommend removing the
drain at least five days after surgery after a normal esophagogram is performed. The patient can be fed after this
point.
Pneumothorax
Hemorrhage
The incidence of pneumothorax occurring during

esophageal dissection is almost 2 per cent.4 Contributing
factors are peri-esophagitis from severe Barretts disease,
prior endoscopic therapy, large hiatal hernias, and prior
operations upon this area (i.e. prior fundoplication).
There is little to prevent this complication other than
careful, meticulous dissection. Pneumothorax may present in two ways: the first, and most common, is visualization of an opening in the pleura by the operating team.
Usually, the patient has no immediate respiratory compromise, such as increasing end tidal carbon dioxide or
increased peak airway pressures. Should a rent in the
pleura occur, then it might be closed using a stitch or
clip, in order to avert ventilatory compromise. The anesthesiologist may also ventilate the patient manually with
several large tidal volume breaths to expel carbon dioxide
trapped in the pleural space. The operation may then
continue while using a lower insufflation pressure
(810 mmHg). Postoperatively, a chest X-ray can be
obtained. The majority of patients will not require a thoracostomy tube, as the carbon dioxide is readily absorbed
and a repeat chest X-ray will document resolution of
any pneumothorax. Should the chest radiograph in the
postanesthesia unit reveal a large pneumothorax ()50
per cent), then a small chest tube may be necessary,
especially if the patient appears symptomatic.
The second presentation of pneumothorax may be
more dramatic. In this scenario, the anesthesiologist
will suddenly comment on increasing end-tidal carbon
dioxide, increased peak airway pressures, or decreasing
hemodynamics. If the presentation is limited to endtidal carbon dioxide, then the surgeon should decrease
the intra-abdominal pneumoperitoneum pressure after
safely removing the instruments from the abdomen. The
anesthesiologist should then ventilate the patient manually to clear any intrapleural collection of trapped carbon
dioxide. If the patient is experiencing elevated peak airway pressures or decreased hemodynamics, then the same
initial approach of lowering the intra-abdominal pressure
and manual ventilation of the patient should occur. If
peak airway pressures do not decrease or if the hemodynamics continue to deteriorate, then tension pneumothorax is likely. The decision to place a thoracostomy
tube should not be delayed. If a chest tube is not available
immediately, then a 14-gauge angiocatheter needle
should be placed in the second intercostal space at
the midclavicular line. To determine the appropriate side,
one should auscultate the chest or attempt to visualize the
pleural tear. However, the placement of an angiocatheter
needle is only a temporary measure. This should be followed by the introduction of a 2832 French chest tube
connected to a closed suction drain. A postoperative chest
X-ray should confirm the proper location.
The development of bleeding is always an unnerving

experience, especially as it is visually magnified when
performing laparoscopic surgery. Laparoscopic procedures have the additional complexity of requiring the
judgment necessary to know when to convert to an open
operation to obtain control. This question has as many
answers as there are operative cases. In general, there are
three specific situations in which excessive hemorrhage
occurs during the performance of laparoscopic fundoplications: retraction of the left liver lobe, division of
the short gastric vessels, and dissection of the superior
gastrosplenic ligament.
The position and type of the liver retractor vary with
the surgeon performing the operation. Preventing injury
is preferable to treating injury, so adequacy and clarity of
optics are mandatory. This allows identification of any
adhesions from prior surgeries or inflammation, and
then allows the selective division of them with cautery or
an ultrasonic scalpel. If a laceration or puncture occurs,
several options are available. First, place a 4 ! 4 gauze
into the abdomen and apply direct pressure to the injury.
If the bleeding is controlled, the gauze may be held in
place under the liver retractor while the surgery proceeds. At the end of surgery, careful removal of the gauze
and visualization of the injury will confirm whether
the bleeding has stopped. This will be sufficient for the
majority of liver injuries. It is also recommended that
the intra-abdominal pressure is decreased at the time of
this inspection to ensure that the pneumoperitoneum is
not creating a tamponade effect. If bleeding continues,
then one should try the placement of one of the many
available hemostatic agents, either liquid or solid, at the
site. Other therapies include electrocautery and the
argon-beam coagulator. Only rarely have we found cases
of hepatic bleeding that could not be controlled with one
or more of these modalities.
Division of the short gastric vessels is another step
that potentially can result in a hemorrhagic complication. The majority of surgeons performing fundoplications today use ultrasonic scalpels. Other possible
techniques include the use of clips followed by their division or bipolar coagulation. Regardless of the instrument
employed, the standard warning of careful visualization
and maintaining patience is applicable. The surgeon
should elevate the greater curve of the stomach while the
assistant elevates the omentum. The initial opening of the
greater sac is usually uncomplicated. The greatest occurrence of bleeding is seen when approaching the superior
aspect of the greater curve. In this area are the most superior and posterior short gastric vessels. At this level, the
assistant should use a blunt grasper to push the greater
curve of the stomach medially and inferiorly. This will
allow the surgeon to gently retract the redundant portion
Figure 32.2 Exposure of the most superior-posteriorly

located short gastric vessel requires careful dissection and
transection.
of the fundus in an inferior and medial direction to expose

the last short gastric vessel. Once identified, the surgeon
should bluntly create an opening posteriorly to the vessel
to allow complete visualization of the occlusion of the vessel by the instrument of choice for division (Figure 32.2).
Finally, the spleen is in close approximation to this
dissection. Again, only careful progression of the surgery
will ensure prevention. Multiple reports have shown a
decreased incidence of splenic injury with the increasing
performance of laparoscopic fundoplication.2,9,10 One
frequent precipitating factor is multiple adhesions from
the gastric wall to the spleen. In this situation, a quick
remedy is to use an endoscopic linear stapler to transect
across the greater curve of the stomach and leave a small
gastric remnant attached to the splenic hilum. This is a
better alternative to incurring uncontrollable bleeding
from a tear of splenic capsule and does not exert any significant impact on the patient. Again, depending on the
degree of injury, direct pressure to the injury is the best
initial approach if the bleeding is minimal. If bleeding is
profuse, then one should be comfortable in performing
laparoscopic splenectomy or have a low threshold for
conversion to an open surgery to ensure the patients
safety first and foremost. The latter is preferred.
Shortened esophagus
The concept of a shortened esophagus generates much
controversy. If appropriate preoperative work-up was
performed, then the barium swallow and esophageal
manometry should indicate the length of intra-abdominal
esophagus, ideally 23 cm. Patients with severe or longstanding esophagitis and long-segment Barretts esophagus are at increased risk of esophageal shortening. If
identified preoperatively, the patient should be informed
Figure 32.3 Short esophagus: The gastroesophageal junction

can be seen easily above the diaphragm. The esophagus does not
show folds, which is usually a sign of a short esophagus. When
the esophagus appears tortuous, the chances of being able to
reach the abdomen are very high.
of the potential need for a Collis gastroplasty, either laparoscopically or via a thoracic approach. In our experience,
however, preoperative identification of a shortened esophagus is not always correlated with intraoperative findings
(Figure 32.3). Should the esophagus be found to not have
the necessary 23-cm length within the abdomen, then
proximal circumferential dissection of the esophagus will
free up more thoracic esophagus to reach further into the
abdomen. The surgeon should not settle for less than the
minimum intra-abdominal length, as this will likely lead to
slippage of the fundoplication, migration of the wrap into
the thoracic cavity, or improper placement of the wrap on
to the upper stomach rather than the esophagus.
Large hiatal hernia

This should be identified preoperatively by barium swallow, esophageal manometry, or esophagogastroduodenoscopy (EGD). If the hernia is no larger than 4 cm, then it
can be repaired primarily with standard crural closure,

using interrupted nonabsorbable sutures. If the hernia is
large or if the diaphragm is thinned, then closure of the
hernia primarily without undue tension may not be possible. Reinforcement of the repair using pledgets made of
expanded polytetrafluoroethylene (ePTFE; W. L. Gore &
Associates) can be attempted. These should be cut into
small rectangular shapes and placed perpendicular to the
fibers of the crura to buttress the repair. If the closure
remains under tension or if the surgeon is still unable
to close the hiatus completely, then a prosthetic patch
should be placed. Previously, polypropylene mesh was
used, but this led to migration and erosion into the
stomach and/or esophagus. Currently, most surgeons
prefer the use of ePTFE mesh because of the markedly
decreased risk of erosion. We use the technique described
by Huntington.11 A relaxing incision is made to the right
of the right crus to allow a tension-free primary closure
of the hiatus. This allows the crura to be in direct contact
with the esophagus rather than the mesh. The ePTFE
patch is then placed over the relaxing incision in order to
cover the defect, and is secured with either sutures
or tacks. It is critical that the placement of these tacks or
sutures is not into the esophagus, pericardium, inferior
vena cava, or aorta.
Gastric necrosis/perforation
Injury to the gastric fundus is most likely to occur during
the manipulation of the tissues to provide exposure, during passage of the wrap, or during the division of the
short gastric vessels and causing thermal injury. If identified, a primary closure of the perforation is required. This
may be accomplished by over-sewing the perforation in a
two-layered fashion using an inner absorbable suture and
a nonabsorbable outer suture. This requires the ability to
perform intracorporeal suturing. The surgeon performing the laparoscopic fundoplication should possess
this skill. The second option is to use an endoscopic linear
stapler. An endoscopic Babcock grasper can be used to
approximate both edges of the defect and incorporate
them into the stapler line. If one is unsure of the security
of the repair, then a closed suction drain may be placed
near the site of perforation at the end of the case.
POSTOPERATIVE COMPLICATIONS
Following laparoscopic fundoplication, patients generally present with complaints in either the early (#30
days) or late ("30 days) timeframe. Early complaints
of dysphagia, nausea, bloating, and early satiety are
reported by 2040 per cent of patients.12,13 A large portion of these patients will do well after careful questioning
and verbal reassurance, as these complaints drop to five

per cent after three months.12 The surgeon must question patients about their diet and activity in the immediate postoperative period to differentiate between patients
who require radiographic studies and patients who
require only reassurance. Instructing patients preoperatively about necessary diet restrictions and activity limitations will avert many from overzealous eating or
exercising. During questioning, often the surgeon can
identify whether the patient has eaten certain foods
(breads, meats, raw vegetables) at too early a time and
may be experiencing obstruction, or whether they have
overexerted themselves (weight-lifting, heavy manual
labor, etc.) too early (before two months). For patients
who complain of these symptoms, the easiest and most
prudent study to obtain is a barium swallow. This reveals
the anatomy responsible for the majority of early complications. If the barium swallow study is equivocal, then
it is reasonable to undertake an EGD examination if the
symptoms persist after six to eight weeks. Repeat studies
of 24-hour pH monitoring and esophageal manometry
may be pursued if the symptoms of reflux, asthma,
cough or hoarseness persist after a trial of antisecretory
medication. Finally, persistent gastric bloating may
necessitate gastric emptying studies.
Bloating/nausea/epigastric pain/increased
flatulence
A majority of patients will return to the clinic with specific
complaints of feeling bloated, occasional nausea, epigastric pain, and generally an increased incidence of flatulence. This is due to the patients habit of swallowing saliva
and air to neutralize the presence of acid in the esophagus.
Once a fundoplication is performed, this air progresses
through the bowel rather than retrograde through the
esophagus, as before surgery. This is an expected event
postoperatively. Because of this, it is important to inform
the patient in preoperative counseling to decrease anxiety
levels when it does occur. Most patients will have significant improvement in these symptoms with just several
weeks of expectant management, which includes a critical
review of their current diet. One important question to
ask patients postoperatively is whether their symptoms of
reflux have been treated. Often, reflux patients are of the
anxious type and tend to concentrate on a new type of
problem once the reflux has been treated.
If the patient is unable to tolerate liquids at any time
or the patient has persistent nausea and vomiting, then
the surgeon should obtain a barium swallow as an initial
diagnostic test to evaluate the post-surgical anatomy. If
no gross abnormality is seen, an EGD may be warranted.
Some patients will self-medicate with previous antacids
or proton-pump inhibitors as they are almost dependent
upon them. If the barium study shows no anatomical

defect and the patient feels better with medical therapy,
then one can continue to follow the patient and treat on
an as-needed basis.
Para-esophageal herniation
An occurrence of para-esophageal hernias of up to seven
per cent was noted when laparoscopic fundoplication was
initially performed.9,14 Patients present with persistent
nausea, vomiting, and intolerance of solids. This may occur
at any time following surgery, but usually it is early (within
one to two weeks) and generally it follows a report of sustained coughing and/or straining associated with heavy
lifting or Valsalva-type maneuvers. The best initial workup is to obtain a barium swallow. Abnormal anatomy is
revealed in 90 per cent of patients (Figure 32.4). This radiographic finding alone, with a symptomatic patient, is
justification enough to return to the operating room for
urgent repair before strangulation of the herniated viscera
occurs. The incidence of para-esophageal hernia has
decreased as more surgeons are routinely performing
careful re-approximation of the posterior crura. Careful

attention to ensure the closure is tension-free is also paramount. We generally close the crura, beginning at the
most inferior portion, using interrupted 0-Silk sutures
placed 0.5 cm apart. After two or three sutures are placed,
a 56 French Maloney dilator is passed, and the tightness of
the crura closure is assessed. Closure is then tailored to
ensure that it is snug, with no obvious gaps, but not overly
restrictive. If a para-esophageal hernia develops postoperatively, then the wrap should be taken down completely to
assist in visualizing any technical complications that may
have contributed to the early failure of the wrap. In addition, this allows better visualization in the repair and reapproximation of the crura while assessing the possibility
that an overlooked shortened esophagus was present at
the initial surgery.
Slipped Nissen
The term slipped Nissen refers to one of several anatomical complications following laparoscopic fundoplication.
It is most often discovered by a barium swallow study
after complaints of dysphagia, early satiety, or symptomatic complaints of recurrent reflux type symptoms.
The barium swallow may display one of the following
anatomic failures (see Figures 32.532.8.):
gastroesophageal junction and wrap above the

diaphragm;
gastroesophageal junction only above the diaphragm;
para-esophageal herniation;
malformation of the wrap.
Regardless of the type of failure, the patient will

require the fundoplication to be redone. If none of these
anatomical failures are seen on the initial radiographic
Figure 32.4 Para-esophageal herniation following

fundoplication. Note the position of a portion of the stomach
above the diaphragm.
Figure 32.5 Type IA hernia.
Figure 32.6 Type IB hernia.
study, then an EGD should be performed. This may show

that the wrap was performed too tightly, placed too low
on the stomach, or placed at an increased angulation,
causing the lower esophagus to twist. Treatment for these
complications requires advanced laparoscopic skills if the
repair is to be attempted laparoscopically. Success rates at
tertiary centers with advanced laparoscopic training programs are reported to be as high as 8591 per cent.7,13 If
one is to undertake such an effort, then keep in mind that
the best time to attempt this is within the first week,
before numerous dense adhesions are encountered. The
ideal approach is to undo the initial fundoplication completely. This entails careful and deliberate dissection of
the wrap from the anterior stomach wall, removal of the
posterior crural sutures, and mobilization of the esophagus. This will ensure that there is sufficient esophageal
length within the abdomen and that it is not under significant tension. If the esophagus does not allow for at least
2 cm of intra-abdominal length, then further circumferential mobilization of the esophagus is required. If this
does not obtain more length, then the patient may require
a Collis gastroplasty. Also, it is advisable to ensure sufficient mobilization of the fundus and greater curve of
the stomach so that no tension or torque exists after
creation of the wrap. After completely mobilizing the previous wrap, then the cause of the patients complaint is
generally evident.
Vagal nerve injury
Figure 32.7 Type II hernia.
Figure 32.8 Type III hernia.
Identification of the vagus nerves is paramount in

performing laparoscopic fundoplication. It is generally
agreed that the magnification afforded by the laparoscope
enhances the ability of the surgeon to visualize these
structures. The left vagus will be seen as it progresses from
its lateral to anterior position on the gastric wall. It may be
obscured by the anterior fat pad just inferior to the gastroesophageal junction. The right vagus will course posteriorly behind the stomach. Meticulous dissection and a
bloodless field are critical at this point of dissection. It is
best to visualize, but not dissect, both vagi at their normal
anatomical positions. This will decrease the possibility of
retraction, thermal injury from cauterization, or transection of the nerve. A no-touch technique avoids directly
grasping or manipulating the vagi and esophagus. This
will decrease injury and irritation of the nerves and ultimately decrease complaints of postoperative dysphagia
secondary to postoperative edema.
If a patient suffers a vagal nerve injury, then symptoms of delayed gastric emptying may include bloating,
early satiety, regurgitation, and diarrhea.15 Most patients
are not studied preoperatively with a gastric-emptying
test. However, if these symptoms are present during
the initial clinical visit, then it is prudent to obtain a
baseline measurement. Some authors advocate performance of a pyloroplasty at the time of fundoplication if
the patient has evidence of delayed gastric emptying.
However, most authors do not advocate this, as studies
have shown that gastric emptying times generally improve
following fundoplication. In addition, a symptomatic
patient may be tried on several prokinetic medications
(e.g. metoclopramide, erythromycin) before undertaking
surgery.
Patients who return with complaints of postprandial
weakness, palpitations, diaphoresis, and feelings of anxiety
may be experiencing postprandial hypoglycemia. This was
reported in several cases and confirmed with the performance of an oral glucose tolerance test.16 Postprandial
hypoglycemia may be associated with a vagal nerve injury,
thus causing early dumping and a hyperinsulin response
to the glucose load. This probably represents a neuropraxic injury because it resolves with time and does not
require treatment.
Ileus
Ileus following laparoscopic fundoplication is usually
mild due to the short time of the operation and minimal
manipulation of the bowel. Most surgeons will not place
a nasogastric tube postoperatively as it is rarely required
and most patients start a liquid diet the same night as
surgery. If a patient does experience intolerance of
liquids, then placement of a nasogastric tube and decompression of the stomach is required. In addition, a low
threshold for obtaining a barium swallow with small
bowel follow-through can rule out any anatomical
reason for ileus. Any treatment will be dictated by the
clinical condition and results of testing of the patient.
Dysphagia
Immediate postoperative dysphagia is attributed to postoperative edema from the surgical dissection. Late dysphagia may be from scarring at the hiatus, missed or new
onset of achalasia, increasing dysmotility, worsening
Barretts esophagus, esophagitis, or new development of
esophageal carcinoma. At the time of diagnostic workup, barium swallow should be the first test performed.
Anatomical deviations from standard surgical results will
usually be identified. Occasionally, retained food is noted
on the study. Whether the dysphagia occurs early or late
will play a role in the determination of how quickly a
patient should be taken back to the operating room for
reconstruction. If it occurs early on, then it is most likely
that a technical error has occurred. If it occurs late, then
a trial with antisecretory medications may be warranted,
as the success of repeat fundoplications decreases with
each attempt at surgical repair.12,13
Diagnosis of achalasia is best confirmed with

