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
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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 xi
Preface xiii
Abbreviations xv
Manufacturers xvii
PART 1 OVERVIEW 1
1 Laparoscopic general surgery 3

Roger K.J. Simmermacher
2 Technological and instrumentation aspects of laparoscopic hernia surgery 7

Gina L. Adrales and Adrian E. Park
3 Prosthetic biomaterials for hernioplasty 17

Karl A. LeBlanc
4 Fixation devices for laparoscopic hernioplasty 25

Karl A. LeBlanc
PART 2 LAPAROSCOPIC INGUINAL/FEMORAL HERNIOPLASTY 31
5 History 33
Michael S. Kavic and Stephen M. Kavic
6 Anatomy and physiology 41

B. Page and Patrick J. O’Dwyer
7 Intraperitoneal onlay mesh approach 47

Morris Franklin
8 Transabdominal pre-peritoneal approach 53

Reinhard Bittner, Claus-Georg Schmedt and Bernhard Josef Leibl
9 Totally extraperitoneal approach 65

Ed Felix
10 Femoral and pelvic herniorrhaphy 75

Christine A. Ely and Maurice E. Arregui
11 Results of laparoscopic inguinal/femoral hernia repair 83

Ketan M. Desai and Nathaniel J. Soper
12 Complications and their management 89

Ricardo V. Cohen, Carlos A. Schiavon, Sérgio Roll and José C.P. Filho
viii Contents
PART 3 LAPAROSCOPIC INCISIONAL AND VENTRAL HERNIOPLASTY 97
13 History 99
Kristi L. Harold, Brent D. Matthews and B. Todd Heniford
Karl A. LeBlanc
15 Laparoscopic repair in the emergent setting 111
Guy R. Voeller
16 Herniorrhaphy with the use of transfascial sutures 115
Karl A. LeBlanc
17 Pre-peritoneal herniorrhaphy 125
Sérgio Roll, Wagner C. Marujo and Ricardo V. Cohen
18 Hernioplasty with the double-crown technique 133
Salvador Morales-Conde and Salvador Morales-Méndez
19 Parastomal hernia repair 143
Karl A. LeBlanc
20 Lumbar hernia and ‘denervation’ hernia repair 151
Karl A. LeBlanc
21 Results of laparoscopic incisional and ventral hernia repair 155
Rodrigo Gonzalez and Bruce J. Ramshaw
Samuel K. Miller, Stephen D. Carey, Francisco J. Rodriguez and Roy T. Smoot, Jr
PART 4 LAPAROSCOPIC TREATMENT OF DIAPHRAGMATIC HERNIATION 171
23 History 173
Raymond C. Read
Mark A. Reiner
25 Preoperative evaluation 187
Marco G. Patti and Piero M. Fisichella
26 Gastroesophageal reflux disease 193
J. Barry McKernan and Charles R. Finley
27 Para-esophageal hernias 201
Hugo Bonatti, Beate Neuhauser and Ronald A. Hinder
28 Traumatic and unusual herniation 209
Sergio G. Susmallian and Ilan Charuzi
29 Etiology of recurrent gastroesophageal reflux disease 217
Ziad T. Awad and Charles J. Filipi
30 Reoperation for recurrent gastroesophageal reflux disease 227
Thomas R. Eubanks
31 Results of laparoscopic treatment of hiatal hernias 235
Patrick R. Reardon and Stirling E. Craig

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

35 Diaphragmatic herniation 257


PART 6 FUTURE CONSIDERATIONS 263
37 Robotics and hernia surgery 265

Amit Trivedi and Garth H. Ballantyne
38 Socioeconomic issues 273

Karl A. LeBlanc, Andrew N. Kingsnorth and Zinda Z. LeBlanc
Index 283
Contributors
Gina L. Adrales MD Ed Felix MD