esophageal manometric studies. The lower esophageal
sphincter should be identifiable and demonstrate a nonrelaxing and hypertensive pressure value. Development
of achalasia after a fundoplication has been reported, but
most cases are probably the result of inadequate preoperative evaluation. Treatment for achalasia is dilation,
botulism toxin injection, or cardiomyotomy. If a surgical
cure is undertaken, then the fundoplication will need to
be taken down completely, cardiomyotomy performed,
and a partial fundoplication carried out.
Radiographic evidence of a wrap that is too tight is
best appreciated with a barium marshmallow-swallow
study. Liquids may pass easily through the wrap, but
foods with thicker consistency may become lodged above
the wrap. The best therapy is an initial attempt at dilation using either pneumatic dilatation or bougies of an
increasing diameter. Most frequently, this will be successful if the complaint of dysphagia presents within the first
three months. If the complaint of dysphagia arises more
than three months after surgery, then dilation may be
attempted but it is less likely to be successful.
Finally, the hiatal opening may be the source of dysphagia following fundoplication. If the crura are approximated
too tightly, then complaints will be almost immediate following surgery. Several authors have reported scarring at
the hiatal opening, causing a stricture seen on postoperative barium swallow.17 It is suspected that the use of
diathermy near the diaphragm is the source of injury.
Treatment involves surgical incision of the scarred
diaphragm to release the tension at this site.
Complications arising more than 30 days after successful fundoplication may originate from anatomical
failure or from functional problems. Anatomical failures
include essentially the same difficulties listed above, in
the early categories. Regardless of the timing of presentation, a barium swallow should be the first test obtained,
followed by esophageal manometry, 24-hour pH studies,
or EGD, depending upon the symptoms of the patient.
The management of these problems is similar to those
presented above.
Recurrent reflux
Patients who return with complaints of persistent or
unrelenting reflux warrant a thorough work-up to
ensure adequate anatomical integrity and functional
success of the fundoplication. Again, start with a barium
swallow study to assess anatomical changes and any evidence of herniation of the stomach or the wrap itself. If
this appears normal, then a 24-hour pH study may show
objective data relative to a functional failure of the fundoplication. Finally, EGD may show persistent irritation
of the esophagus from refluxate as well as confirm proper
placement of the wrap. If these studies all appear normal

and show no definitive pathology, then it is reasonable to
give the patient a trial of antisecretory medications. If
symptomatic relief is obtained from these, then it is best
to medicate the patient. Little is to be gained by attempting further surgery if the initial fundoplication is seen
to be anatomically correct and providing a mechanical
barrier towards reflux.
2
3
4
5
CONCLUSION
Laparoscopic fundoplication affords a good to excellent

result in more than 90 per cent of patients with refractory
and chronic GERD. There is a 1.3 per cent chance of complications.1,9 However, the majority of complications are
minor and can be limited in occurrence if careful attention
to preoperative symptoms, diagnostic work-up, and appropriate intraoperative techniques are followed. The use
of careful laparoscopic technique will help minimize
intraoperative complications. Postoperative complications
should always be studied with X-ray, endoscopy, 24-hour
pH study, and manometry if an early solution and explanation cannot be found. As more surgeons acquire advanced
laparoscopic techniques, the general surgeons scope of
advanced laparoscopic procedures will also continue to
broaden. Fundamentals, however, will not change; therefore, solid, practical judgment should always be used with
the patients safety and outcome at the forefront of the
surgeons considerations.
8
9
10
11
12
13
14
15
16
REFERENCES
1
Rantanen T, Salo J, Sipponen J. Fatal and life-threatening

complications in antireflux surgery: analysis of 5,502 operations.
Br J Surg 1999; 86: 15737.
17
Evans S, Jackson P, Czerniach D, et al. A stepwise approach to

laparoscopic Nissen fundoplication. Arch Surg 2000; 135: 7238.
Soper N, Dunnegan D. Anatomic fundoplication failure after
laparoscopic antireflux surgery. Ann Surg 1999; 229: 66977.
Watson D, de Beaux A. Complications of laparoscopic antireflux
surgery. Surg Endosc 2001; 15: 34452.
Pohl D, Eubanks T, Omelanczuk P, Pellegrini C. Management and
outcome of complications after laparoscopic antireflux operations.
Arch Surg 2001; 136: 399404.
Hunter J, Smith D, Branum G, et al. Laparoscopic fundoplication
failures. Patterns of failure and response to fundoplication
revision. Ann Surg 1999; 230: 595606.
Horgan S, Pohl D, Bogetti D, et al. Failed antireflux surgery.
What have we learned from reoperations? Arch Surg 1999;
134: 80917.
Horgan S, Pellegrini, C. Surgical treatment of gastroesophageal
reflux disease. Surg Clin North Am 1997; 77: 106382.
Carlson M, Frantzides C. Complications and results of primary
minimally invasive antireflux procedures: a review of 10735
reported cases. J Am Coll Surg 2001; 193: 42839.
Collet D, Cadiere G. Conversions and complications of laparoscopic
treatment of gastroesophageal reflux disease. Am J Surg 1995;
169: 6226.
Huntington T. Laparoscopic mesh repair of the esophageal hiatus.
J Am Coll Surg 1997; 184: 399400.
Perdikis G, Hinder R, Wetscher G. Nissen fundoplication
for gastroesophageal reflux disease: laparoscopic Nissen
fundoplication technique and results. Dis Esophagus 1996; 9:
2727.
Hinder R, Klinger P, Perdikis G, Smith, S. Management of the failed
antireflux operation. Surg Clin North Am 1997; 77: 108398.
Watson D, Jamieson G, Devitt P, et al. Paraoesophageal hiatus
hernia: an important complication of laparoscopic Nissen
fundoplication. Br J Surg 1995; 82: 5213.
Hunter R, Metz D, Morris J, Rothstein R. Gastroparesis: a potential
pitfall of laparoscopic Nissen fundoplication. Am J Gastroenterol
1996; 91: 261718.
Zaloga G, Chernow B. Postprandial hypoglycemia after Nissen
fundoplication for reflux esophagitis. Gastroenterology 1983;
84: 8402.
Watson D, Jamieson G, Mitchell P, et al. Stenosis of the esophageal
hiatus following laparoscopic fundoplication. Arch Surg 1995; 130:
101416.
PART
Laparoscopy in the pediatric

hernia patient
33 History
34 Anatomy and physiology
251
255
35 Diaphragmatic herniation
257
261
33
History
RAJEEV PRASAD AND THOM E. LOBE
Pediatric laparoscopy
Laparoscopic exploration of the contralateral groin
251
251
Laparoscopy in pediatric hernia patients has undergone

a rapid, albeit delayed, evolution. While laparoscopic
herniorrhaphy was being popularized in adults, the
approach was considered to be cumbersome, unnecessary, and even contraindicated in children. The perception that a child would outgrow the repair, particularly
one involving mesh, dominated early thoughts about the
laparoscopic approach. Other considerations, such as the
physiological stress of laparoscopy in infants and children
and the size and availability of appropriate instruments,
initially precluded pediatric laparoscopic herniorrhaphy.
However, once these barriers were overcome in other
pediatric surgical maladies, it was inevitable that herniorrhaphy would be revisited. With steady progress, pediatric
surgeons have applied their endoscopic skills to pediatric
hernia patients, and today many surgeons prefer this
approach for the repair of inguinal, ventral and diaphragmatic hernias in infants and children.
PEDIATRIC LAPAROSCOPY
Gans and Berci were among the first to describe
laparoscopy in pediatric patients when they published
their experience with visualization of the contents of the
peritoneal cavity by means of a small telescope introduced
through the anterior abdominal wall after establishment
of pneumoperitoneum.1 Since then, this approach has
been rediscovered. New instruments and techniques have
been developed, and there is a greater understanding of
the physiological impact of pneumoperitoneum in infants
and children.
Laparoscopy in general has experienced a huge
growth in its application in pediatric surgery. This is a
Laparoscopic inguinal herniorrhaphy

References
252
254
relatively recent advance. While initially used solely for

diagnosis, its use has expanded. It is now used routinely
for cholecystectomy, appendectomy and pyloromyotomy, as well as more complex procedures, including
fundoplication, colectomy, and pull-through procedures
for Hirschsprungs disease and high imperforate anus.
Initially, herniorrhaphy was not considered an appropriate laparoscopic procedure in infants and children.
Pediatric surgeons believed that a child would outgrow
herniorrhaphy as it was applied in adults because the
child had not reached its full development and size. Also,
the physiological impact of the procedure in infants and
children was unknown and initially overestimated.
LAPAROSCOPIC EXPLORATION OF THE

CONTRALATERAL GROIN
Routine open exploration of an asymptomatic contralateral groin during surgery for a clinically apparent
unilateral hernia is common practice among pediatric surgeons. Supporters of this approach base their view on the
reported 29 per cent incidence of the future development
of a symptomatic hernia on the unexplored side.2 Others
cite a lower incidence of bilateral hernia and feel that the
increased cost and risk of damage to cord structures in
males precludes the safe exploration of a clinically asymptomatic groin.3
Many alternative methods of detecting a contralateral
hernia have been described, including simple pneumoperitoneum and external inspection of the inguinal canal,
herniography, ultrasonography, and the passage of dilators
across the lower abdomen through the open hernia sac.47
Lobe and Schropp first introduced laparoscopy to aid in
252 Laparoscopy in the pediatric hernia patient
the recognition of a patent processus vaginalis in the contralateral asymptomatic groin during open unilateral
inguinal herniorrhaphy in 1992.8 In this initial series of 22
patients, an infra-umbilical 3-mm port was placed and a
2-mm, zero-degree telescope was used to visually inspect
the contralateral groin. Fifty per cent of the patients with a
clinically negative groin had an occult hernia, and the
technique was 96 per cent accurate in detecting such hernias. Wolf and Hopkins used the same method in 38 boys
and noted a 52.6 per cent incidence of bilateral hernia.9
Chu and colleagues were the first to perform both insufflation and laparoscopy through the open hernia sac to
visualize the contralateral groin, thus introducing nonpuncture laparoscopy;10 in their series of 74 children, 29
per cent had a second hernia, and there were no false positives or false negatives. Fuenfer and coworkers described
an improved technique in 1996 in which a 14-gauge
angiocath was introduced through the open hernia sac for
intraperitoneal insufflation. A second 14-gauge catheter
was inserted through the abdominal wall on the contralateral side of the abdomen, and a 1.2-mm laparoscope was
passed through this port for direct, in-line visualization of
the contralateral groin.11 They noted a 21 per cent incidence of bilaterality in 110 children. Another technique
described in 1996 employed a 5-mm, 30-degree or 70degree telescope through the open hernia sac.12 This
report, which stratified patients by age, noted that patients
older than 24 months had only a five per cent incidence of
bilaterality, whereas patients younger than 24 months had
a 42.9 per cent incidence of a contralateral hernia. Thus,
they were able to identify patients who might benefit from
contralateral surgery as well as those in whom surgery and
its possible complications could be avoided. Other techniques have since been described, including the use of a
30-degree rigid bronchoscope with a working channel
through which a catheter can be introduced and used to
probe a suspected patent processus vaginalis, providing
even better diagnostic accuracy.13
LAPAROSCOPIC INGUINAL HERNIORRHAPHY

As laparoscopy evolved in children, pediatric surgeons
began to investigate the feasibility of laparoscopic repair
of inguinal hernias. Theoretical advantages included
excellent visual exposure, minimal dissection (and thus
less trauma to the inguinal canal and spermatic cord),
and an improved cosmetic result as compared with the
traditional open approach. In 1997, El-Gohary reported
a series of 28 girls in whom herniorrhaphy was accomplished laparoscopically using one or more endoscopic
loops placed at the base of the inverted hernia sac.14 He
reported that this was an expeditious, effective, and cosmetically superior operation. However, he recommended
that this operation should not be carried out in boys as it

was not possible to exclude the cord structures from the
endoscopic loop ligature. In 1998, Schier described his
technique of placing two to three Z-sutures laparoscopically using intracorporeal suturing and knot-tying techniques to close the neck of the hernia sac.15 Again, the
procedure was limited to girls to avoid the risk of possible damage to the spermatic cord in boys.
Montupet and Esposito were the first to report
successful laparoscopic herniorrhaphy in boys.16 They
specifically applied the laparoscopic approach to boys to
avoid the risks of inadvertent removal of a segment of the
vas deferens, as well as the possible risk of testicular damage (atrophy or high position in the scrotum), which can
occur with the traditional open repair. In their series, 45
boys underwent laparoscopic repair in which an intracorporeal purse-string suture was placed around the
neck of the hernia sac. There were no intraoperative or
post-surgical complications, but two patients developed
a recurrent hernia that required a second laparoscopic
repair. Schier reported his further experience of laparoscopic hernia repair in 2000, concluding that the technique was simple for the experienced laparoscopist, that
cosmesis was superb, and that the procedure was safe in
both sexes.17
Other reports have described the utility of laparoscopy
for direct inguinal hernias and suspected recurrent hernias.18,19 Schier reported that the laparoscopic approach
allowed for easier detection of direct hernias as compared
with the traditional open approach. Out of 109 patients,
five (4.5 per cent) had a direct inguinal hernia. Most of
these hernias were in boys and were on the right side. The
prevalence of direct hernias was higher in this series as
compared with the traditionally accepted rate (0.20.9
per cent) based on two large series of open hernia
repairs,20,21 suggesting that direct hernias may go unrecognized during open repair, and that these cases may
represent some of the recurrences after prior repair for
indirect inguinal hernia. The conclusion was that laparoscopic repair for direct inguinal hernias is more reliable
than open surgery as it is unlikely that an incorrect diagnosis will be made using laparoscopy. Regarding recurrent hernias, Perlstein and Du Bois noted that 44 per
cent of children undergoing laparoscopy for recurrent
inguinal hernias were found to have unsuspected findings, including indirect (missed sacs and true recurrences), direct (unilateral and bilateral), and femoral (all
bilateral) defects.19
Innovative techniques have recently been described for
use in pediatric laparoscopic inguinal hernia surgery. Endo
and Ukiyama introduced the endo-needle, a 19-gauge
hollow needle with a notched tip and pre-attached suture
designed specifically for laparoscopic extraperitoneal
closure of the patent processus vaginalis.22 They used this
instrument in 61 girls and reported no complications or
History 253
Figure 33.1 Demonstration of the positions of the telescope,

the lateral port for the grasper, and the site for insertion of the
ligature passer during laparoscopic inguinal herniorrhaphy in
children.
Figure 33.3 Intraoperative photograph of the nonabsorbable
ligature having been passed around the lateral half of the
hernia sac.
Figure 33.2 Close-up view of the ligature-passer used in

laparoscopic herniorrhaphy.
recurrences. Lee and Liang performed micro-laparoscopic

high ligation in 450 patients, with good results.23 They
reported no complications of the surgery and a remarkably low recurrence rate (0.88 per cent).
In 2001, we began to use a unique technique using
miniature laparoscopic equipment in which a curved
stainless steel awl is used to pass a ligature circumferentially around the neck of the hernia sac. A 1.7-mm needle
scope is introduced through a 2-mm port in or near the
umbilicus, and the abdomen is insufflated with carbon
dioxide gas to 12 mmHg (Figure 33.1). We place a second
2-mm port in the right lateral abdomen. We find this position to be the most useful for traction for both right- and
left-sided hernias. A 1.7-mm laparoscopic grasper, placed
through this second port, is used to manipulate the peritoneum near the hernia defect (right and/or left sides).
The suture-passer (Figure 33.2), introduced through a
stab incision anterolateral to the internal ring, is used to
place a 2-0 nonabsorbable ligature circumferentially at the
neck of the hernia sac. To accomplish this, the suturepasser, with the tie in place through its eyelet, is passed
through the stab incision and the muscle layers to the level
of the peritoneum, or hernia sac. Once the lateral half of
the hernia sac is encircled, the suture-passer pierces the
peritoneum. The ligature is drawn intraperitoneally with
the grasper as the passer is withdrawn (Figure 33.3). The
empty suture-passer is then passed medially around the
hernia sac (again just superficial to the peritoneum), and
the peritoneal cavity is entered at the same point as before.
The ligature is then passed through the eyelet of the
instrument using the grasper so that it can be withdrawn
externally. The ligature is tied extracorporeally, completing
an extraperitoneal high ligation of the sac (Figure 33.4).
The vas deferens and spermatic vessels are seen easily during the ligature placement in males, and it is a relatively
straightforward task to find the tissue plane between
these structures and the hernia sac, ensuring that they
are not included in the ligature. After cutting the excess
suture, the knot retracts subcutaneously. Steri-Strips
(3M Healthcare) are all that are required for skin closure.
The technique adheres to the essential principles of
hernia surgery. We reliably identify and ligate the hernia sac at the level of the internal ring. Additionally, there
is no disruption of the tissues of the inguinal canal.
In males, the spermatic vessels and vas deferens are well
visualized during the circumferential passage of the
suture, ensuring that they are excluded from the repair.
The contralateral inguinal canal is also easily inspected
for the presence of a hernia, which is repaired if present.
Our patients have had minimal postoperative discomfort, and all resume normal activities immediately after
surgery. There is no longitudinal skin incision in the
abdominal wall (only three to four stab incisions), so the
cosmetic result is superior and the risk of infection is less

4
7
8
10
Figure 33.4 Intraoperative photograph of the closed indirect

hernia defect after laparoscopic high ligation of the hernia sac.
11
12
than that of the open approach. In our experience, we

have not noted a single infection in any of the 2-mm stab
incisions. Finally, there have been no major complications and only one recurrence in our patients. We believe
that this technique, as well as others that utilize a circumferential high-ligation of the hernia sac, as opposed to
simple suture closure of the defect with either a pursestring or similar suture, is the most effective means of
repair. There are no gaps in the closure, particularly
medially, where recurrences might occur. Early data in
the literature suggest a lower recurrence rate with these
extraperitoneal, high-ligation techniques.22,23
13
14
15
16
17
18
19
REFERENCES
1
2
Gans SL, Berci G. Peritoneoscopy in infants and children. J Pediatr