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

Department of Surgery, Yale University School of Medicine, Associate Professor of Surgery, Director, Swallowing Center,
New Haven, CT, USA University of California, San Francisco, CA, USA
Andrew N. Kingsnorth BSc MD MS FRCS FACS Rajeev Prasad MD
Professor of Surgery and Consultant Surgeon, Plymouth Fellow in Pediatric Surgery, University of Tennessee College of
Postgraduate Medical School, Derriford Hospital, Plymouth, UK Medicine, and Le Bonheur Children’s Medical Center, Memphis,
Karl A. LeBlanc MD MBA FACS TN, USA
Minimally Invasive Surgery Institute, Inc. Baton Rouge, Bruce J. Ramshaw MD FACS
Louisiana, USA. Clinical Assistant Professor, Surgery, Louisiana Director of Education, Emory Endosurgery Unit, and Assistant
State University School of Medicine, New Orleans, Louisiana, Professor, Surgery Department, Emory University School of
USA. Past President of the American Hernia Society Medicine, Atlanta, GA, USA
Zinda Z. LeBlanc RN BSN MD MBA
Raymond C. Read MD FACS FRCS
Director of Surgical Services/AICU/PACU/TX Rm.,
Professor of Surgery Emeritus, University of Arkansas for
Woman’s Hospital, Baton Rouge, LA, USA
Medical Sciences, Rockville, MD, USA
Bernhard Josef Leibl MD
Department of General and Visceral Surgery Marienhospital Patrick R. Reardon MD
Stuttgart, Stuttgart, Germany Director, Texas Institute for Advanced Minimally Invasive
Surgery Training, Texas Medical Center, Houston, Texas and
Thom E. Lobe MD
Surgical Director, Methodist Reflux Center, The Methodist
Chairman, Section of Pediatric Surgery, and Chairman, Task
Hospital, Texas Medical Center, Houston, Texas
Force on Complementary and Alternative Medicine, and
Professor of Surgery and Pediatrics, University of Tennessee Mark A. Reiner MD
College of Medicine and Le Bonheur Children’s Medical Center, Assistant Clinical Professor of Surgery, Laparoscopic Surgical
Memphis, TN, USA Center of New York, Mount Sinai School of Medicine, New York,
Wagner C. Marujo MD NY, USA
Attending Surgeon, Liver Transplantation Unit, Hospital Albert Francisco J. Rodriguez MD FACS
Einstein, Sao Paulo, and Faculty of Medicine, University of Sao Nanticoke Surgical Associates, Seaford, DE, USA
Paulo, Sao Paulo, Brazil Sérgio Roll MD
Brent D. Matthews MD Director of Laparoscopic Surgery, Department of General
Chief of Research, Carolinas Laparoscopic and Advanced Surgery, Heliopolis Hospital, University of Santos School of
Surgery Program, Carolinas Medical Center, Charlotte, NC, USA Medicine, Sao Paulo, Brazil
J. Barry McKernan MD PhD FACS Carlos A. Schiavon MD
Clinical Professor of Surgery, Medical College of Georgia, Department of Surgical Endoscopy, Sao Camilo Hospital,
Augusta, GA, USA Sao Paulo, Brazil
Samuel K. Miller MD FACS
Claus-Georg Schmedt MD
Nanticoke Surgical Associates, Seaford, DE, USA
Department of General and Visceral Surgery
Salvador Morales-Conde MD Marienhospital Stuttgart, Stuttgart, Germany
Laparoscopic Surgery Unit, University Hospital Virgen
Roger K.J. Simmermacher MD PhD
Macarena, Seville, Spain
General Surgeon, University Medical Centre, Utrecht,
Salvador Morales-Méndez MD The Netherlands
Digestive and General Surgery Unit, University Hospital Virgen
Del Rocío, Seville, Spain Roy T. Smoot, Jr MD FACS
Nanticoke Surgical Associates, Seaford, DE, USA
Beate Neuhauser MD
Department of Surgery, Mayo Clinic, Jacksonville, FL, USA Nathaniel J. Soper MD
Department of Surgery, Washington University School of
Patrick J. O’Dwyer MB BCh MD FRCSI MCh FRCS
Medicine, St Louis, MO, USA
Professor of Gastrointestinal Surgery, University Department of