Surg 1973; 8: 399405.
McGregor DB, Halverson K, McVay CB. The unilateral pediatric
inguinal hernia. Should the contralateral side be explored?
J Pediatr Surg 1980; 15: 31317.
Given JP, Rubin SZ. Occurrence of contralateral inguinal hernia
following unilateral repair in a pediatric hospital. J Pediatr Surg
1989; 24: 9635.
20
21
22
23
Powell RW. Intraoperative diagnostic pneumoperitoneum in

pediatric patients with unilateral inguinal hernias: the Goldstein
test. J Pediatr Surg 1985; 20: 41821.
Ducharme JC, Bertrand R, Chacar R. Is it possible to diagnose
inguinal hernia by X-ray? A preliminary report on herniography.
J Can Assoc Radiol 1967; 18: 44851.
Evez I, Kovalivker M, Schneider N, et al. Elective sonographic
evaluation of inguinal hernia in children an effective alternative
to routine contralateral exploration. Pediatr Surg Int 1993;
8: 41518.
Brown RK. Hernia diagnosis by transperitoneal probing of the
contralateral groin. Surg Gynecol Obstet 1964; 118: 123.
Lobe TE, Schropp KP. Inguinal hernias in pediatrics: initial
experience with laparoscopic inguinal exploration of the
asymptomatic contralateral side. J Laparoendosc Surg 1992;
2: 13540.
Wolf SA, Hopkins JW. Laparoscopic incidence of patent processus
vaginalis in boys with clinical unilateral inguinal hernias. J Pediatr
Surg 1994; 29: 111821.
Chu C, Chou C, Hsu T, et al. Intraoperative laparoscopy in
unilateral hernia repair to detect a contralateral patent processus
vaginalis. Pediatr Surg Int 1993; 8: 3858.
Feunfer MM, Pitts RM, Georgeson KE. Laparoscopic exploration
of the contralateral groin in children: an improved technique.
J Laparoendosc Surg 1996; 6 (suppl 1): S14.
Zitsman JL. Transinguinal diagnostic laparoscopy in pediatric
inguinal hernia. J Laparoendosc Surg 1996; 6 (suppl 1): S1520.
Saad SA, Goldfarb MA, Danikas D. Groin laparoscopy in pediatric
patients with clinical unilateral hernia: an improved technique
using the bronchoscope. Pediatr Endosurg Innov Tech 1999;
3: 5965.
El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls.
Pediatr Endosurg Innov Tech 1997; 1: 1858.
Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;
33: 14957.
Montupet P, Esposito C. Laparoscopic treatment of congenital
inguinal hernia in children. J Pediatr Surg 1999; 34: 4203.
Schier F. Laparoscopic surgery of inguinal hernias in children
initial experience. J Pediatr Surg 2000; 35: 13315.
Schier F. Direct inguinal hernias in children: laparoscopic aspects.
Pediatr Surg Int 2000; 16: 5624.
Perlstein J, Du Bois JJ. The role of laparoscopy in the management
of suspected recurrent pediatric hernias. J Pediatr Surg 2000;
35: 12058.
Fonkalsrud EW, de Lorimier AA, Clatworthy HW. Femoral and
direct hernias in infants and children. JAMA 1965; 192: 1013.
Wright JE. Direct inguinal hernia in infancy and childhood.
Endo M, Ukiyama E. Laparoscopic closure of patent processus
vaginalis in girls with inguinal hernia using specially devised
suture needle. Pediatr Endosurg Innov Tech 2001; 5: 18791.
Lee Y, Liang J. Experience with 450 cases of micro-laparoscopic
herniotomy in infants and children. Pediatr Endosurg Innov Tech
2002; 6: 258.
34
Anatomy
Physiology
255
255
ANATOMY
A comprehensive review of the anatomy of the inguinal
canal is beyond the scope of this chapter. Chapter 6
describes this anatomy, which does not differ significantly
from the adult patient. However, certain aspects of the
anatomy of the abdominal wall should be considered in
the context of laparoscopy. The layers of the abdominal
wall must be traversed during port placement. The initial
port that we place is the infra-umbilical port through
which the 1.7-mm telescope is placed. We choose to place
this in an infra-umbilical position to reduce the risk of
infection. Ideally, the port traverses the midline. The fascia
of the external abdominal oblique, internal abdominal
oblique, and transversus abdominus muscles, which join
anterior to the rectus muscles inferior to the arcuate line,
are penetrated. The urachus, or median umbilical ligament, is in this area and should be avoided. The lateral
port, through which a grasper is placed for traction,
traverses the same muscles. Structures near the internal
inguinal ring, where the hernia sac is ligated, must be considered. In our technique, the suture is passed through all
layers of the abdominal wall that are superficial to the peritoneum or hernia sac. In males, the spermatic vessels, the
genital branch of the genitofemoral nerve, and the vas deferens pass superficial to the sac, and great care is taken not
to include these structures in the ligature. The external
iliac vessels are near but deep to the ligature. They should
be visualized and, obviously, avoided. Similarly, the inferior epigastric vessels, which are branches of the external
iliac vessels, are easily identified and avoided. Once tied
and cut, the permanent suture that we use to perform the
high ligation of the sac retracts into the subcutaneous
References
256
tissue and has not caused any wound complications in our

experience.
PHYSIOLOGY
Physiological factors to consider during pediatric laparoscopic hernia surgery are essentially identical to those for
any other intra-abdominal laparoscopic procedures performed in children. The cardiovascular and respiratory
effects of pneumoperitoneum are the issues that most
often raise interest for the surgeon and anesthesiologist
alike. The extremes of patient positioning, postoperative
pain management, and postoperative nausea and vomiting also deserve consideration.
Insufflation of carbon dioxide gas is essential for
proper visualization during pediatric laparoscopic hernia surgery. In general, lower volumes and pressures
(612 mmHg) are required than in adult patients. We use
a Veress needle inferior to the umbilicus for insufflation
and placement of the telescope. In our hands, the risks of
visceral injury and pre-peritoneal insufflation are low
with this technique. Carbon dioxide approaches the ideal
insufflating gas, and is the gas used most often.1 It does
not support combustion, and residual intraperitoneal gas
is absorbed rapidly and subsequently excreted. The major
drawback of carbon dioxide is its rapid intravascular
absorption across the peritoneal lining, which can lead to
hypercapnea during long procedures. This is generally
not of concern in pediatric laparoscopic inguinal hernia
surgery, as the procedures are relatively short.
The pneumoperitoneum itself creates cardiovascular,
respiratory and neurological effects in infants and
256 Laparascopy in the pediatric hernia patient
children. In an investigation involving 12 healthy infants,

a pressure of 10 mmHg resulted in a decrease in aortic
blood flow and cardiac stroke volume and an increase in
systemic vascular resistance, when compared with controls.2 These changes, however, were reversed after peritoneal exsufflation and caused no clinically deleterious
effects in healthy infants. In a study of the effects of
pneumoperitoneum in pediatric hernia patients, a pressure between 6 and 12 mmHg did not cause clinically significant changes in cardiac index or systemic vascular
resistance.3 These cardiac effects may be exaggerated by
patient positioning during laparoscopy, particularly with
the reverse Trendelenburg position when venous return
and cardiac output are further decreased.4 However, in
the Trendelenburg position, as may be used for laparoscopic hernia surgery, venous return is augmented and
blood pressure returns to normal or supranormal levels.
Other potential sources of cardiovascular compromise
during laparoscopic hernia surgery include vasovagal
reflex, myocardial sensitization by halothane, hypovolemia, and venous gas embolism.1
Deleterious respiratory effects during laparoscopy are
the result of upward displacement of the diaphragm. This
may result in early closure of small airways, an increase
in peak airway pressure, and a reduction in functional
residual capacity.1 These effects may be accentuated with
positive-pressure ventilation and Trendelenburg positioning in herniorrhaphy. Tobias and colleagues demonstrated that an intra-abdominal pressure of 15 mmHg in
children during inguinal laparoscopy increased the airway pressure by a mean of 3 cm water, and end-tidal carbon dioxide increased by a mean of 3 cm water.5 These
values returned to normal within ten minutes of the
completion of surgery.
Increased intra-abdominal pressure can also result in
increased intracranial pressure and, thus, a decrease in cerebral perfusion pressure.6 Consequently, it may be inadvisable to perform laparoscopic hernia surgery in patients
with the potential for neurological complications.
Control of pain and anxiety in the perioperative period
is no different for laparoscopic hernia surgery than for
other laparoscopic operations, except for certain adjuncts
that may be useful specifically for the pediatric hernia
patient. Premedication is a matter of routine surgical care.
Atropine is useful to prevent some of the possible deleterious cardiorespiratory events that may occur, such as the
vasovagal reflex. Intraoperatively, general endotracheal
anesthesia is our choice. Conversely, Tobias and colleagues

have suggested that general face-mask anesthesia plus
spontaneous ventilation with concurrent caudal block
may be useful for short diagnostic procedures.7 However,
this would likely be cumbersome for actual herniorrhaphy, which occasionally can be a difficult and long
procedure.
Postoperative pain management is less of a concern
for laparoscopic herniorrhaphy compared with open
inguinal hernia repair. In our experience, patients seem
to have less discomfort and very rarely require a narcotic
analgesic. Stretching of the peritoneum and phrenic
nerves secondary to peritoneal insufflation, which can
result in shoulder pain, has not occurred in our experience. Complete exsufflation is important in avoiding this
postoperative complaint. Local anesthetic infiltration at
the puncture sites as well as perioperative caudal block
may be useful adjuncts to ameliorate postoperative pain.
In the vast majority of cases, our patients have required
only paracetamol (acetaminophen) for pain control. They
are all able to return to immediate unrestricted activity. Postoperative nausea and vomiting, which can be
problematic after laparoscopy, has not occurred in our
experience with pediatric laparoscopic herniorrhaphy.
REFERENCES
1
2
4
5
6
Pennant JH. Anesthesia for laparoscopy in the pediatric patient.

Anesthesiol Clin North Am 2001; 19: 6988.
Gueugniaud PY, Abisseror M, Moussa M, et al. The hemodynamic
effects of pneumoperitoneum during laparoscopic surgery in
healthy infants: assessment by continuous esophageal aortic blood
flow echo-Doppler. Anesth Analg 1998; 88: 4689.
Sakka SG, Huettemann E, Petrat G, et al. Transoesophageal
echocardiographic assessment of haemodynamic changes during
laparoscopic herniorrhaphy in small children. Br J Anaesth 2000;
84: 3304.
Joris JN, Noirot DP, Legrand MJ, et al. Hemodynamic changes
during laparoscopic cholecystectomy. Anesth Analg 1993; 76: 1067.
Tobias JD, Holcomb GW, Brock JW, et al. Cardiorespiratory changes
in children during laparoscopy. J Pediat Surg 1995; 30: 33.
Bloomfield GL, Ridings PC, Blocher CR, et al. Effects of increased
intra-abdominal pressure upon intracranial and cerebral
perfusion pressure before and after volume expansion.
J Trauma 1996; 40: 936.
Tobias JD, Holcomb GW, Brock JW, et al. General anesthesia by
mask with spontaneous ventilation during brief laparoscopic
inspection of the peritoneum in children. J Laparoendosc Surg
1994; 3: 379.
35
Diaphragmatic herniation
History
Patient selection
Surgical technique: Bochdalek hernia
257
257
257
HISTORY
In 1848, the anatomist Vincent Bochdalek described
two postmortem cases of diaphragmatic hernia. In 1902,
Heidenhaim was the first to successfully repair such a
defect in a child. Four decades later, Ladd and Gross
described the repair of a diaphragmatic hernia in an infant.
Thereafter, there was a steady increase in the success of
repair of diaphragmatic hernias up to the 1970s, when
survival reached a plateau and the physiological effects
of persistent pulmonary hypertension and bilateral pulmonary hypoplasia were better appreciated. Since then,
there has been slower progress in the surgical approach to
this disease. The greatest advance has been with the application of extracorporeal membrane oxygenation (ECMO).
The most significant change in the postnatal management
of diaphragmatic hernias since ECMO has been the advent
of minimally invasive techniques of repair. In 1995, van
der Zee and Bax described the laparoscopic repair of a
posterolateral diaphragmatic hernia in a six-month old
infant.1 Since then, anterior Morgagni and posterolateral
Bochdalek defects have been treated with minimally invasive techniques by experienced laparoscopists in stable, less
critically ill infants.
PATIENT SELECTION
The minimally invasive approach to diaphragmatic hernias should be considered only in infants who are hemodynamically stable, who are without signs of pulmonary
Surgical technique: Morgagni hernia

Results
References
258
259
259
hypertension, and who are on either oxygen by nasal cannula or minimal conventional ventilator settings. Older
children who present either incidentally or with minimal
symptoms are also suitable candidates.2
SURGICAL TECHNIQUE: BOCHDALEK

HERNIA
Posterolateral Bochdalek hernias may be approached
through either the chest or the abdomen, depending on
the preference of the surgeon. Supporters of the thoracoscopic route state that the herniated viscera are reduced
easily with carbon dioxide insufflation.3,4 Those who
support the laparoscopic approach state that the instruments are manipulated more easily and that the reduced
viscera can be inspected easily for possible injury.5
For thoracoscopic repair, at least three ports are necessary: two 3-mm working ports and a 5-mm port for
the camera (Figure 35.1). Carbon dioxide insufflation,
as stated above, helps to reduce the herniated viscera. A
hernia sac, if present, is resected as the defect is sutured
(Figure 35.2).2 If a hypoplastic lung is present, as is often
the case, then visualization is actually easier. Following
completion of the repair, a pleural catheter is placed
through the 5-mm port site.
For laparoscopic repair, three to five ports are needed.
An umbilical port is used to pass a 5-mm, 30-degree
telescope. Two working ports (one 3 mm, one 5 mm)
are essential. Additionally, a port for a liver retractor and
an extra port for retraction by an assistant are useful.
258 Laparascopy in the pediatric hernia patient
Figure 35.1 Port placement for the thoracoscopic repair of a

Bochdalek hernia.
Figure 35.2 Endoscopic view of a thoracoscopic Bochdalek

hernia repair.
The viscera are reduced into the abdominal cavity, and

the sac, if present, is resected first. We close the defect
with 2-0 Ethibond (Ethicon, Inc.) sutures placed in an
interrupted fashion. The viscera are inspected for injury
at the completion of the repair.
SURGICAL TECHNIQUE: MORGAGNI

HERNIA
Morgagni hernias occur as anterior retrosternal or
parasternal defects. Embryologically, they occur where
the septum transversum joins the chest wall in the area
where the mammary vessels pass from the chest to the
abdomen. These defects are rare, accounting for only one
to two per cent of congenital diaphragmatic defects.
Associated anomalies can occur, particularly heart
defects, as this type of hernia is one component of the
Figure 35.3 Port placement for Morgagni hernia repair.
Figure 35.4 Laparoscopic view of a Morgagni hernia repair

using nitinol clips and a porcine submucosal patch.
pentalogy of Cantrell. These defects are often asymptomatic. They may not be diagnosed until well after the
neonatal period, either as an incidental finding on chest
radiography or during the work-up of respiratory symptoms in an older child.
Morgagni hernias are repaired through the abdomen.
Three ports are necessary. A 5-mm port at the umbilicus is
used to place a 30-degree telescope, and a 3-mm right
abdominal port and a 5-mm left abdominal port are placed
for instruments (Figure 35.3). The hernia contents are then
reduced. The sac is resected, and the hernia defect is closed
using 2-0 Ethibond sutures placed in an interrupted fashion. More recently, we have repaired a Morgagni hernia
laparoscopically using an alternative closure device. In this
case, we used clips of nitinol, a shape-memory metal
(U-CLIP, Coalescent), to secure a prosthetic patch over the
defect (Figure 35.4). Alternatively, a running suture of
barbed Prolene (Ethicon, Inc.) is used by some surgeons to
complete the repair in order to prevent slippage of the
suture.4
Diaphragmatic herniation 259
Morgagni hernias, as well as Bochdalek hernias that are

large, may require the insertion of a prosthetic patch, as
stated above, for adequate closure. Expanded polytetrafluoroethylene (ePTFE) (Gore-Tex, W. L. Gore & Associates,
Inc.) or porcine small-intestinal submucosal (Surgisis,
Cook Surgical) patches are both suitable. A potential
advantage of the latter is that the tissue collagen replaces
the collagen of the Surgisis, which may enhance the
strength and longevity of the closure.
RESULTS
The results of Bochdalek and Morgagni herniorrhaphy are
similar. The postoperative course of the patient is highly
dependent on the preoperative condition of the patient.2
In patients who do not require mechanical ventilation or
are weaned from it preoperatively, the postoperative
course is usually straightforward. Postoperative pain is
minimal, and the recovery is often rapid, particularly in
patients who are asymptomatic before the discovery of the

defect. Often, feeding can be initiated in the immediate
postoperative period, and the patient can be discharged
2448 hours following operation.
REFERENCES
1
Van der Zee DC, Bax NM. Laparoscopic repair of congenital

diaphragmatic hernia in a 6-month old child. Surg Endosc 1995;
60: 44850.
2 Ferro MM. Video-assisted repair of diaphragmatic defects. In: Lobe
TE, ed. Pediatric Laparoscopy. Georgetown, TX: Landes Bioscience,
2002, in press.
3 Farmer DL, Sydorak R, Harrison MR, et al. Thoracoscopic repair of
neonatal congenital diaphragmatic hernia. Pediatr Endosurg Innov
Tech 2000; 4: 98.
4 Berchi FJ, Allal H, Cano I, et al. Diaphragmatic conditions in infants
and children: endosurgery repair perspectives. Pediatr Endosurg
Innov Tech 2001; 4: 65.
5 Smith J, Ghani AJ. Morgagni hernia: incidental repair during
laparoscopic cholecystectomy. Laparoendosc Surg 1995; 5: 1235.
36
Anesthetic complications
Surgical complications
Recurrence
261
261
262
ANESTHETIC COMPLICATIONS
Anesthetic complications include deleterious cardiovascular and respiratory effects, such as decreased cardiac
output, hypercapnea, shunting and atelectasis due to peritoneal insufflation, and the extremes of patient positioning.1 Premedication, which includes the use of atropine,
may alleviate these effects. The choice of anesthetic agent
may differ in laparoscopic hernia surgery. For instance,
nitrous oxide is avoided due to the increased incidence of
bowel distention, which will obscure the view during
laparoscopy. A balanced anesthetic technique using controlled ventilation with inhalation agents (sevoflurane,
desflurane or isoflurane), intravenous opioids, and nondepolarizing muscle relaxants is preferred.2 Patient selection is important, and those patients at greater risk than
usual for the above complications, such as premature
infants or children with cardiopulmonary disease, should
not be considered for laparoscopic herniorrhaphy.
SURGICAL COMPLICATIONS
Adherence to meticulous technique is the best way to
prevent surgical complications. The laparoscopist should
consider their experience and level of comfort before
embarking on or continuing difficult operations. One
should attempt more complex operations only after simpler operations are mastered. Also, one should always
consider the option to open when difficulty is encountered. Of course, this possibility should always be presented to the patient and family preoperatively.
Hydrocele and testicular atrophy

References
262
262
Chen and colleagues reviewed the surgical complications that occurred in all patients undergoing laparoscopy
or thoracoscopy over a five-year period.3 Thoracoscopy
was performed in 62 children, with a 13 per cent rate
of conversion to thoracotomy, and laparoscopy was
performed in 574 children, with a 2.6 per cent rate of
conversion to laparotomy. The reasons for conversion to
laparotomy included hemorrhage, esophagotomy during
fundoplication, and malpositioned fundoplication. A case
of a gastric volvulus after fundoplication and gastrostomy
required a laparotomy in the postoperative period and
was the result of a malpositioned gastrostomy tube. Other
complications in the postoperative period included two
children who developed hernias at the umbilical trocar
sites used for contralateral groin exploration. Trocarsite cellulitis developed in three patients after laparoscopic gastrostomy in which the tube was brought out
through the left upper quadrant port site. Other complications following laparoscopy included five instances of
pelvic abscess after appendectomy, small-bowel obstruction after jejunostomy as well as after combined
appendectomy/cholecystectomy, one case of enterocolitis
after pull-through for Hirschsprungs disease, and one case
of pneumonia after splenectomy. There were no deaths,
and complications were noted to decline with increased
experience.
Thus far, we, and others who perform laparoscopic
herniorrhaphy, have experienced very few surgical complications. In their series of 450 patients undergoing
laparoscopic herniorrhaphy, Lee and Liang had no operative complications.4 Schier and coworkers reported a
series of 933 laparoscopic herniorrhaphies in boys and
girls in whom no intraoperative complications occurred
other than minor bleeding from peritoneal vessels in

three patients.5 We have had one conversion to open
herniorrhaphy following pre-peritoneal insufflation.
This resulted in distortion of the pre-peritoneal plane
through which the ligature and passer must be directed.
The subsequent open procedure was completed uneventfully. There have been no cases of hemorrhage or visceral
injury in our series of patients.
RECURRENCE
The reported recurrence rate after traditional open
inguinal herniorrhaphy is 0.9 per cent. In their multicenter experience, Schier and colleagues had a recurrence rate
of 3.4 per cent, higher than that for open repair.5 Their
technique of closure with either a purse-string suture or a
Z-suture potentially left a gap in the herniorrhaphy medially, because they noted that all recurrences occurred at
the medial margin between the suture and the epigastric
vessels. Other reported series with smaller numbers of
patients have had recurrence rates between zero and 4.4
per cent.69 Lee and Liang used a circumferential closure
as their herniorrhaphy technique, and their recurrence
rate in 450 cases was only 0.88 per cent.4 In our experience in approximately 50 patients with a follow-up of ten
to 15 months, there have been no recurrences. We also use
a circumferential ligature placed at the neck of the hernia
sac, which leaves no gap. This may be a more effective
means of closure of the hernia defect.
Perlstein and Du Bois used diagnostic laparoscopy in
19 patients with recurrent inguinal hernias.10 Seventeen
indirect hernias and one femoral hernia were repaired at
the original procedure. One child had no hernia identified during the primary procedure. Overall, 11 recurrences were indirect hernias, four were direct hernias,
and four were found to be femoral hernias. Forty-four
per cent of these patients had unsuspected findings at
diagnostic laparoscopy (contralateral indirect, direct or
femoral hernias). Recurrent hernias themselves can be
managed effectively with laparoscopy and laparoscopic
repair.11 Direct hernias can be detected at the time of
repair of recurrences, suggesting that they might have
been missed at the initial operation.
HYDROCELE AND TESTICULAR ATROPHY

We consider a non-communicating hydrocele that
is present preoperatively, alone or in conjunction with an
ipsilateral hernia, to be a relative contraindication for

laparoscopic hernia repair in infants and children. Others,
however, repair these defects laparoscopically. Postoperative hydrocele as a complication of laparoscopic herniorrhaphy is a different entity. We have not yet seen any
postoperative hydroceles in our series of patients. In their
large series, Schier and colleagues reported a 0.4 per cent
incidence of postoperative hydroceles.5 Testicular atrophy, presumably from damage to the spermatic vessels or
a high-riding testis (iatrogenic cryptorchidism), are also
concerns, but these seem to occur only rarely. We have not
encountered either of these complications, and Schier
and colleagues have had only one patient with a highriding testis postoperatively.5 It is difficult to predict
which patients will develop either of these complications
postoperatively. Again, meticulous technique is likely to
be the best measure for preventing these rare but real
complications.
REFERENCES
1
2
3
4
6
7
8
9
10
11
Pennant JH. Anesthesia for laparoscopy in the pediatric patient.

Anesthesiol Clin North Am 2001; 19: 6988.
Tobias JD. Anesthetic considerations for laparoscopy in children.
Semin Laparosc Surg 1998; 5: 60.
Chen MK, Schropp KP, Lobe TE. Complications of minimal access
surgery in children. J Pediatr Surg 1996; 31: 11615.
Lee Y, Liang J. Experience with 450 cases of micro-laparoscopic
herniotomy in infants and children. Pediatr Endosurg Innov Tech
2002; 6: 258.
Schier F, Montupet P, Esposito C. Laparoscopic inguinal
herniorrhaphy in children: a three center experience with 933
repairs. J Pediatr Surg 2002; 37: 3957.
El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls.
Pediatr Endosurg Innov Tech 1997; 1: 1858.
Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;
33: 14957.
Montupet P, Esposito C. Laparoscopic treatment of congenital
inguinal hernia in children. J Pediatr Surg 1999; 34: 42023.
Schier F. Laparoscopic surgery of inguinal hernias in
children initial experience. J Pediatr Surg 2000; 35: 13315.
Perlstein J, Du Bois JJ. The role of laparoscopy in the management
of suspected recurrent pediatric hernias. J Pediatr Surg 2000; 35:
12058.
Schier F. Direct inguinal hernias in children: laparoscopic aspects.
PART
Future considerations
37 Robotics and hernia surgery
265
38 Socioeconomic issues
273
37
Robotics and hernia surgery
AMIT TRIVEDI AND GARTH H. BALLANTYNE
AESOP robotic arm

Da Vinci and Zeus tele-robotic systems
Tele-robotic laparoscopic ventral and
incisional hernia repair
265
268
Conclusion
References
272
272
270
Over the past several years, there has been an ever-increasing presence of robotics in the operating room. These
devices have been designed to help the surgeon overcome
the limitations of conventional open surgery and laparoscopic surgery. These limitations range from the decreasing availability of qualified surgical assistants, through the
limited dexterity offered by conventional laparoscopic
instruments, to the lack of a three-dimensional operating
field.1 The potential advantages of such systems set the
stage for the next major change in the field of surgery. As
availability increases and costs decline, proficiency with
such devices will be required by all future generations of
surgeons. Additionally, the demands of patients for a
robotic operation are expected to increase as more media
attention is placed on this technology.
Currently there are three Food and Drug Administration (FDA)-approved devices on the market that facilitate
surgery: the AESOP robotic arm (Computer Motion,
Inc.), the da Vinci tele-robotic system (Intuitive Surgical),
and the Zeus tele-robotic system (Computer Motion
Inc.). The use of these devices has a definite learning
curve that often deters busy surgeons from investing the
time required to become proficient in this technology.2
This chapter aims to serve as an introduction to the use
of robotic devices in laparoscopic hernia surgery by outlining the potential advantages of the technology. The
aforementioned devices have been used in inguinal, ventral and diaphragmatic hernias. The frequency with which
these cases are encountered by the general surgeon makes
hernia surgery an ideal platform on which to develop and
refine the skills needed to perform more challenging cases

with the use of robotics.
AESOP ROBOTIC ARM

The AESOP robotic arm uses proprietary speechrecognition technology as the interface between the surgeon and the robotic arm. Simple voice commands are
used to direct the field of view of the laparoscope. The
advantages of this technology include 24-hour availability, thereby eliminating the need for an assistant to hold
the camera for a wide variety of laparoscopic operations,
including inguinal hernia procedures. Additionally, the
field of view is controlled by the surgeon and is completely free of tremor and straying.
AESOP solo-surgeon laparoscopic

hernia repair
Since 1995, over 500 laparoscopic totally extraperitoneal
(TEP) and transabdominal pre-peritoneal (TAPP) patch
hernia repairs have been performed at our institution
using the AESOP robotic arm. The majority of these have
been TEP repairs performed by a single practitioner as a
solo surgeon operation.3
Because AESOP uses voice recognition as the interface between surgeon and the robotic arm, before using
AESOP for the first time each surgeon must create a voice
card that recognizes his or her individual voice. Frequent
266 Future considerations
use at our institution allows AESOP to be set up in less

than ten minutes.
Technique
After bilateral pneumatic compression boots are placed on
the patient, general anesthesia is induced and a Foley
catheter is placed to decompress the bladder. A single dose
of preoperative antibiotics is given approximately one hour
before incision. The surgeon puts on the voice-control
headset before scrubbing and performs the operation from
the side opposite to the hernia. Laparoscopic monitors are
placed at the foot of the bed (Figure 37.1). The AESOP
robotic arm is mounted on the table before prepping the
patient. The central articulated arm of AESOP is positioned over the patients umbilicus. Once the patient is
draped, a sterile plastic sleeve is placed over the robotic arm
and the arm is positioned manually over the operative field.
A 1-cm vertical para-umbilical incision is made on the
ipsilateral side of the hernia. The incision is made approximately 0.75 cm lateral to the umbilicus. The incision is
carried down through the fat until the anterior rectus
sheath is identified clearly. A 0.75-cm vertical incision is
then made through the anterior rectus sheath, exposing
the underlying rectus fibers. The medial edge of the rectus
muscle is identified and the fibers are then pushed laterally
Figure 37.1 Set-up of the operating room for a solo-surgeon

laparoscopic inguinal hernia repair. An electronically integrated
operating room facilitates advanced laparoscopic operations.
The laparoscopic equipment is suspended from the ceiling by
booms, allowing easy movement. The laparoscopic equipment
can be controlled either by the scrub nurse via a touch screen
(not draped in this photograph) or by the surgeon via voice.
An array of flat-screened digital and analog monitors are
distributed around the feet of the patient. This ensures that
the surgeon can view the laparoscopic video image in an
ergonomically comfortable position throughout the operation.
by the use of an S-retractor. This maneuver exposes the

posterior rectus sheath. Using blunt finger dissection, the
space between the rectus muscle anteriorly and the posterior rectus sheath is developed. A stay suture is placed,
which encompasses the anterior rectus sheath laterally
and the midline fascia.
The patient is dropped into a Trendelenburg position
(Figure 37.2). An Origin Medsystems balloon dissector is
then inserted into the space between the rectus muscle and
the posterior rectus sheath. It is passed down gently parallel to the midline until the tip reaches the pubic bone. Care
is taken during this step to keep a slightly upward slant to
the balloon dissector tip, so as to avoid inadvertent entry
into the peritoneal space and possible bowel injury. A
10-mm, zero-degree telescope is inserted through the
trocar, and the balloon is inflated according to the manufacturers specifications under direct visualization. The
balloon is kept inflated for approximately five minutes to
allow for hemostasis. Next, the balloon is withdrawn and
the pre-peritoneal space is insufflated to a pressure of
12 mmHg. Once the pre-peritoneal space is insufflated, a
5-mm trocar is placed in the suprapubic position and
another 5-mm trocar is placed in the midline between
the umbilical port and the suprapubic port.
At this point, the laparoscope is changed to a 45-degree,
10-mm telescope. Trial and error have established that this
angled telescope offers the best field of view and the least
interference with the working ports. The telescope is premounted with a coupler that enables the telescope to be
attached to the AESOP robotic arm via a strong magnet.
The telescope is positioned such that the angle is looking
upwards and the operative horizon is horizontal. Once
positioned, the AESOP robotic arm will maintain these
Figure 37.2 Position of the patient and the surgeon for solosurgeon robot-assisted laparoscopic hernia repair. The patient is
in a mild Trendelenburg position. A three-trocar technique is
used: one port for the video-telescope and two ports for the
surgeons right and left hands. A voice-controlled robot, AESOP,
holds the video-telescope.
Robotics and hernia surgery 267
preset angles as it is directed to move the camera anywhere

in the operative field. It has been our consistent experience
that the camera does not have to be removed or manipulated until the placement of the mesh. The constant need
to remove the camera for cleaning is reduced considerably
with AESOP compared with the use of surgical assistants.
Additionally, the surgeons anatomical orientation is
maintained much better when using an angled camera in
a confined space with the use of AESOP. Lastly, the operative surgeon retains control over the now tremor-free field
of view.4 The simple voice commands available to the surgeon with AESOP include move in, move out, move left,
move right, move up, and move down.
In the TEP method, the hernia sac is bluntly dissected
free from the surrounding fat and cord structures. Once
this is done, the camera is disconnected from the robotic
arm and removed. A large piece of Prolene mesh is passed
through the umbilical port and into the pre-peritoneal
space. The camera is reinserted, and the mesh is positioned
to cover the direct, indirect and femoral spaces. A minimal
number of spiral tacks is used to secure the mesh in place.5
The pre-peritoneal space is deflated and the ports are
withdrawn. The fascia is closed at the umbilical port and
a subcutaneous suture of the ports is preformed after
0.25 per cent bupivacaine infiltration.
Moreover, the need to connect and disconnect sophisticated equipment for each operation leads to equipment
malfunction. Electronic integration of operating rooms
facilitates advanced laparoscopic operations, improves
turnover times, and provides a more pleasant working
environment. Computer Motion first introduced voice
control for AESOP and then extended it to other laparoscopic electronic equipment with HERMES. Storz
Endoscopy has recently introduced a similar system
SESEM that uses both touch-control panels and voice
control (Figure 37.1). These integrated control systems
facilitate advanced laparoscopic operations by permitting
the surgeon to control most aspects of the operating room.
AESOP decreases the footprint of the camera holder.
In many laparoscopic operations, the camera holder interferes with the excursion arcs of the surgeons arms. The
surgeon and the camera holder often stand in uncomfortable positions. In contrast, AESOP permits the surgeon to stand erect in an ergonomically comfortable
position (Figure 37.3). There is no crossing of arms with
the camera holder. AESOP decreases the fatigue of the
surgeon in these solo operations.
Advantages
The advantages of using the AESOP robotic arm in this
setting are clear. The use of the arm facilitates a solo-surgeon operation, provides a stable camera platform, further
integrates the surgeons control of the operating room,
and promotes an ergonomically advantageous posture.
Solo-surgeon operations have been also reported for
laparoscopic cholecystectomy, laparoscopic Nissen fundoplication, and laparoscopic colectomy.4,6 In our hospital,
the number of surgical residents available to assist in operations is dropping. As a result, we frequently perform these
operations with the assistance of only a scrub nurse or
technician. The use of AESOP keeps both of the assistants
hands free to pass instruments, prepare the mesh, and
maintain surgical counts.
AESOP provides a stable camera platform. The video
image remains properly oriented to the horizon. This
avoids motion sickness in the operating-room staff and
helps to maintain the surgeons orientation within the
operative field. Telephone calls, conversations with the
nurses, and boredom do not distract from AESOP.
The video image does not wander off the operative field,
and the number of times the telescope requires cleaning
is decreased.6
Advanced laparoscopic operations increase the complexity of the operating-room environment. The need to
roll various electronic towers and auxiliary equipment
into the operating room slows turnover of operations.
Figure 37.3 The surgeon wears a microphone through which

he or she controls the robotic camera-holder and laparoscopic
equipment. The voice-controlled robotic camera holder works
unobtrusively, without interfering with the stance or arm
movements of the surgeon. The overhead surgical light supports
a video camera in its center for telecasting outside views of the
operation.
The use of AESOP for laparoscopic hernia operations

allows for the steady flow of the operation without
breaking the momentum with distractions such as camera cleaning or a moving operative field. Additionally, the
consistency of the dissection required in laparoscopic
hernia repairs aids in the learning curve of the robot.
After more than 500 laparoscopic hernia repairs by a
single surgeon at our institution, operative times are
now typically 45 minutes for a unilateral hernia repair
and 60 minutes for a bilateral repair.
DA VINCI AND ZEUS TELE-ROBOTIC