Surgery, Western Infirmary, Glasgow, UK Sergio G. Susmallian MD
Department of Surgery, Wolfson Medical Center, Holon, Israel
B. Page BSc MD MBChB MRCS
Research Fellow, University Department of Surgery, Western Amit Trivedi MD
Infirmary, Glasgow, UK Division of Minimally Invasive and Telerobotic Surgery,
Adrian E. Park MD FRCS FACS Hackensack University Medical Center, Hackensack, NJ, USA
Department of Surgery, Center for Minimally Invasive Surgery, Guy R. Voeller MD FACS
University of Kentucky Chandler Medical Center, Lexington, KY, Associate Professor, Surgery, University of Tennessee, Memphis,
USA Memphis, TN, USA
Preface
The laparoscopic repair of inguinal hernias quickly fol- world, the availability of the pediatric surgeon is quite
lowed the development of the laparoscopic approach to uncommon. The information imparted in these chapters
the cholecystectomy. This operation was, and continues should provide guidance to the general laparoscopic sur-
to be, a controversial subject. In contrast, the adoption of geon in this setting.
the laparoscopic methodology for the treatment of the The era of robotics is also upon us. It may be surpris-
other hernias of the abdominal wall has experienced con- ing to many of us but there is utility in the repair of her-
tinued growth. While there are textbooks that have dealt nias also.
with general laparoscopic surgical techniques and others The final chapter on socioeconomics is needed to
that are comprehensive texts on the subject of hernias, educate the surgeon as he or she makes the operative
none have been dedicated solely to the laparoscopic treat- choices that are available. Many issues will be regional
ment of this malady in all aspects of the abdomen. while others are national and international. We are all
A review of the authors that have contributed to this continually faced with the economic realities of the prac-
work is a testament of my efforts to provide a true “oper- tice of surgery. More attention should be given to this
ative guide” to those surgeons-in-training and those who subject in the training programs. It is hoped that this
desire more detailed information on this subject matter. book provides a sound basis to begin this process.
An international representation is evident. These are the I wish to thank all of the contributors for their persist-
opinion leaders and the surgeons that have helped to ence in this work. It is rather difficult and time-consum-
develop this field. I appreciate their efforts to share their ing to provide a chapter of the detail and with the
knowledge. significant references that I desired. It is the expertise of
I have tried to provide the reader with the different these authors that will truly make this text a reference
techniques that are currently being used to repair the source. I would also express my appreciation of all of the
hernias in the inguinal region, the incisional and hiatal staff from Arnold Publishers and Naughton Management
locations. I have also relied on different authors to pro- that have helped in the production of this text. I hope that
vide the details of the pertinent anatomy, the current the reader will realize the goals that I set forth upon the
results and the various complications and the manage- commencement of this operative guide to laparoscopic
ment. The segregation of these topics should remove any hernia surgery.
bias that may be seen in the usual textbooks of this type.
A section on the use of the laparoscope in the pedi- Karl A. LeBlanc Louisiana
atric hernia patient is also included. In many areas of the July 2003
Abbreviations
CGRP calcitonin gene-related peptide