SYSTEMS
The FDA has approved two tele-robotic surgical systems
for use in general surgical operations within the USA: the
da Vinci (Intuitive Surgical) and the Zeus (Computer
Motion, Inc.). The two tele-robots differ in certain features
(see below). In tele-robotic surgery, the surgeon sits at a
computer console remote from the patient (Figure 37.4).
The computer controls robotic surgical instruments that
perform the operation. The computer translates the
motions of the surgeons hands into motions of the robotic
instruments and refines the motion by eliminating tremor
and allowing for motion scaling. The FDA currently
requires the surgeon who performs the operation to be in
the same operating room as the patient; however, the technology permits the surgeon to sit thousands of miles away
from the patient. Marescaux performed a tele-robotic
laparoscopic cholecystectomy on a patient in Strasbourg,
France while sitting at a Zeus surgeons console in New
York City.7
Figure 37.4 Surgeons console and hand masters for da Vinci

tele-robotic surgery. The surgeon views a virtual threedimensional operative field through binoculars in the surgeons
console. The surgeon places his or her hands into the masters,
which translate the motions of the surgeons hands into motions
of the robotic instruments (insert).
Da Vinci
The da Vinci tele-robotic surgical system was designed
from scratch to perform tele-robotic operations within a
virtual operative field. Da Vinci telecasts a true threedimensional field of view. This is accomplished with a
special 12-mm laparoscope that has two smaller 5-mm
telescopes within it. The video images from the two 5-mm
telescopes remain separate and are projected on to two
separate monitors within the surgeons console. The surgeon sees the left console with their left eye and the right
monitor with their right eye, much like using field binoculars (Figure 37.4). This telecast system purposely isolates
the surgeons field of view. The surgeon gets the sense of
immersion within a virtual three-dimensional operative
field. This helps the surgeon to maintain their orientation
within the operative field despite their remote location.
The surgeon controls the robotic instruments by placing their hands within the masters (Figure 37.4 insert).
A foot pedal determines whether the masters are controlling the camera or two robotic surgical instruments. The
da Vinci robotic instruments offer hand-like motions.
The robotic instruments move with seven degrees of freedom, like the human wrist. These hand-like motions
overcome the limitations of traditional straight laparoscopic instruments. Da Vinci also offers motion scaling.
The computer translates coarse movements of the surgeons hands into finer motions of the robotic instruments. Buttons on the surgeons console set the motion
scaling to one-, three- or five-to-one scales. The computer
also performs a fast Fourier transform (FFT) on the
hand motions. This allows identification and filtering
of periodic motions such as tremors. This adds to the
precision of robotic surgical instruments.
The da Vinci robotic tower holds three robotic
arms (Figure 37.5). The robotic arms are attached to
laparoscopic trocars. The tower does not attach to the
operating table. The robotic arms must be separated
Figure 37.5 The da Vinci electronics tower and four robotic arms.
The electronics tower holds the video and electronics equipment
for the stereoscopic telescope. In this prototype, the robotic tower
holds four robotic arms. One arm holds the camera and the other
three hold robotic laparoscopic surgical instruments.
from the trocars whenever the surgical table is repositioned. The FDA has recently approved use of a fourth
arm with the da Vinci system, which became available
commercially in 2003.
Zeus
Zeus evolved from AESOP. Zeus consists of a surgeons
console and three modified AESOPs that attach directly
to the surgical table. The surgeon sits at a computer console with an open architecture (Figure 37.6). The surgeon maintains direct visual contact with the patient and
the operative field. The surgeon controls movements of
the camera with voice commands and controls the
robotic instruments with the two hand interfaces (Figure
37.6 insert). This permits simultaneous control of all
three robotic arms. The voice-control system, Hermes,
can also control other electronics equipment in the operating room.
Zeus offers a three-dimensional image but with a
technology that is different to that of da Vinci. In the
Zeus system, alternating images from the left and right
video cameras are projected on to the main monitor.
Polarizing filters permit the surgeons right eye to see
only the right image and the left eye the left image. This
causes a three-dimensional image to project out from the
two-dimensional monitor.
Zeus provides hand-like motions for the robotic
instruments. The Zeus instruments move with six
degrees of freedom, compared with the seven of da Vinci.
This means that the surgeon must compensate for one
less degree of freedom by moving the robotic arm in
various directions.
Figure 37.6 Zeus surgeons console and hand device. The

surgeon sits at a computer console with an open architecture.
The surgeon sees the operative field in a three-dimensional video
projection from the main monitor. Other flat-screen monitors
display controls for the surgical instruments. The insert shows
the Zeus hand interface.
The three modified AESOP arms attach directly to the

surgical table (Figure 37.7). The surgical instruments are
inserted into the abdomen through standard laparoscopic trocars. Movements of the surgical table do not
require repositioning of the AESOP arms. This is advantageous in advanced laparoscopic procedures, such as
colectomy, in which the patient is repositioned several
times during the course of the operation.
We believe that these tele-robotic surgical systems
offer specific technologic solutions to specific limitations
of traditional laparoscopic surgery. Both Zeus and da
Vinci project three-dimensional operative fields. This
helps the surgeon to maintain their orientation and
also helps to avoid complications generated by past
pointing. The hand-like motions of the robotic instruments replace the extreme limitations of straight laparoscopic instruments. Motion-scaling and tremor-filtration
increase significantly the precision of laparoscopic tasks
such as suturing. The surgeon sits in an ergonomically
comfortable position at the computer console.
Surgeons face a learning curve before mastering
tele-robotic surgery. Before the use of these devices,
surgeons and operating-room staff must attend an
FDA-approved training course. After completion of this
Figure 37.7 Zeus robotic arms. The three robotic arms attach
directly to the surgical table. The camera holder is a modified
AESOP that is voice-controlled by the surgeon. The two other
arms are AESOPs that have been modified to hold robotic
surgical instruments.
course, individual hospitals may have specific requirements for granting privileges towards the use of this
emerging technology.8 In our hospital, we require that
surgeons practice tele-robotic operations in live animal
models, act as a first assistant in five to ten operations,
and are then observed by a proctor for an additional
five to ten operations. This process for granting clinical
privileges has successfully introduced tele-robotic surgery
safely into clinical practice at our hospital.
TELE-ROBOTIC LAPAROSCOPIC VENTRAL

AND INCISIONAL HERNIA REPAIR
We obtained two da Vinci systems in November 2000. We
initiated our clinical experience with da Vinci by performing a series of tele-robotic laparoscopic cholecystectomies.9
After demonstrating that we could perform cholecystectomies with outcomes similar to our standard laparoscopic
cholecystectomy, we used the da Vinci system for Nissen
fundoplication, colectomy, and incisional ventral hernia
repair. The use of tele-robotic systems for a wide range of
general, urology and cardiac surgery procedures has been
described elsewhere.1014 We have found that the da Vinci
tele-robotic surgery system facilitates the performance of a
laparoscopic Stoppa ventral hernia repair.
placed on the anterior axillary line above and below the

camera port (Figure 37.8).
This operation begins by using a solo-surgeon technique. The scrub technician changes the instruments as
needed. The first assistant, although scrubbed, is used only
when a fourth port is placed or for emergency laparotomy.
At the end of the procedure, the assistant surgeon is
required to help pass the fixation sutures through the
abdominal wall. The surgeon is seated comfortably at
the operative console and views the operation through
the three-dimensional imaging system within the console.
At this point, the surgeon has full control over the operative field. Foot pedals are used to control the camera
movements, and ergonomically positioned fingertip controls are used to manipulate the surgical instruments in
real time within the patient.
Technique for laparoscopic repair of

incisional or ventral hernias with the use of
the da Vinci tele-robotic system
The tele-robotic team at our institution consists of a nurse,
a scrub technician, a scrubbed laparoscopic fellow who
serves as first assistant, and an attending surgeon.15 Each
member of the team has completed the FDA-approved
training session. The patient is positioned supine on the
table. Bilateral pneumatic compression boots wrap both
legs. After the induction of general anesthesia, an orogastric tube and urinary catheter are inserted. The patient is
shaved and prepared with an iodine-containing solution.
The abdominal wall skin is covered with an impermeable
plastic drape. A single dose of antibiotics is given one hour
before surgery. A sterile plastic covering is placed over the
three robotic arms (two arms for the surgeons right and
left hands, one arm for the laparoscope).
Trocar placement varies somewhat with the location of
the incisional hernia. The trocars are inserted as far away
as possible from the defect. We select the side of the patient
away from the previous operation for trocar insertion. If
the patient had previously undergone sigmoid colectomy,
for example, we would insert our trocars on the patients
right side. For a midline hernia, three incisions are used:
the camera port is placed at the level of the umbilicus in
the mid-axillary line and the remaining two ports are
(a)
8mm
12mm
8mm
(b)
Figure 37.8 (a) Trocar placement for a tele-robotic Stoppa

repair of an incisional ventral hernia. (b) A three-trocar
technique is used. The 12-mm stereoscopic telescope is inserted
through the 12-mm trocar. The two robotic surgical instruments
are inserted through the 8-mm trocars.
The first part of the operation involves reducing the

hernia and lysis of any adhesions to the anterior abdominal wall. A 30-degree telescope is used. Angulation of the
telescope upwards improves visualization of the anterior
abdominal wall. The hernia can usually be reduced with
the use of two graspers and a hand-over-hand technique
with gentle downward pressure to avoid tearing or injuring the hernia contents. Once this is done, any adhesions
to the anterior abdominal wall can be lysed easily, using
the electrocautery hook, harmonic scalpel scissors, or
surgical scissors (Figure 37.9). Working on the underside
of the abdominal wall is facilitated greatly by the
dexterous instruments.
After adequate lysis of adhesions, the fascial defect is
usually evident. The limits of the defect are marked on the
abdominal wall and measured. We like to overlap the mesh
at least 2.2 cm beyond the perimeter of the hernia defect.
DualMesh Plus (W. L. Gore & Associates) is fashioned so
that a degree of overlap is achieved. We place Gore-Tex
sutures every two inches around the perimeter of the
mesh. The sutures are tied with two throws to the mesh
and the ends are left long. The head, foot, and left and right
sides of the mesh are marked on the light side of the mesh
with a marking pen. The pneumoperitoneum is deflated.
The perimeter of the mesh is traced on to the plastic drape
that covers the hernia defect. The position of the sutures is
also marked.
The mesh is rolled tightly into a cylinder, with the tails
of the sutures rolled within. The mesh is inserted into the
abdominal cavity through the 12-mm trocar and unfurled
maintaining the proper orientation. The pneumoperitoneum is maintained at this point at a pressure of
10 mmHg. The labels on the light side of the mesh are
visualized easily with the video camera. Small stab incisions are made in the skin at the positions of the sutures.
A Storz suture-passer is inserted through the abdominal

wall at each of the stab incisions and used to retrieve the
ends of the Gore-Tex sutures (Figure 37.10). Once all of
the suture ends are retrieved, they are tied. The edge of the
mesh is inspected. The mesh needs to sit firmly against
the anterior abdominal wall. Pleats between the sutures are
flattened out with 5-mm surgical tacks (Autosuture).
The abdomen is deflated and the trocars are removed.
The fascial defect of the 12-mm trocar is closed with an
absorbable suture. The skin edges of the three trocar sites
are closed with absorbable subcutaneous sutures. All
wounds are covered with impermeable dressings.
Advantages
We have found that the da Vinci facilitates laparoscopic
repair of ventral and incisional hernias. The da Vinci provides a stable camera platform, permits a solo-surgeon
approach to the lysis of adhesions, helps to maintain the
surgeons orientation within the operative field, promotes
dissection on the anterior abdominal wall, and simplifies
(a)
(b)
Figure 37.9 Robotic scissors and atraumatic Cadierre grasper.

The adhesions are divided with robotic instruments. The Cadiere
grasper retracts the bowel, and the adhesions to the abdominal
wall are divided with scissors.
Figure 37.10 Passing sutures through the abdominal wall to fix

the dual-sided mesh in place. The da Vincis stereoscopic view
facilitates passing the sutures. A suture-passer drags the sutures
through the abdominal wall (a). Two robotic graspers are used to
hand the sutures to and from the suture-passer (b).
the passage of the fixation sutures through the abdominal

wall. The da Vinci holds the video camera. The robot does
not tire and does not wander from the operative field.
This stable camera platform avoids the eye fatigue generated by a constantly moving, human-held video camera.
Although all laparoscopic surgeons have been trained
to operate from a two-dimensional monitor, the true
three-dimensional virtual operative field provides immediate advantages and rapidly became our preferred field
of view. The surgeon comprehends more easily the threedimensional virtual operative field. Our impression is
that this makes it easier for us to maintain our orientation
and helps to avoid past pointing injuries.
Straight laparoscopic instruments often fail to reach
the anterior abdominal wall. The wrist-like motion
generated by seven degrees of freedom overcomes this
shortcoming and simplifies lysis of the adhesions to the
anterior abdominal wall. This maneuver is awkward at
best with conventional straight laparoscopic instruments
because of their anterior position. Straight laparoscopic
instruments are often limited from reaching the anterior
abdominal wall by the point of fixation of the trocar at
the abdominal wall. The angulated movements of the
robotic instrument tips permit the attack of the adhesions from a wide variety of angles.
Three-dimensional imaging also assists in the passage
of the fixation stitches through the abdominal wall.
Although this process can be accomplished with twodimensional video cameras, novice laparoscopic surgeons
accomplish this task more quickly in a three-dimensional
operative field.
CONCLUSION
Tele-robotic surgery remains in a period of rapid evolution. Newer generations of both da Vinci and Zeus continue to be developed rapidly. Whether tele-robotics will
become the standard of care in the near future remains
uncertain. Nonetheless, even at this early juncture, telerobotic surgical systems address some of the specific limitations of standard laparoscopic surgery. Tele-robotic
surgical systems maintain a stable camera platform,
immerse the surgeon in a three-dimensional virtual operative field, move the surgical instruments with six or seven
degrees of freedom, and further improve the ergonomics
for the surgeon. Tele-robotics also have the potential usage
in very remote settings, such as the battlefield and outer
space.
REFERENCES
1
2
3
4
7
8
Many surgeons perform advanced laparoscopic operations with standard twentieth-century technologies.
Nonetheless, standard laparoscopy presents certain
limitations that impede the learning of advanced skills
and prevent many surgeons from performing advanced
laparoscopic operations. Robotics offers technological
solutions to some of these shortcomings. We have found
that AESOP provides a stable camera platform, maintains
a stable relationship with the horizon, adequately replaces
a human camera-holder, and lets the surgeon stand in an
ergonomically comfortable position. Voice-control systems help to integrate the operating room and to keep the
surgeon in control of an ever more complicated operating
environment. In our hospital, robot-assisted laparoscopic
pre-peritoneal inguinal hernia repair in an integrated
operating room is our standard of care. We believe that
this technique permits the surgeon the best opportunity
to replicate the operation in a high-volume mode with
excellent clinical outcomes.
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Ballantyne GH. The pitfalls of laparoscopic surgery: challenges for

robotics and telerobotic surgery. Surg Laparosc Endosc Percutan
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Talamini MA. Surgery in the 21 century [editorial]. Ann Surg 2001;
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Fan P. Surgical grand rounds presentation: laparoscopic hernia
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Merola S, Weber P, Wasielewski A, Ballantyne GH. Comparison of
laparoscopic colectomy with and without the aid of a robotic
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Felix EL. Laparoscopic extraperitoneal hernia repair. In: Eubanks
SW, ed. Mastery of Endoscopic and Laparoscopic Surgery.
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Geis WP, Kim HC, Brennan EJ, Jr, et al. Robotic arm enhancement
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Marescaux J, Leroy J, Gagner M, et al. Transatlantic robot-assisted
telesurgery. Nature 2001; 413: 37980.
Ballantyne GH, Kelley WE, Jr. Granting clinical privileges for
telerobotic surgery. Surg Laparosc Endosc Percutan Tech 2002;
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Hourmont K, Pereira S, Wasielewski A, et al. Robotic versus
telerobotic laparoscopic cholecystectomy: duration of surgery and
outcomes. Surg Clin North Am 2003; in press.
Cadiere GB, Himpens J, Vertruyen M, Favretti F. The worlds first
obesity surgery performed by a surgeon at a distance. Obes Surg
1999; 9: 2069.
Cadiere GB, Himpens J, Vertruyen M, et al. Evaluation of
telesurgical (robotic) Nissen fundoplication. Surg Endosc 2001;
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Gould JC, Melvin WS. Computer-assisted robotic antireflux
surgery. Surg Laparosc Endosc Percutan Tech 2002; 12: 269.
Shah J, Rockall T, Darzi A. Robot-assisted laparoscopic Hellers
cardiomyotomy. Surg Laparosc Endosc Percutan Tech 2002; 12:
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Horgan S, Vanuno D, Benedetti E. Early experience with robotically
assisted laparoscopic donor nephrectomy. Surg Laparosc Endosc
Ballantyne GH, Hourmont K, Wasielewski A. Telerobotic
laparoscopic repair of incisional ventral hernias using intraperitoneal prosthetic mesh (Stoppa technique): report of two
cases. J Soc Laparoendosc Surg 2003; in press.
38
Socioeconomic issues
KARL A. LEBLANC, ANDREW N. KINGSNORTH AND ZINDA Z. LEBLANC
Economics of hernia repair

Economics of day-case surgery
Incentives and day-case hernioplasty
Return to normal activity and work
274
275
276
276
Economic evaluations of new and existing healthcare

interventions are an essential input into decision-making.
Healthcare systems around the world face steady increases
in expenditure as a result of demographic change and
improvements in medical technology. Increasingly, payers
must choose which interventions will be provided and
which will not be reimbursed from limited public or private funds. This creates difficult choices, as systems are no
longer limited by what is technically possible to improve
the health of patients but by what is practically possible
given resource constraints. In a situation where resources
are scarce, all choices about who will be treated have an
opportunity cost the value of the benefit foregone. Health
economics and the techniques of economic evaluation aim
to maximize the amount of health that is produced within
the scarce resources available. In the UK, the National
Institute for Clinical Excellence (NICE) synthesizes evidence and reaches a judgment as to whether on balance the
intervention can be recommended as a cost-effective use of
National Health Service (NHS) resources.1 In 2000, NICE
published recommendations for the use of laparoscopic
hernia surgery. It recommended its use outside centers of
expertise only in cases of bilateral inguinal hernia or recurrent inguinal hernia. In the UK in 1996, approximately ten
per cent of hernia repairs were carried out laparoscopically.2 Since the publication of the NICE guidelines, this figure has decreased dramatically and supports the concept
that the application of clinical pathways can reduce costs.
Such measures are important in the UK, where the numbers of medical staff and the annual NHS budget are well
below those in other European countries, Organization for
Economics of laparoscopic surgery

Payment changes
Conclusion
References
278
280
281
281
Economic Cooperation and Development (OECD) countries, and the USA.3