CT computerized tomography
DES diffuse esophageal spasm
DPL diagnostic peritoneal lavage
ECG electrocardiogram
ECMO extracorporeal membrane oxygenation
EGD esophagogastroduodenoscopy
ePTFE expanded polytetrafluoroethylene
GER gastroesophageal reflux
GERD gastroesophageal reflux disease
GPRVS giant prosthetic reinforcement of the
visceral sac
HAL hand-assisted laparoscopy
IEM ineffective esophageal motility
IPOM intraperitoneal onlay of mesh
LES lower esophageal sphincter
LIVH laparoscopic incisional and ventral
hernioplasty
MIS minimally invasive surgery
MRI magnetic resonance imaging
NSEMD non-specific esophageal motility
disorder
PCA patient-controlled analgesia
PEH para-esophageal hernia
PFA platelet function assay
PONV postoperative nausea and vomiting
PPM polypropylene mesh
PTFE polytetrafluoroethylene
TAPP transabdominal pre-peritoneal
TEP total extraperitoneal
TLESR 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-Saône, 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
1
Overview
1 Laparoscopic general surgery 3 3 Prosthetic biomaterials for hernioplasty 17

2 Technological and instrumentation aspects of 4 Fixation devices for laparoscopic hernioplasty 25
laparoscopic hernia surgery 7
1
Laparoscopic general surgery
ROGER K.J. SIMMERMACHER
References 5
Fortunately the time when many surgeons and their mention thoracoscopy, a procedure that he initially felt had
patients thought that laparoscopy should be a purpose a better chance than laparoscopy for further development.
rather than a means to an end has passed. Although the In 1927, the first textbook dealing with thoracoscopy
‘scopic’ approach has become the gold standard for some and laparoscopy was published by Korbsch in Munich,
indications, it has not brought completely new ideas on Germany. After World War II, the development of laparo-
how to handle surgical diseases, but it has changed our scopic investigations into the human body was led mainly
certain approach in order to facilitate the postoperative by European gynecologists. An extensive overview of their
recovery of the patient. Principally, a surgical disease contributions into the development of endoscopic sur-
should be managed by a surgeon. Who, in order to treat gery is beyond the scope of this chapter, but some of their
his or her patient optimally, is not limited by technology advancements are interesting and worth consideration.7
(a scalpel for open surgery or the laparoscope for some of Once technical innovations allowed more than one per-
us) rather than trying to find the best treatment modal- son to view through the laparoscope at the same time, it
ity by chance, which might include techniques still to be was only a few years before Phillipe Mouret of Lyon,
envisioned.1 For many of us, laparoscopy is, or was, the France performed the first human laparoscopic chole-
first expansion of our rather limited armamentarium. cystectomy in 1987. This event initiated an explosion of
As with many things in surgery, Hippocrates is credited experiments that has brought us to the current position of
as the first physician to have used a tool to obtain a better laparoscopy as an important part of the surgical arma-
view of the human interior, in his case the rectum.2 Fur- mentarium. Nowadays, laparoscopic cholecystectomy, by
ther development of this idea, however, was hampered for far the most extensively described and most frequently
nearly 2000 years due to a lack of progression in techno- performed laparoscopic procedure, is the gold standard
logical innovation.3 The evolution of laparoscopic surgery treatment for most diseases that merit removal of the
parallels the evolution of two distinct technical factors, gallbladder,8 irrespective of age and comorbidity.9 Addi-
which are the basis for all current endoscopic interven- tionally, cholecystectomy is very often the first laparo-
tions: the invention and development of a lens system that scopic operation that trainees are taught. It should
could be connected to a computer-chip television camera be emphasized that the principles and indications for
and an effective lighting system via fiber-optic delivery cholecystectomy have not changed because of the laparo-
were the essential prerequisites for the current possibilities scopic approach. However, the old controversy of whether
of laparoscopic technology. This allowed other surgeons intraoperative cholangiography should be a routine part
and their assistants to handle the endoscope while actively of the procedure returned early in the development of this
participating and assisting in the scopic procedures. It is procedure.10 Additional concerns were exposed, partly
difficult to state with certainty who should be credited with because the laparoscopic exploration of the common bile
performing the first human laparoscopy, complete with duct was in its infancy.11,12 Even today, these arguments
pneumoperitoneum. However, at the beginning of the are not resolved.10
twentieth century, three names are mentioned: Kelling,4 Within a short period of time, the scopists turned their
Jacobaeus5 and Ott.6 Jacobaeus was the first physician to interest towards another frequent surgical procedure,
4 Overview
appendectomy.13 Laparoscopic appendectomy had been Introduction of improved techniques for intracorpo-
reported as early as 1977 in a paper from The Netherlands,14 real hemostasis, stapling and knot-tying make it possible
and since then there has been an ongoing discussion about to treat many colorectal diseases laparoscopically,37 even
the merits of the laparoscopic approach in the surgical in the presence of generalized peritonitis.38 Despite ini-
treatment of appendicitis. A recent review by Fingerhut tial doubts about the maintenance of oncological resec-
concluded that because many of the surgical aspects of tion principles, it has been shown that both types of
the open appendectomy have improved so greatly, the operations, laparoscopic and open, do not differ greatly
apparent advantages of a laparoscopic approach are hard in this respect.39 The incidences of anastomotic leakage,
to demonstrate.15 It is acknowledged, however, that local morbidity and mortality are not significantly different
cultural factors, as well as operative experience, are impor- between the two methodologies, but the laparoscopic
tant considerations that should dictate the strategic approach requires more operative time.39
decisions of any individual surgeon and/or hospital.15 Laparoscopic resection of cystic and solid liver tumors,
Recently, a randomized clinical trial in children, which curative or palliative, is receiving increasing interest
compared both approaches, demonstrated clearly that as reports of the different techniques and their pitfalls
laparoscopic appendectomy did not offer advantages are accumulating.40–43 Staging, of course, has also been
over the open method.16 These findings are disputed shown to be feasible.44 The spleen has also been the target
heavily by others.17 Advantages of laparoscopic appen- of the laparoscopist. Currently, open splenic resection is
dectomy appear to be limited to obese patients and usually reserved for treating a very large spleen with hyper-
patients whose preoperative diagnosis is not clear-cut.18 splenism and in the acute trauma setting.45
Another organ system that received a lot of attention Retroperitoneal organs, such as the pancreas, adrenal
in the early years of laparoscopy was the upper gastro- glands and prostate, have also become the domain of
intestinal tract.19 The initial interest began with the treat- laparoscopically trained surgeons.46–49 Admittedly, these
ment of duodenal ulcers and gastroesophageal reflux more advanced procedures require sufficient training
disease.20 Since its introduction of laparoscopic surgery of and skills in both laparoscopic and open surgery.
the upper gastrointestinal tract, has become the gold stan- Vascular surgeons are now evaluating the newest
dard for the surgical treatment of gastroesophageal reflux treatment modalities of endovascular procedures and
disease (GERD).21 It is frequently performed in daycare endoscopic techniques. Veins50 and the aorta51 can be
situations,22 although there can be persistent complaints handled via a laparoscope, although this is still experi-
years after the operation.23 mental in most cases.52
According to the French literature, gastric ulcers Future developments will probably focus on the
should be approached laparoscopically at the initial oper- improvement of intraoperative imaging techniques,
ation,24 as both retrospective25 and prospective26 analyses improved tactile feedback through the so-called ‘endo-
have shown excellent results and low conversion rates.25 hand’,53 navigation,54 and robotic assistance.55 The pri-