It is no longer sufficient to consider the clinical or
therapeutic effects of healthcare interventions: purchasing
choices will be predicated on studies that identify, measure
and value what is given up when an intervention is used
(the cost) and what is gained (improved patient health
outcomes). This requires explicit economic evaluation of
healthcare interventions. Purchasers have a fixed budget
and are aware of the opportunity costs of interventions.
Increasingly, they are likely to require evidence of effectiveness and cost-effectiveness, and they may develop
contracts and enforce protocols to ensure this.
Economic evaluation values both inputs (costs) and
outcomes (consequences) of an intervention, comparing
more than one alternative. This builds upon clinical evaluations that assess efficacy (can an intervention work in
experimental circumstances?) and effectiveness (does it
work in normal clinical practice?) to assess efficiency
(does it provide the greatest benefit at least cost?). The
type of economic evaluation depends upon the outcome
measure chosen:
Cost-minimization analysis is appropriate only when

the outcomes of two or more interventions have
been demonstrated to be equivalent, in which case
the least costly alternative is the most efficient, and
only cost analysis is required.
Cost-effectiveness analysis includes both costs and
outcomes using a single outcome measure, usually a
natural unit. This allows comparisons between
treatments in a particular therapeutic area where

effectiveness is unequal, but not between therapeutic
areas where natural outcome measures differ.
Cost-utility analysis combines multiple outcomes
into a single measure of utility (e.g. a qualityadjusted life year, QALY). This allows comparisons
between alternatives in different therapeutic
categories with different natural outcomes.
Cost-benefit analysis links costs and outcomes by
expressing both in monetary units, forcing an
explicit decision about whether an intervention is
worth its cost. Various techniques have been used to
attach monetary values to health outcomes, but the
technique remains rare in health economics.
Considerations in cost-effectiveness are particularly

relevant at a time when healthcare costs are escalating
disproportionately in relation to gross national product
in many westernized countries.4 The value of any indicated treatment is directly proportional to treatment
outcome and inversely proportional to treatment cost.
Evaluation of both the numerator (outcome quality) and
the denominator (cost) of the equation are subject to
many methodological limitations. The value depends on
whether it is viewed from the perspective of the patient,
surgeon, hospital, employer, payer or industry. Moreover,
cost does not equate with charge. In hernia surgery, the
total cost includes pretreatment (diagnostics), treatment,
post-treatment medical care including complications
and recurrence, and societal and employer costs, which
include insurance, workers disability compensation,
worker replacement costs, and loss of productivity. Each
sector of the treatment process has variable fixed and
semi-fixed costs. The trends to eliminate general anesthesia and to perform conventional herniorrhaphy in an
ambulatory setting have been cost-beneficial. Ideally, cost
containment could be achieved by performing all elective
inguinal hernia repairs at ambulatory surgical centers for
a standardized charge.
Technological innovation in surgery and in other areas
(e.g. diagnostic innovation) is not regulated in the same
way as innovative pharmaceutical therapies. A new pharmaceutical product is subjected to rigorous clinical trials
to identify evidence of safety and efficacy, before licensing
for public use. Increasingly, new and existing pharmaceutical products are also subjected to well-defined economic
evaluation to show evidence of effectiveness and efficiency.
Guidelines issued by the UK Department of Health state
that the economic evaluation of pharmaceuticals should
become part of taking decisions about treatment, and
set out clear guidelines regarding how a high-quality
economic evaluation should be carried out.5
The careful procedures that control the introduction
of innovative pharmaceutical products are essential for
innovative surgical and diagnostic therapies. How, then,
should technological innovations such as laparoscopic

surgery be introduced? All such pioneering innovations
should be evaluated in well-designed trials. There are
difficulties in implementing randomized controlled trials
of surgical techniques due to the difficulties of blinding,
but a carefully designed trial can mitigate these problems. Clinical trials protect the safety of patients and
ensure that new technologies produce effective healthcare.
Economic evaluations ensure that such health gains are
purchased at least cost. The guidelines applied to pharmaceutical products, intended to protect societys health
and scarce resources, should also be applied to surgical
innovations, but this is a difficult task to institute.
The principle of evaluating innovative surgical interventions was accepted by the Department of Health in the
UK in a press release in 1995, which announced that major
innovations were to be scrutinised, evaluated and then, if
approved, fast tracked throughout the health service.6 A
major advance should, under a new system, be subjected to
clinical trials, and a central register would give information
on approved operations. Purchasers could then consult the
register as a measure of the effectiveness of various operations and procedures. This register, the Safety and Efficacy
Register of New Interventional Procedures (SERNIP), is
managed by the Academy of Medical Royal Colleges and
funded by the Department of Health. Doctors are asked
to register new techniques that they intend to pilot, and
to check the register to discover the current status of new
invasive procedures.7 An advisory committee convened by
SERNIP will then assess all known data and assign the
procedure to one of four categories:
1 Safety and efficacy unsatisfactory procedure must
not be used.
2 Safety and efficacy established procedure can be used.
3 The procedure is sufficiently similar to one of
established safety and efficacy to raise no reasonable
doubts and can be used.
4 Safety and efficacy are not established controlled
evaluation is needed.
The proposed system is voluntary and controlled clinically. In time, economic evaluation of innovative invasive
procedures will be required, as is the case for pharmaceutical products. In the majority of other countries, including the USA, such a system does not exist at any level.
ECONOMICS OF HERNIA REPAIR

Hernia repair is an established and effective procedure.
Its relatively fixed cost and high volume among surgical
procedures mean that economic evaluation of the procedure itself has become a priority. Hernias create pain and
discomfort for patients and limit their ability to work or
Socioeconomic issues 275
carry out other productive activities. While the increased

risk of surgical procedures in elderly people means that
repair of some small direct hernias may not be mandatory, there would seem to be clear clinical and economic
arguments in favor of carrying out hernia repairs among
the majority of the working population.8
J.W. Hurst, a health economist, has compared the benefits and costs of hernia repair with the benefits and costs
of home dialysis for renal failure, and with the benefits
and costs of a successful renal transplant.9 Drawing on a
measure of health status that measures two dimensions of
health (disability and distress), and using Department of
Health and Social Security (DHSS) cost data, Hurst calculated the health status yield per pound sterling for the
three selected treatments. Using this cost-benefit equation, uncomplicated hernia repair comes out better than
a successful renal transplant, and a renal transplant is better value than continuous home hemodialysis. Memories
of Cecil Wakeleys aphorism crowd in to confirm that
refined clinical judgment may well be as valuable in
evaluating the benefits of clinical care as the statistical
gymnastics of contemporary health economists.10
Innovations in the procedure of hernia repair and the
management of patients should, however, be subject to
economic evaluation, ideally based upon a randomized
controlled trial. The recent developments in hernia repair,
such as the expansion of day-case surgery in Europe,
require a clinical and economic base. However, the experience from the Shouldice clinic in Canada and the results
from the USA support the use of limited hospitalization
for the repair of hernias. Laparoscopic inguinal hernia
surgery has not been proven to represent an economic
benefit for the unilateral primary hernia. There may be
some benefit for the patient with bilateral and/or recurrent herniation. Other laparoscopic hernia surgeries, such
as hiatal and incisional hernia repair, have reduced the
length of hospitalization significantly.
ECONOMICS OF DAY-CASE SURGERY

Reductions in length of stay for many surgical and other
inpatient procedures result from improvements in surgical
procedures reducing recovery time, changing preferences
of patients, and financial and political pressures on hospitals to reduce costs. Day-case surgery is often preferred
by patients, and it may encourage early mobilization and
reduce the risk of hospital-acquired infection.11 Day-case
treatment for hernia repair may result in good outcomes
for lower costs than other organizational forms of care.12,13
The Royal College of Surgeons recommends that at least
30 per cent of elective hernioplasties should be performed
on a day-case basis.14 In the USA, however, all but the most
ill or infirm individuals with inguinal hernias are operated
on as outpatients. Additionally, because of the increasing

trend of incisional herniorrhaphy by the laparoscopic
method, many incisional and ventral hernias are performed with a length of stay of 23 hours or less.15,16
Economic appraisal is unlike surgical decisionmaking. Economists analyze the results of their interventions by comparing them within different scenarios:
as the scenarios change employment prospects, labor
relations, etc. the economics change too. Surgeons are
used to evaluating their outcomes over time with the scenario held constant. For instance, with day-case surgery
and a constant surgeon-related scenario, one impact of
shortening the patients stay will be empty beds, which
the surgeon will perceive as the currency of an efficiency
saving. The economist would not call this a saving; the
concept of opportunity cost means that no benefit has
accrued until the empty beds (resources) are put to some
alternative use. Benefit is thus not necessarily the same to
the surgeon as to the economist.
Any economic appraisal of day-case surgery must,
therefore, first address the crucial issue of the term
benefit. Are the benefits to be:
more surgery, using the freed resources to undertake

a greater volume of surgery or more complex
innovative surgery?
a redeployment of the freed resources towards a
different client group, e.g. elderly or mentally ill
people?
a reduction in overall health service expenditure by
the amount saved?
A day-case surgery policy will need to be appraised in

the short run and in the long run. Short-run benefits may
be very difficult to gain; for instance, a reduction in surgical bed requirements by 15 may confer no benefit since
one cannot eliminate half a 30-bed ward and reduce staff
costs by 50 per cent overnight. While there may be no
short-term gains, the long-term gains could be substantial and allow explicit alterations to existing surgical and
nursing practice. Consequently, new hospital provision
could include fewer traditional inpatient surgical wards
and instead have dedicated day-case units. In the USA,
there are, in fact, many centers that are free-standing and
dedicated to day-case surgery or short-stay procedures.
Stepping through the looking-glass, more day-case
surgery will need less capital expenditure on surgical
inpatient facilities, and fewer nursing staff will need to be
employed for the same volume of work in the long term.
The quantification of savings accruing from a day-case
policy is difficult; four approaches have been advanced:
Comparing the bills paid by patients in private

practice.17
The analytical device of holding the level of service
constant and estimating the benefits that could be
bought with the now unused resources.18
The technique of comparing average per diem

inpatient and outpatient costs.19 Farquharson
produced the seminal paper advocating this type of
economic evaluation.20
Comparing and computing the one-year costs of a
day-care facility with the one-year costs of a
traditional in-patient unit.21
Bailey, an economist from the Audit Commission in

the UK, has proposed an alternative strategy to determine the resources that might be released as a result of
a change from inpatient to day-case while treating an
equivalent patient.22 He states that the costs of day surgery are substantially less than inpatient care, but it is
misleading to interpret such measures as savings. The
resource implications of more day surgery should be
estimated directly by looking at precisely what changes
are planned to take place.
In conclusion, there is evidence that the unit costs of
day-case surgery are much lower than inpatient care:
of the order of 4075 per cent per treatment episode,
however calculated. These lower unit costs will free up
resources to carry out more surgery or for alternative uses.
Day-case surgery has been found to be superior to inpatient surgery in terms of wound infection and return to
work, although this finding is not statistically significant.23
Day-case surgery is also becoming increasingly acceptable
to patients. A dedicated five-day care unit allows more
resources to be saved compared with day cases in a traditional theater suite and ward, where all the resources cannot be redeployed easily, particularly in the short run. This
is consistent with the conclusions of a US review of costeffectiveness of management of hernia by Millikan and
Deziel.4 These authors concluded that the most costeffective approach to hernia repair would use an ambulatory surgical center with open-mesh repair for primary
inguinal hernia and failed primary suture repair.
INCENTIVES AND DAY-CASE HERNIOPLASTY

To date, resource savings from day-case surgery in the
NHS have been used largely to expand surgical services
either quantitatively or qualitatively. Every hospital
experienced this phenomenon in the 1970s. It has been
quantified and shown that as resources are liberated by
day-case work, they are used up in other surgical endeavors. This extra work sucks in further resources, and the
overall surgical budget becomes larger.
Increasing the proportion of day cases in the surgical
unit mix will lead to a fall in the average cost of each
patient treated. This may enable more cases to be operated upon; even though the marginal costs of doing each
extra case within normal working hours are low, the
aggregated cost to the hospital will be higher, although
greater demand will initially be met and the queue

reduced. If there is no queue and no excess demand, then
reducing costs should allow premises to be closed and
staff made redundant, with considerable reduction in
fixed and variable costs. The cost of doing an extra case
after hours in a day-case unit, when staff must be paid
overtime, is a very high marginal price a fact to be
remembered when case-scheduling is considered.
If day-case surgery is used to cut unit costs and increase
the overall volume of surgery, then this extra burden of rising productivity will fall on the surgeons and nurses. There
are reports of the proportion of day cases rising to close
to 40 per cent in some units, with consequent increases
in surgical throughputs. Ultimately, the increased output
may demand an alteration on the supply side of the equation, and more doctors and nurses may then need to be
employed to cope with increased demand.24 While the
relationship between demand and output of a surgical
service is elastic in the short term, in the longer term supply
inevitably must be increased to allow greater output. This is
particularly evident in many areas in the USA, where there
are nursing and anesthesia staff shortages.
It must be apparent that there is no economic incentive for surgeons and other hospital employees to expand
day-case surgery. Substantial savings can be achieved
only by maintaining constant the quantity of surgery
carried out, by not allowing day cases to increase the output, and by closing premises and dismissing redundant
staff. The development of free-standing centers, however,
will transfer these cases to these centers and allow more
efficient use of the hospital staff and/or relocate these
employees.
RETURN TO NORMAL ACTIVITY AND WORK

There is enormous variation in reported times for return
to normal activity and work. For instance, in a socialized
system of healthcare where patients expectations and
the insurance system still favor hospitalization, length
of hospital stay after hernia surgery may be in excess of
eight days.25 Even in the USA, where ambulatory surgery
units are quite commonplace, the length of stay may be
several days in institutions where reimbursement is not
controlled as strictly as the private sector, although this is
rapidly becoming uncommon. Customers of the Metropolitan Life Insurance Company surveyed by a nationwide
claims questionnaire revealed a length of stay that averaged 2.9 days.26 In the US army, average hospital stay for
hernia surgery is 4.6 days.27 In reality, housing conditions,
the distance from home to hospital, and the availability
of home nursing care (spouse, relative, friend) are the
major factors affecting early discharge after hernia repair.28
These societal issues are more frequently problematic with
other larger procedures. Payers, however, seldom provide

consideration for these important matters that involve
patient care.
The technique adopted has little predictive value for
early postoperative pain and analgesic consumption.
Kawji and colleagues, in a study of 240 patients who had
been treated with Lichtenstein under general anesthesia,
Lichtenstein under local anesthesia, laparoscopic transabdominal pre-peritoneal (TAPP), Shouldice operation,
or pre-peritoneal Wantz procedure, found that the only
technical factor significantly reducing analgesic requirement during the first three perioperative days was the use
of intraoperative local anesthesia.29 Lau and Lee studied
postoperative pain by linear analogue scores in 239 patients
having inguinal herniorrhaphy with a variety of techniques.30 With multiple regression analysis, older patient
age was the only independent factor of pain, a finding in
keeping with anecdotal experience of surgeons used to
operating on patients under local anesthesia.
The French Association for Surgical Research investigated the feasibility of discharge within 48 hours of
inguinal hernia repair in 500 consecutive men with unilateral, uncomplicated non-recurrent inguinal hernias.
Of 411 patients suitable for early discharge, 107 (26 per
cent) eventually stayed for more than 48 hours, early
discharge was declined by 84, and early discharge was
contraindicated in 42 (these patients had local or general
complications), which finally resulted in one-day surgery
being performed in only 51 (ten per cent) of the patients.
These results emphasize the need for careful preoperative
evaluation, which includes not only the hernia and the
patients general medical condition, but also any social
conditions, such as isolation, flights of stairs, or lack of a
telephone, that may limit the ability to discharge a patient
soon after surgery.
Advice concerning return to normal activity has been
managed poorly by surgeons. Recent studies indicate
that factors limiting a patients return to activity and
work are governed principally by the perceived amount
of postoperative pain. Socioeconomic factors strongly
influence this perception over and above the actual procedure performed or the anatomy involved.31 In a casecontrolled comparison of patients receiving workers
compensation compared with patients having commercial insurance, seven surgeons from a single clinic compared 22 consecutive workers compensation patients
with 22 commercial insurance patients. All patients had
received open hernioplasty, and the duration of postoperative pain and the days off work were compared. The
differences between the two groups were striking: the
median duration of postoperative pain in the workers
compensation group was 27 days, with 36.5 days off
work. In the commercial insurance patients, the duration
of postoperative pain was 7.5 days and they went back to
work after only 8.5 days. Personal motivation, therefore,
appears to be the most important factor affecting clinical

outcome and return to activities. Callesen and coworkers
have demonstrated that well-defined recommendations
and improved pain management can shorten convalescence.32 One hundred patients having elective herniorrhaphy under local anesthesia and managed analgesia
were recommended to have one day of convalescence for
light/moderate work and three weeks of abstinence from
strenuous physical activity. The overall median absence
from work was six days; unemployed patients returned
to activities in just one day, those in light/moderate work
returned in six days, and those in heavy jobs returned by
25 days. A more detailed prospective study of return to
work after inguinal hernia repair has been undertaken by
Jones and colleagues.33 Data were collected by personal
interviews, written surveys, and medical record reviews
in 235 patients, the main outcome measures being actual
and expected return to work. Age, educational level,
income level, occupation, symptoms of depression, and
the expected day of return to work (ten days) accounted
for 61 per cent of the variation in actual (12 days) return
to work.
Advice given in the UK on driving after groin-hernia
surgery varies widely because there is no evidence-based
information.34 In a postal questionnaire sent to 200 surgeons, the advice ranged from it being acceptable to drive
on the same day of surgery (three per cent of respondents) to suggesting that patients wait six to eight weeks
before driving (nine per cent of respondents); the most
common response was that patients should wait two
weeks (37 per cent of respondents). Amid has stated that
the recovery period is dependent solely on the amount of
postoperative discomfort, which should be minimal and
should not usually require narcotic analgesia.35 Amid
recommends that patients can resume driving as early
as one week or less after surgery, depending on their
comfort and whether they are using narcotic analgesics.
Those who drive different types of vehicles need different
advice. An additional consideration should be the complexity of the operative procedure. Intra-abdominal procedures will require longer periods of convalescence than
inguinal hernia repair.
It must be apparent that there is no economic incentive for surgeons and other hospital employees to expand
day-case surgery. Substantial savings can be achieved
only by maintaining constant the quantity of surgery
carried out, by not allowing day cases to increase the output, and by closing premises and dismissing redundant
staff. Such a policy is unlikely to make surgeons who take
up day-case surgery popular. However, the experience in
the USA, where day surgery is quite commonplace, has
proven that the patients and their surgeons are quite satisfied with these economics. In fact, many patients are
dismayed when they are told that their medical condition
dictates a hospital stay of even one night.
ECONOMICS OF LAPAROSCOPIC SURGERY