Other diseases of the stomach for which laparoscopy is mary efforts of the developments of laparoscopic surgery
frequently performed in some centers with standardized focused upon the improvements for the care of the
laparoscopic methods include achalasia,26,27 perforated patients, which of course continues today (e.g. the devel-
peptic ulcer,28 and gastric cancer. With respect to bariatric opment of gasless pneumoperitoneum by lifting of the
surgery, there appear to be current differences between abdominal wall).42,53 Current innovative attention seeks
the use of the gastric bypass (more popular in the USA) to improve the range of motion, precision and control of
and the application of adjustable bands on the stomach the surgeon through the development of intracorporeal
(more popular in Europe). The laparoscopic approach for instruments that are handled via the endo-hand or revo-
both procedures continues to grow rapidly, but random- lutionary improvements of the tip of the laparoscopic
ized controlled trials comparing the different methods are instruments53 as the ‘endo-wrist’ of the da Vinci® robotic
needed urgently.29 system.55 Furthermore, gastroenterologists might be chal-
Laparoscopy offers an important advantage in the lenged as some surgeons turn their interest into endo-
treatment of many types of intra-abdominal cancers, as organ laparoscopic management. However, there are
it allows staging of the disease prior to any intended only limited anecdotal reports of resections of gastric
resection. However, careful patient selection is necessary leiomyomas56 or small neoplasms, which predicts that
to effectively limit the number of unnecessary laparo- further investigations will be undertaken in the future.57
tomies.30,31 Additionally, intraoperative laparoscopic ultra- In conclusion, it is evident that laparoscopy is cur-
sonography may become mandatory in the future because rently part of the surgical armamentarium as much as
it allows more accurate pretreatment staging.32 Preopera- the hand and scalpel have always been. Due to the cur-
tive staging will allow the correct operation to be chosen rent availability of rapid communication facilities,58 the
from one of the many different types of resections that development of laparoscopy has been quicker than that
are feasible.33–36 of any other innovation within surgery. In fact, this may
Laparoscopic general surgery 5
have pushed some surgeons to use laparoscopy for very 11 Phillips EH, Rosenthal RJ, Caroll BJ, Fallas MJ. Laparoscopic trans-
many different indications with, in some cases, less than cystic common bile duct exploration. Surg Endosc 1994; 8: 1389.
12 Berci G, Morgenstern L. Laparoscopic management of common bile
optimal preparation.59 Laparoscopy is well established duct stones. A multi-institutional SAGES-study. Surg Endosc 1994;
for cholecystectomy and gastric fundoplication,18 but for 8: 1168.
many other indications its position still has to be deter- 13 Schreiber JH. Early experience with laparoscopic appendectomy in
mined, because many reports of successful laparoscopic women. Surg Endosc 1987; 1: 211–16.
management for various indications are either from 14 Kok HJ. A new technique for resecting the non-inflamed
not-adhesive appendix through a mini-laparotomy with the aid
anecdotal or personal experiences. The following chap- of the laparoscope. Arch Chir Neerl 1977; 29: 195–8.
ters of this book indicate the current state of the art con- 15 Fingerhut A, Millat B, Borrie F. Laparoscopic versus open
cerning hernia surgery. Certainly, there is enough evidence appendectomy: time to decide. World J Surg 1999; 23: 835–45.
to direct a choice. Thus far, the discussion regarding the 16 Little DC, Custer MD, May BH, Blalock SE, Cooney DR. Laparoscopic
value of laparoscopy in trauma has yet to be finalized with appendectomy: an unnecessary and expensive procedure in
children? J Pediatr Surg 2002; 37: 310–17.
respect to its indications60,61 and its potential risks.62 The 17 Garbutt JM, Soper NJ, Shannon WD, et al. Meta-analysis of
alleged or partly demonstrated advantages of laparoscopic randomized controlled trials comparing laparoscopic and open
surgery, such as reductions in postoperative morbidity,63 appendectomy. Surg Laparosc Endosc 1999; 9: 17–26.
postoperative intra-abdominal adhesions,64 postoperative 18 Tittel A, Schumpelick V. Laparoskopische Chirurgie: Erwartungen
analgesia requirements, sleep disturbances,65 blood loss, und Realität. Chirurg 2001: 72: 227–35.