Since the pioneering laparoscopic removal of a gall
bladder by French surgeon Phillippe Mouret in 1987, the
introduction and rapid diffusion of laparoscopic surgical
techniques was accepted with unbridled enthusiasm, and
often without question, by many surgeons, the media
and the general public. The years that have passed since
then have allowed a more rational approach to many
of these procedures. The majority of laparoscopic adaptations of the general surgical operations have proven to
be cost-effective due to the diminution in the length of
hospital stay. The great exception is laparoscopic repair
of inguinal hernias, which is always more costly.
Some economic arguments have been used to support
the rapid diffusion of laparoscopic surgery. Studies often
quote reductions in the length of inpatient hospital stay
in comparison with standard surgical procedures and
imply that this will necessarily save hospitals money. This
is, however, not necessarily the case, and hospital managers are increasingly questioning the appropriateness of
procedures that involve purchase of sophisticated and
expensive capital equipment and considerably increased
operative time, resulting in lower patient throughput for
surgical procedures. Available time in the operating
theatre is a scarce resource, and although operating time
in laparoscopic surgery declines as experience increases,
Cuschieri estimated that on average it will continue to
take about one-third longer than the corresponding conventional operation, with the excess of time over open
surgery the higher the more complicated the basic operation.36 Time, however, has proven that once past the
learning curve, many of these operations are only as long
as or are shorter than that of the open method. Many of
these comparisons may be flawed because there are slow
operators and quick operators. Many of the operations
discussed in this book are commonly performed with
less operative time than their open counterparts in
centers with surgeons skilled in these procedures.
The effect of length of inpatient stay on health service
resource use is an important issue in many studies.
Cuschieri estimates that discharge may, on average,
be expected to be within less than 48 hours.36 This is
thought to result in cost-savings from earlier discharge
and earlier return to normal activities, including work.
However, economists such as Sculpher note that this may
not always be the case.37 First, a reduction in the demand
for hospital beds may not result in cash-savings unless it
allows ward closures. At one time, this was felt to be
unlikely as laparoscopic surgery represented a small proportion of all hospital procedures. Other arguments were
that laparoscopy did not release other resources used for
surgical procedures, particularly theater time, and that
some laparoscopic procedures replaced non-invasive
therapies rather than open surgery. It is important to

remember that lengths of inpatient stay were falling for
many years, and the additional savings from laparoscopic
surgery may be lower than anticipated. History, however,
has proven that many of these worries have not resulted
in a decline in the use of laparoscopic surgery. In most
procedures, except for inguinal hernia repair, the trend is
upward.
Complication rates are important determinants of the
overall costs of any surgical procedure. Complications
with laparoscopic surgery procedures, such as bile-duct
injuries with laparoscopic cholecystectomy, have been
well documented (see Table 1 in Soper et al.38). Most bileduct injuries occur early in a surgeons experience, highlighting the need for careful training and accreditation of
surgeons, and clinical practice guidelines.39 The rate of
conversions from laparoscopic operations to open operations ranges from 1.8 to 8.5 per cent, and tends to be highest early in a surgeons experience.38 The cost implications
of complication rates include increased operating time,
increased length of inpatient stay, increased care burden
on families or other caregivers, and increased time for the
patient to return to work or normal activities. The current
rates of complications, however, have now established the
laparoscopic cholecystectomy as the standard of care for
gallbladder disease because they are comparable, whether
open or laparoscopic.
A recent systematic review of the effectiveness and
safety of laparoscopic cholecystectomy showed that effectiveness of this procedure is similar to that of open and
mini-cholecystectomy.40 Complete alleviation of symptoms was achieved in 6070 per cent of patients. However,
safety profiles differ, with more technical support and
specialized surgical equipment required for the laparoscopic procedure. Differences in complication rates were
difficult to assess because of methodological problems
and differences between studies. In particular, studies
often do not have sufficient statistical power to identify
clinically important differences in outcomes, particularly
bile-duct injury, because the rate of adverse events is low.
Sculpher argues that laparoscopic surgery has a different production function to conventional surgical techniques, i.e. it requires a different mix of inputs to the
production process, more inputs of theater and medical
staff time, more sophisticated equipment, and fewer
inputs of inpatient bed days.37 The overall effect on
hospital costs and on overall costs to society is unclear
and requires economic evaluation. Evaluation should be
long-term in order to include any effects of different
re-admission rates, and should include not only hospital
costs and effects but also the burden on communitybased services, patients and carers, which may change
due to earlier discharge.
The production function description of surgery is
useful in considering other issues. The appropriate level
of individual and center specialization should be determined by evidence of economies of scale. If a center specializes in laparoscopic surgery, then this may influence
costs per patient, as theater time may be reduced as familiarity with the procedure increases. In addition, outcomes
may be improved, particularly by reduced complication
rates. However, the appropriate level of individual and
center specialization requires careful evaluation: could the
alleged benefits of centralization be matched by careful
training and treatment protocols at local levels? Identification of the conditions necessary for the production of
efficient laparoscopic procedures is absent but inhibits
neither unsubstantiated assertions by policymakers nor
significant investments in new facilities.
The repair of inguinal hernias with the laparoscopic
method continues to raise many questions, particularly
regarding economics. Whereas it is generally accepted
that this technique is effective for these hernias, the costs
associated with this method causes many surgeons to
question the usefulness of this technique. In 1996, the
benefits were unclear.41 In 2003, the clinical efficacy is not
generally questioned. The cost issues have been resolved
for the most part. It is more expensive to perform the
minimally invasive method except in a very few areas that
have managed to eliminate the use of disposable instruments and tissue-expansion balloons.
Evidenced-based studies have definitely revealed that
the levels of pain and subsequent convalescence after
laparoscopic repair are decreased when compared with
open repair.42 This is particularly true with the comparison of pure tissue repairs, but it has also been found with
open prosthetic repairs. However, some studies have
reported that while these patients experience less pain
postoperatively, the return to work interval was not different after TAPP repair. The opinion of these authors
was that the increase in costs did not justify the operation
unless the operative costs could be reduced.43 Another
study found that laparoscopically repaired patients returned
to their usual activities seven days earlier than those of
the open group. The incremental cost for this time frame
was 55 548 per QALY over the open method. This report
showed that there might be specific situations in which
this laparoscopic repair may be a viable alternative,
particularly when reusable rather than disposable instruments were used because these costs were decreased
significantly.44
The operative costs that are increased with the laparoscopic approach are the use of disposable instruments,
balloon dissection devices, balloon trocars, additional
personnel, and the length of the operation. These costs
can be reduced to the extent that the cost of the operation
can approach that of the open procedure. Lorenz has
shown that by the deliberate attempt to decrease costs, the
laparoscopic approach can be less expensive to the hospital.45 Beets and Dirksen found that the open approach can
be more expensive than the laparoscopic approach (open,

US$1150; laparoscopic, US$1179).46 In many centers,
however, this has been a stimulus for surgeons to abandon
the procedure altogether (willingly or unwillingly). The
insurance industry has refused to reimburse hospitals and
surgeons for the procedure, leading to the rapid demise of
the procedure. Medicare in the USA actually pays surgeons less to perform these operations laparoscopically
than through the open technique (see below).
These realities have resulted in the trend of many centers to utilize this operation only in the bilateral situation
and for recurrent hernias. The success for this diagnosis is
proven.47,48 The ongoing studies of the Medical Research
Council (MRC) Laparoscopic Groin Hernia Trial Group
support the move to specialist surgeons to perform this
operation.49 Based upon the experience in the USA, this
appears to be the trend.
Data comparing open versus laparoscopic repair of
inguinal hernias are now voluminous, and a detailed
analysis of all the factors is beyond the scope of this chapter. Suffice to say that the vast majority of reports have
identified the same findings that are commonly known.
That is, in general the laparoscopic operation is more
expensive but postoperative pain is diminished and the
return to work is notably shorter. The learning curve and
the payors of these operations will force this procedure
into the hands of a few skilled surgeons with excellent
outcomes. Even in this case, this will be for bilateral and
recurrent hernias. Studies such as that by Lawrence and
coworkers used a UK randomized controlled trial as the
basis of an economic evaluation of laparoscopic versus
open inguinal hernia repair, on data collected from 104
day-case patients.41 The mean total health service cost of
laparoscopic repair was 1074, compared with 489 for
open repair. Linking this additional cost with the additional pain-free days in the laparoscopic group showed
an additional cost per pain-free day of 109 (95 per cent
confidence interval, 41393). The authors concluded
that there were strong arguments against the introduction of laparoscopic hernia repair until evidence on
long-term outcomes becomes available. Such studies,
although important, are few. Hekkinnen and colleagues
conversely proved that the overall societal costs are less
with the laparoscopic method.50 Regardless, the cost
benefit structure of the insurance industry does not
appreciate the societal costs as do the individual patient
and surgeon. Therefore, this limited use of the laparoscope to repair inguinal hernias will probably be permanent in the USA. In other countries, such as those in
Europe, a more critical look at these issues may be possible because of the public nature of the healthcare system.
This is needed.
Unlike those of laparoscopic inguinal herniorrhaphy,
the clinical and economic benefits are clearer with the
laparoscopic repair of incisional and ventral hernias.
Open repair
Operative time,
range (min)
Operative time,
average (min)
Length of hospital
stay, range (days)
Length of hospital
stay, average (days)
Complication rate
(%)
Recurrence rate
(%)
Cost, range (US$)
Cost, average (US$)
45259*
27148
60180
25220
N/A
97.6*
78.5
111.5
82
N/A
N/A
226*
321*
N/A
0.514*
4.9
6.5*
9.06*
2.8
4.4*
31
36.7*
?
36
N/A
12.5
34.7
2
20.7
0
198712 611*
N/A
N/A
N/A
657418 448
7299*
N/A
N/A
N/A
12 461
*Statistically significant difference.
Laparoscopic
repair
70211*
45170
30180
18225
N/A
128.5*
95.4
87
58
N/A
N/A
117*
115*
N/A
0.53*
1.6
3.4*
2.23*
1.7
0.8*
15
17.9*
10
N/A
1
11
0
2.5
4.8
35555235*
N/A
N/A
N/A
532311 223
4395*
N/A
N/A
N/A
8273
Ref.
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
PAYMENT CHANGES
Despite the points discussed above, the financial realities
of governmental reimbursement in the USA have declined
continuously. We selected the comparison of the payments
from Medicare in the USA since 1993 for four hernia operations (Figure 38.1). Unless noted otherwise, all of these
are inguinal hernia repairs. It is readily apparent that these
levels of payment have not changed significantly in nine
years. These payments do not reflect the inflationary
increases in office overheads and the enormous elevations
in the cost of medical liability insurance. Additionally, the
payment for the repair of bilateral inguinal hernias is 1.5
times the payment for the repair of a single hernia. Because
of this, some surgeons simply cannot afford to repair bilateral hernias at the same time. Instead, these are repaired
sequentially in two separate procedures. It is particularly
disturbing that payment for the repair of an incisional
hernia (US$636.69) is less than the repair of a recurrent
incarcerated inguinal hernia (US$644.07). The differences
US dollars
Table 38.1 Results of comparative analysis of open and

laparoscopic incisional and ventral herniorrhaphy
evaluated the cost of the repair.16,54 In both papers, the

laparoscopic method was associated with less cost than
the open repair. This is based primarily upon the
decreased length of stay of laparoscopically repaired
patients. This occurred even when the additional costs of
any re-admissions were included in the overall determination. Interestingly, the work by DeMarie and colleagues evaluated the costs based upon open repair using
a polypropylene product versus the laparoscopic repair
using an expanded polytetrafluoroethylene (ePTFE)
patch.16 Therefore, based upon the limited study that has
been done on this operation, it appears that laparoscopic
herniorrhaphy for incisional and ventral hernia is the
economically preferred choice.
These issues are discussed more frequently with the
repair of inguinal and incisional hernias. The use of the
laparoscope to repair the other hernias discussed in this
textbook appears to compare favorably with open repair.
Decreased length of stay, decreased morbidity, and a more
rapid return to normal activity have been shown.
800
700
600
500
400
300
200
100
0
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
Many papers in the literature have demonstrated the

short period of hospitalization seen with this approach
to this problem.15,16,51,52 It is generally believed by surgeons
proficient in this technique that this method lessens the
length of hospitalization for the patients. Five publications have compared open and laparoscopic repair of
incisional and ventral hernias (Table 38.1).16,5356 In all
of these series, laparoscopic repair was associated with
fewer complications and fewer days of hospitalization
than those of open method. Only two of these papers
Open
Recurrent
Recurrent
incarcerated
Incisional
Laparoscopic
inguinal
Laparoscopic
recurrent
inguinal
Figure 38.1 Medicare reimbursement in real dollar values

from 1993 to 2002.
in the complexity of the operations, potential morbidity,

and length of postoperative care are obvious to every
surgeon. The financial realities of the practice of surgery
in the USA are subtly affecting the ethics of surgery.
Laparoscopic repair of primary inguinal hernias is
reimbursed less than that of the open repair. There is no
consideration given to the extra level of expertise and
training that is required to perform that operation. One
could postulate that the financial disincentive is placed to
discourage the use of the procedure in these patients
because of the extra cost associated with the operation.
This is especially troubling, as this will inhibit its use in
patients who might benefit from that method of repair.
At the time of writing, there is no code in which to bill for
the laparoscopic incisional hernia repair, although one
should be available soon.
In the USA, access to healthcare by the recipients of
governmental healthcare is being affected adversely. Many
people cannot find physicians who will accept these low
levels of payment. Some surgeons no longer repair bilateral hernias simultaneously. Because of the costs of doing
business, the ethics of medicine are being impacted. There
does not appear to be hope of any meaningful relief in the
near term. In fact, there may be less reimbursement by
Medicare to the surgeon to perform any operation laparoscopically rather than by the open technique. Further government intervention may avert this unfortunate event,
but politics are part of the medical landscape in all countries. Unless changes are forthcoming, few surgeons will
adopt these newer techniques.
CONCLUSION
It is no longer sufficient to consider only the clinical and
therapeutic effects of healthcare: purchasing choices
require explicit economic evaluation to identify, measure
and value costs and patient health outcomes. Surgical
interventions are no exception to this business principle.
Hernia repair is an established and effective procedure
for most patient groups, and its relatively low cost among
surgical procedures means that economic evaluation of
the procedure itself is not a priority. However, innovations in the procedure of hernia repair and the management of patients, such as day-case and laparoscopic repair
of the different hernias, should be subject to economic
evaluation.
The unit costs of day-case surgery are lower than
those of traditional in-hospital care. Any money saved
will enable more operations to be carried out and more
patients to be treated. Alternatively, savings generated
could be used to develop other services.
Laparoscopic surgery has spread rapidly through many
surgical specialties, but there are still major knowledge
gaps about its clinical and economic attributes. The potential clinical and economic benefits of laparoscopic inguinal
hernia repair are particularly unclear given the need for
general anesthesia and the possibility of rare but serious
injuries to intra-abdominal organs. This procedure benefitted from large-scale clinical trials and economic evaluations for inguinal hernia repair. The use of laparoscopy in
the repair of many of the other hernias of the abdominal
wall seems to have a strong economic benefit, however.
The future development of advanced techniques and
even the availability of even the simplest of hernia repairs
may become more difficult due to the negative financial
consequences of governmental payment schedules.
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Grotzinger U. Ambulante Herniechirurgie. Therapeutische Umschau
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Rutkow IM, Robbins AW. Demographic, classificatory, and
socioeconomic aspects of hernia repair in the United States. Surg
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Haydorm WH, Velanovich V. A five year U.S. Army experience with
36,250 abdominal hernia repairs. Am Surg 1990; 56: 596.
Millat B, Fingerhut A, Gignoux M, et al. Factors associated with
early discharge after inguinal hernia repair in 500 consecutive
unselected patients. Br J Surg 1993; 80: 115860.
Kawji R, Feichter A, Fuchsjager N, Kux M. Postoperative pain and
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Lau H, Lee F. Determinant factors of pain after ambulatory inguinal
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Saledo-Wasicek CM, Thirlby RC. Postoperative course after inguinal
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Callesen T, Klarskov B, Bech K, Kehlet H. Short convalescence after
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Jones KR, Burney RE, Peterson M, Christy B. Return to work after
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Ismail W, Taylor SJC, Beddow E. Advice on driving after groin hernia
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56
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82732.
Index
Note: References to figures are indicated by f and references to tables are indicated by t when they fall on a page not covered by the text reference.
abdominal bloating, after fundoplication
218, 2434
abdominal wall, anterior anatomy see
anterior abdominal wall anatomy
achalasia 1989
adhesiolysis, and bowel injury 163
adhesives 1112
AESOP robotic arm 2668
alkaline reflux gastritis 218
Allisons procedure 1745
Alloderm prosthetic material 224
Anatomical Mesh 21
anatomy
anterior abdominal wall see anterior
abdominal wall anatomy
in children 255
diaphragm 17983
inguinal/femoral region see
inguinal/femoral anatomy
peritoneal cavity 412
pre-peritoneal space 423
and total extraperitoneal (TEP) patch
technique 667, 68f
anesthetic complications 89
in children 261
Angimesh prosthetic material 1718
anterior abdominal wall anatomy 1045
and cosmetic results 109
and functional outcomes 10910
and hernia formation 1056
and hernia repair methods 1067
and prosthetic biomaterial fixation 1078
and scar healing 1089
arcuate line 42f, 44
balloon trocars 9
barium swallow 188, 190
Bassini, E 34
bilateral hernia 62
in children 2512
bioadhesives 1112
biochemical changes, and hernia
formation 36
biological prosthetic materials 224
Biomesh prosthetic materials 1718
bladder injury 92
Bochdalek hernia 2578
bone complications 93
bowel injury 1613
bowel obstruction 923
laparoscopic repair 11113
calcitonin gene-related peptide
(CGRP) 456
Cheatle, GL 34
children
anatomy 255
complications in 2612
diaphragmatic hernia repair
history 257
patient selection 257
surgical technique
Morgagni hernia 2589
history of laparoscopy in 2514
physiology 2556
cigarette smoking, and hernia
formation 36
clinical studies, ventral/incisional
hernioplasty
comparative studies 1579
series comparisons 1557
collagen defects 46
Collis gastroplasty 198
colostomy, parastomal hernias see
parastomal hernias
compartmented stomach, after
fundoplication 21920
complication rates
laparoscopic method comparisons 834
laparoscopic vs open methods 846
complications
in children 2556, 2612
diaphragmatic hernia repair 2357
economic evaluation 278
fundoplication
intraoperative 23940
bougie perforation 2401
esophageal perforation 240
gastric injury 243
hemorrhage 2412
large hernia 243
pneumothorax 241
short esophagus 2423
postoperative
dysphagia 246
gastrointestinal symptoms 2434
ileus 246
para-esophageal hernia 244
recurrent reflux 247
slipped Nissen 2445
symptom assessment 243
vagal nerve injury 2456
inguinal/femoral hernioplasty
anesthesia 89
hydrocele 90
laparoscopic access 8990
nerve injury 912
organ complications 90
prosthetic mesh problems 93
recurrence rates 934
seroma 901
vascular injury 91
visceral injury 923
laparoscopic assisted ventral hernia
repair 1634
para-esophageal hernia repair 2067
with prosthetic biomaterials 1721
and recurrent gastroesophageal reflux
disease 21722
and return to work 2767
with transfascial sutures 1345
ventral/incisional hernioplasty
bowel injury 1613
gastrointestinal complications 166
postoperative pain 166
prosthetic mesh fixation 1078
prosthetic mesh infection 1645
series comparisons 156t, 157
seroma 1656
see also recurrence rates
Composix prosthetic biomaterials 212
congenital hernias 2579
connective tissue damage
and pathophysiology 46
convalescence after surgery 2767
Coopers ligament 423
cosmetic outcomes, ventral/incisional
hernioplasty 109
crural disruption, after fundoplication 219
cyanoacrylate fixation 12
da Vinci tele-robotic system 2689
ventral/incisional hernioplasty 2702
day-case surgery, economic evaluation
2756
denervation hernias
anatomy 151, 152f
formation of 1056
surgical repair
indications/contraindications 152
operative technique 1523
outcomes 153
diaphragm
anatomy 17983
and hernia surgery 1845
physiology 1834
diaphragmatic hernia
in children 257
fundoplication see fundoplication
history of surgery for
Allison, P 1745
in children 257
early surgery 173
laparoscopic approach 1756
284 Index
diaphragmatic hernia (Contd)
Nissen fundoplication 175
short esophagus 174
outcomes of surgery 2357
para-esophageal hernias see
para-esophageal hernias
from traumatic injury 20910
acute herniation 21012
chronic herniation 21214
types of hiatal hernia 235
see also gastroesophageal reflux
disease (GERD)
diarrhea, after fundoplication 218
diffuse esophageal spasm 1989
disposable instruments 78
dissecting instruments 8
instrumentation 1356
operating room set-up 137
outcomes 141
postoperative management 141
preoperative management 1356
prosthetic biomaterials 1367
surgical technique 13741
transfascial suture comparison 1345
driving, after surgery 277
DualMesh prosthetic biomaterials 1821
in ventral/incisional hernioplasty
double-crown technique 1367
parastomal hernias 1467
transfascial suture technique 11718
Dulex prosthetic biomaterial 1821
dysphagia, after fundoplication
21718, 246
day-case surgery 2756
hernia repair 2745
laparoscopic surgery 27880
payment methods 2801
return to work 2767
electrosurgery 10
employment, return to after surgery 2767
EMS stapler 256
EndoAnchor fixation device 278
Endopath EMS stapler 26
endoscopy 188, 190, 2278
endosopic gastroplasty 194
enterotomy 1613
epigastric hernia 106
ergonomics 13
esophageal hiatus 1813
esophageal manometry 1889, 190, 228f,
229
esophageal perforation, with fundoplication
2401
esophagography 2289
esophagomytomy 1989
expanded polytetrafluoroethylene (ePTFE)
products
composite products 212
flat, single-component products 1821
in ventral/incisional hernioplasty 126
fixation 108
obstructed/incarcerated bowel 11213
transfascial suture technique 11718
external oblique muscle 44, 104
fascia transversalis 424

pathophysiology 46
femoral canal 45
femoral hernioplasty
history 76
incidence of femoral hernias 756
femoral nerve 45
femoral sheath 45
fibrin adhesive agents 1112
fixation devices 1112
EndoAnchor device 278
helical coil devices 27
Salute device 27, 28f
staple devices 257
Fortagen prosthetic material 224
Fortaperm prosthetic material 224
fundoplication 194
anatomical considerations 1845
complications
intraoperative 23940
bougie perforation 2401
esophageal perforation 240
gastric injury 243
hemorrhage 2412
large hernia 243
pneumothorax 241
postoperative
dysphagia 246
gastrointestinal symptoms 2434
ileus 246
para-esophageal hernia 244
recurrent reflux 247
slipped Nissen 2445
vagal nerve injury 2456
short esophagus 2423
failure of
clinical presentation 21718
mechanisms of failure 21921
history 1756
Nissen fundoplication see Nissen
fundoplication
operative technique
crural closure 1956
esophagomytomy 1989
mobilization 1945
modified Toupet 1967
pyloroplasty 199
preoperative evaluation
esophageal manometry 1889
pH monitoring 18990
for recurrent disease
preoperative evaluation 22730
gastric blood vessel injury 2412
gastric emptying studies 230
gastric injury 243
gastroesophageal reflux disease (GERD)
diaphragmatic anatomy 17983
and surgical repair 1845
diaphragmatic physiology 1834
fundoplication see fundoplication
non-surgical treatment 1934
preoperative evaluation
esophageal manometry 1889
pH monitoring 18990

recurrent disease 217
clinical presentation 21718
evaluation after failed surgery 1901
incorrect diagnosis 2212
incorrect surgery 221
mechanisms of failure 21921
surgery for
indications 2224
surgical treatment
individualization of therapy 199200
operative technique
crural closure 1956
esophagomytomy 1989
mobilization 1945
modified Toupet 1967
pyloroplasty 199
patient preparation 194
see also diaphragmatic hernia
gastrointestinal complications
after fundoplication 2434
after ventral/incisional hernioplasty 166
recurrent gastroesophageal disease
21719
genitofemoral nerve 45
injury to 912
giant prosthetic reinforcement of the
visceral sac (GPRVS), history 36
Glucamesh prosthetic biomaterial 212
Glucatex 3D prosthetic biomaterial 212
grasping instruments 8
hand-assisted laparoscopy (HAL) 1213
Hasson trocar 89
health economics
hernia repair surgery 2745
payment methods 2801
helical coil fixation devices 11, 27
hemorrhage
with fundoplication 2412
with inguinal/femoral hernioplasty 91
Henry, AK 34
hepatocyte growth factor/scatter factor
(HGF/SF) 456
Hermesh prosthetic biomaterials 1718
Hertra prosthetic biomaterials 1718
Hesselbachs triangle 43
Hesserts triangle 46
hiatal hernia see diaphragmatic hernia
hiatal stenosis 220
history
diaphragmatic hernia in children 257
diaphragmatic hernia surgery
Allison, P 1745
early surgery 173
laparoscopic approach 1756
early surgery 33
femoral hernioplasty 76
fixation devices 258
intraperitoneal onlay of mesh (IPOM)
procedure 478
laparoscopic general surgery 35
laparoscopic hernia repair 379
Index 285
nonoperative management 33
obturator hernioplasty 76
open hernia repair 336
hydrocele 90
in children 262
hypertensive lower-esophageal
sphincter 1989
ileostomy, parastomal hernias see
parastomal hernias
ileus 246
ilio-hypogastric nerve 45
ilio-inguinal nerve 45
iliopubic tract 423
imaging systems 12
see also robotic devices
incarcerated bowel repair 11113
incarcerated inguinal hernia 63
incisional hernias
diagnosis 125
incidence 125
pre-peritoneal hernioplasty see
pre-peritoneal hernioplasty
repair methods 1257, 12930
risk factors 125
see also ventral/incisional hernioplasty
infants see children
infection, with prosthetic biomaterials 93,
113, 1645
inferior epigastric vessels 41
injury to 91
infertility, and prosthetic mesh 93
inguinal canal 44
femoral canal 45
femoral sheath 45
inguinal canal 44
myopectineal orifice 445
nerves 45
oblique muscles 44
peritoneal cavity 412
pre-peritoneal space 423
spermatic cord 44
transversalis fascia 434
complications
anesthesia 89
hydrocele 90
nerve injury 912
prosthetic mesh problems 93
seroma 901
vascular injury 91
visceral injury 923
femoral hernioplasty
history 76
incidence of femoral hernias 756
history
in children 2524
early surgery 33
nonoperative management 33
open hernia repair 336
procedure see intraperitoneal onlay
of mesh (IPOM) procedure
lipomas 801
low Spigelian hernia 81
obturator hernioplasty see obturator

hernioplasty
outcomes
laparoscopic method comparisons
834
perineal hernia 7980
prevascular hernia 80
sciatic hernia 779
supravesical hernia 79
total extraperitoneal (TEP) patch
technique see total extraperitoneal
(TEP) patch technique
transabdominal pre-peritoneal (TAPP)
patch technique see transabdominal
pre-peritoneal (TAPP) patch
technique
injuries
from laparoscopic access 8990
traumatic diaphragmatic injuries see
traumatic diaphragmatic injuries
from trocars 810
see also complications
instrumentation
disposable 78
dissecting and grasping instruments 8
energy sources 1011
ergonomics 13
fixation devices 1112, 258
hand-assisted laparoscopy 1213
robotic devices see robotic devices
trocars 810
videoendoscopy systems 12
internal inguinal ring 412
internal oblique muscle 44, 104
intestinal complications 923, 1613
intestinal stomas, parastomal hernias
see parastomal hernias
Intramesh prosthetic biomaterials 1718
procedure
advantages and disadvantages 51
history 37, 478
irreducible inguinal hernia 63
ischemic orchitis 90
laparoscopic assisted ventral hernia
repair 1634
laparoscopic hernia repair
history 379
open method comparison 846
laparoscopic surgery
history 35
lateral cutaneous nerve of thigh 45
Lichtenstein repair
history 356
laparoscopic method comparison
845
lipomas 801
liver injuries 241
low Spigelian hernia 81
lower-esophageal sphincter 1834
lumbar hernias
anatomy 151, 152f
surgical repair
outcomes 153
Marcy, HO 334
Marlex prosthetic biomaterial 1718
history 345
Mersilene prosthetic biomaterial 18
mesh prosthetics see prosthetic biomaterials
modified Toupet fundoplication 1967
muscular denervation see denervation
hernias
Mycromesh prosthetic biomaterials
1821
myopectineal orifice 35, 36f, 445
Nanticoke Hernia Stapler 26
National Institute for Clinical Excellence
(NICE) 273
needle drivers 11
neoplasia, and recurrent gastroesophageal
reflux disease 220, 2212
nerves
anatomy 45
injury to 912
with prosthetic biomaterial
fixation 108
and recurrent gastroesophageal
reflux disease 221, 2456
Nissen fundoplication
complications 220, 2445
history 175
non-cutting trocar 10
nutcracker esophagus 1989
Nyhus, LM 34
oblique muscles 44
obstructed bowel repair 11113
obturator artery, injury to 91
obturator hernioplasty
history 76
incidence of obturator hernias 76
Omni-Tack 267
open hernia repair
and anterior abdominal wall
anatomy 1067
history 336
for incisional hernias 1267
laparoscopic method comparison
for ventral/incisional hernias 12930,
1579
for para-esophageal hernias 202
optical view trocar 9
Origin tacker 27
outcome of surgery
laparoscopic method
comparisons 834
cosmetic results 109
denervation hernias 153
functional outcomes 10910
lumbar hernias 153
pre-peritoneal hernioplasty 12930
286 Index
pain
after ventral/incisional hernioplasty 166
management in children 256
para-esophageal hernias
surgical repair
types of 201
parastomal hernias
assessment 144
outcomes 1489
surgical repair
methods 144
preoperative preparation 145
types of 1434
Parietene prosthetic biomaterial 1718
Paritex prosthetic biomaterials 18, 212
partitioned stomach, after
pathophysiology 36, 456
pectineal ligament 423
pediatric hernia
complications
anesthesia 261
hydrocele 262
surgical complications 2612
testicular complications 262
diaphragmatic hernia repair
history 257
surgical technique
pathophysiology 44, 456
physiological considerations 2556
pediatric laparoscopy, history 2514
pelvic anatomy
anterior abdominal wall see anterior
abdominal wall anatomy
inguinal/femoral region see
pelvic hernia repair see femoral hernioplasty;
obturator hernioplasty
perineal hernioplasty 7980
peritoneal cavity, anatomy 412
pH monitoring 18990, 1901, 22930
phreno-esophageal ligament 181
physiology
in children 2556
diaphragm 1834
inguinal region 456
plug-and-patch technique, history 37
pneumothorax 206, 241
polyester biomaterials
flat, single-component products 18, 19f
preformed products 21
in ventral/incisional hernioplasty 126
polypropylene mesh (PPM) products

flat, single-component products
1718
history 345
108, 126
obstructed/incarcerated bowel
11213
postoperative complications see
complications
comparison with other techniques
12930
indications 127
outcomes 129
tele-robotic systems 2702
see also total extraperitoneal (TEP)
patch technique
pre-peritoneal space, anatomy 423
prevascular hernioplasty 80
processus vaginalis
anatomy 44
pathophysiology 456
Prolene prosthetic biomaterials 1718
Prolite prosthetic biomaterial 1718
prosthetic biomaterials
history 345, 379
infection 93, 1645
non-synthetic materials 224
and outcome of surgery, laparoscopic vs
open methods 856
synthetic materials
see also individual surgical procedures
Protack device 27
protease/antiprotease imbalance, and
hernia formation 36
pyloroplasty 199
radially expanding trocar 10
Reconix prosthetic biomaterial 1821
rectus abdominus muscle 104
recurrence rates
gastroesophageal reflux disease (GERD)
see gastroesophageal reflux disease
(GERD), recurrent disease
hiatal hernia repair 2357
inguinal/femoral hernioplasty 934
pediatric hernia 262
total extraperitoneal (TEP) patch
technique 84
patch repair 623, 84
comparative studies 158t, 159
reflux esophagitis see gastroesophageal
reflux disease (GERD)
respiration
and incisional hernias 106
and laparoscopy in children 256
robotic devices 13

da Vinci system 2689
2702
Zeus system 26970
round ligament, lipoma 801
Safety and Efficacy Register of New
Interventional Procedures
(SERNIP) 274
Salute fixation device 11, 27, 28f
scar healing 1089
sciatic hernioplasty 779
scrotal hernioplasty 63
Sepramesh prosthetic biomaterial 212
seroma 901, 1656
shielded trocar 910
short esophagus
and fundoplication 2423
history of surgery for 1734
and recurrent gastroesophageal reflux
disease 219
Shouldice technique 845
skin
complications 93
cosmetic outcomes 109
smoking, and hernia formation 36
socioeconomic issues
hernia repair 2745
and payment methods 2801
Soft Tissue Patch prosthetic
biomaterial 1821
spastic disorders of esophagus 1989
spermatic blood vessels, injury to 91
spermatic cord
anatomy 44
lipoma 801
Spigelian hernia 81
spiral tack fixation devices 11, 27
splenic injury 242
staple fixation devices 11, 257
stomach complications, after
Stoppa procedure 36
strangulated bowel repair 113
Stretta Procedure 1934
supravesical hernioplasty 78
surgical ergonomics 13
Surgipro prosthetic materials 1718
Surgisis prosthetic materials 224
suture passers 11
synthetic biomaterials
see also prosthetic biomaterials
tack fixation devices 11, 27
TAPP technique see transabdominal
pre-peritoneal (TAPP) patch
technique
da Vinci system 2689
Zeus system 26970
TEP technique see total extraperitoneal
(TEP) patch technique
Index 287
testicular complications
in children 262
inguinal/femoral hernioplasty 90
thermal energy sources 10
3D Max prosthetic biomaterial 21
total extraperitoneal (TEP) patch technique
anatomical considerations 667, 68f
complications
anesthesia 89
hydrocele 90
nerve injury 912
with prosthetic mesh 93
seroma 901
vascular injury 91
visceral injury 923
history 38
instrumentation 68
open method comparison 845
comparison 834
patch technique
for bilateral hernia 62
complications
anesthesia 89
hydrocele 90
nerve injury 912
prosthetic mesh 93
seroma 901
vascular injury 91
visceral injury 923
history 378
instrumentation 55
open method comparison 54, 845
operating room set-up 55, 56f

for recurrent hernia 623
for scrotal hernia 63
transfascial suture technique
adhesiolysis 1201
advantages/disadvantages 1345
instrumentation 11819
prosthetic biomaterials 11718
insertion/fixation 1223
trocar placement 11920
trocar selection 119
transversalis fascia 424
transversus abdominus muscle 1045
traumatic diaphragmatic injuries 20910
acute herniation 21012
chronic herniation 21214
Trelex prosthetic biomaterial 1718
trocars
design of 810
injury from 8990
tumors, and recurrent gastroesophageal
reflux disease 220
twisted fundoplication 220
ultrasonic dissection 1011
ultrasonically activated trocar 10
umbilical hernia 106
urinary bladder injury 92
US Surgical Corporation stapler 26
Usher, FC 345
vagal nerve injury 221, 2456
vas deferens complications 90, 93
vascular injury 8990, 91
with prosthetic biomaterial fixation 1078
and trocar design 810
anterior abdominal wall anatomy 1045
and repair methods 1067
complications
bowel injury 1613
gastrointestinal complications 166
postoperative pain 166
prosthetic mesh infection 1645
seroma 1656
denervation hernias see denervation
hernias
double-crown technique see
history 99100
laparoscopic assisted hernia
repair 1634
lumbar hernias see lumbar hernias
obstructed/incarcerated bowel 11113
outcomes
cosmetic 109
functional 10910
parastomal hernias see parastomal
hernias
pre-peritoneal hernioplasty see
prosthetic biomaterial fixation 1078
scar healing 1089
transfascial suture technique see
transfascial suture technique
Zeus tele-robotic system 2689, 2702
videoendoscopy systems 12
da Vinci tele-robotic system 2689
visceral injury 8990, 923, 243
with para-esophageal hernia repair 206
and trocar design 810
work, return to after surgery 2767
Zeus tele-robotic system 26970

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Laparoscopic Hernia Surgery

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Laparoscopic hernia

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Karl A. LeBlanc MD MBA FACS

A member of the Hodder Headline Group

First published in Great Britain in 2003 by

I wish to dedicate this book to Zinda, my wife. Please forgive my absence in

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Laparoscopic general surgery

Technological and instrumentation aspects of laparoscopic hernia surgery

Prosthetic biomaterials for hernioplasty

Fixation devices for laparoscopic hernioplasty

LAPAROSCOPIC INGUINAL/FEMORAL HERNIOPLASTY

Anatomy and physiology

Intraperitoneal onlay mesh approach

Transabdominal pre-peritoneal approach

Totally extraperitoneal approach

Femoral and pelvic herniorrhaphy

Results of laparoscopic inguinal/femoral hernia repair

Complications and their management

LAPAROSCOPIC INCISIONAL AND VENTRAL HERNIOPLASTY

Anatomy and physiology

Laparoscopic repair in the emergent setting

Herniorrhaphy with the use of transfascial sutures

Hernioplasty with the double-crown technique

Parastomal hernia repair

Lumbar hernia and denervation hernia repair

Results of laparoscopic incisional and ventral hernia repair

Complications and their management

LAPAROSCOPIC TREATMENT OF DIAPHRAGMATIC HERNIATION

Anatomy and physiology

Gastroesophageal reflux disease

Traumatic and unusual herniation

Etiology of recurrent gastroesophageal reflux disease

Reoperation for recurrent gastroesophageal reflux disease

Results of laparoscopic treatment of hiatal hernias

Complications and their management

LAPAROSCOPY IN THE PEDIATRIC HERNIA PATIENT

Anatomy and physiology

Complications and their management

Robotics and hernia surgery

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Andrew N. Kingsnorth BSc MD MS FRCS FACS

Karl A. LeBlanc MD MBA FACS

Bruce J. Ramshaw MD FACS

J. Barry McKernan MD PhD FACS

Samuel K. Miller MD FACS

world, the availability of the pediatric surgeon is quite

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calcitonin gene-related peptide

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Angiologica, S. Martino Sicc., Italy

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1 Laparoscopic general surgery

3 Prosthetic biomaterials for hernioplasty

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Fortunately the time when many surgeons and their

mention thoracoscopy, a procedure that he initially felt had

appendectomy.13 Laparoscopic appendectomy had been

Laparoscopic general surgery 5

have pushed some surgeons to use laparoscopy for very