19 Katkhouda N, Moniel J. A new technique of surgical treatment of
and moderate immunological responses, and, increas- chronic duodenal ulcer without laparotomy by videocoelioscopy.
ingly, lower costs66 are not proven completely,18 despite the Am J Surg 1991; 161: 361–4.
fact that others test endoscopic surgery in rather extreme 20 Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen
circumstances.67 Training of our future colleagues should fundoplication: preliminary report. Surg Laparosc Endosc 1991; 1:
be standardized with well-organized hands-on courses 138–43.
21 Booth MI, Joines L, Stratford J, Dehn TCB. Results of laparoscopic
combined with pelvic trainers and animal models. This Nissen fundoplication at 2–8 years after surgery. Br J Surg 2002;
issue is a matter of concern that still needs attention.68 In 89: 476–81.
order to convince the surgical community of its advan- 22 Trondsen E, Mjåland O, Raeder J, Buanes T. Day-case laparoscopic
tages, randomized clinical trials and thorough analyses of fundoplication for gastro-esophageal reflux disease. Br J Surg
the outcomes from these procedures are mandatory. 2000; 87: 1708–11.
23 Liu JY, Woloshin S, Laycock WS, Schwartz LM. Late outcomes after
Nevertheless, one must not forget the real experts’ wisdom laparoscopic surgery for gastroesophageal reflux. Arch Surg 2002;
and warnings.1 137: 397–401.
24 Yahchouchy E, Debet A, Fingerhut A. Crack cocaine-related prepyloric
perforation treated laparoscopically. Surg Endosc 2002; 16: 220.
REFERENCES 25 Cougard P, Barrat C, Gayral F, et al. Laparoscopic treatment of
perforated duodenal ulcers. Results of a retrospective multicentric
study. French Society of Laparoscopic Surgery. Ann Chir 2000;
1 Scott-Conner CEH, Arregui M. Visions of things that will come to 125: 726–31.
pass. Surg Laparosc Endosc Percutan Tech 1999; 9: 85–6. 26 Alamowitch B, Aouad K, Sellam P, et al. Laparoscopic treatment of
2 Edmondson JM. History of the instruments for gastrointestinal perforated duodenal ulcer. Gastroenterol Clin Biol 2000; 24:
endoscopy. Gastrointest Endosc 1991; 37: S27–57. 1012–17.
3 Gunning JE. The history of laparoscopy. J Reprod Med 1974; 12: 27 Spiess A, Kahrilas P. Treating achalasia: from whalebone to
222–6. laparoscope. JAMA 1998; 280: 638.
4 Kelling G. Über Oesofagoscopie, Gastroscopie und Kölioscopie. 28 Sunderland GT, Chisholm EM, Lau WY, et al. Laparoscopic repair of
Munch Med Wochenschr 1902; 41: 259–71. perforated peptic ulcers. Br J Surg 1992; 79: 785.
5 Jacobaeus HC. Über die Möchligkeit die Zystoscopie bei 29 Gentileschi P, Kini S, Catarci M, Gagner M. Evidence-based
Untersuchung seröser Höhingen auszuwenden. Munch Med medicine: open and laparoscopic bariatric surgery. Surg Endosc
Wochenschr 1910; 57: 2090–92. 2002; 16: 736–44.
6 Ott D. Die direkte Beleuchtung der Bauchhöhle, der Harnblase, des 30 Lehnert T, Rudek B, Kienle P, et al. Impact of diagnostic laparoscopy
Dickdarms und des Uterus zu diagnostischen und operativen on the management of gastric cancer: prospective study of 120
Zwecken. Rev Med Tcheque 1901; 2: 27–9. consecutive patients with primary gastric adenocarcinoma.
7 Taniguchi E, Ohashi S, Takiguchi S, Kanno H, Oriyama T, Ikuma K, Br J Surg 2002; 80: 471–5.
et al. Laparoscopic surgery assisted by a transvaginal approach. 31 Böhm B, Ablassmaier B, Müller JM. Laparoscopische Chirurgie am
Surg Laparosc Endosc 1999; 9: 53–6. oberen Gastrointestinaltrakt. Chirurg 2001; 72: 349–61.
8 Zacks SL, Sandler RS, Rutledge R, Brown RS, Jr. A population- 32 Feussner H, Omote K, Fink U, et al. Pretherapeutic laparoscopic
based cohort study comparing laparoscopic cholecystectomy and staging in advanced gastric carcinoma. Endoscopy 1999; 31:
open cholecystectomy. Am J Gastroenterol 2002; 97: 334–40. 342–7.
9 Ludwig K, Patel K, Wilhelm L, Bernhardt J. Prospective study on 33 Ohgami M, Otani Y, Kumani K, et al. Curative laparoscopic surgery
patients outcome following laparoscopic vs. open for early gastric cancer: 5 years experience. World J Surg 1999;
cholecystectomy. Zentralbl Chir 2002; 127: 41–6. 23: 187.
10 Podnos YD, Gelfand DV, Dulkanchainun TS, et al. Is intraoperative 34 Zornig C, Emmermann A, Blöchle C, Jackle S. Laparoscopische
cholangiography during laparoscopic cholecystectomy cost 2/3-Resektion des Magens mit intracorpaoraler Anastomose nach
effective? Am J Surg 2001; 182: 663–9. Roux-Y. Chirurg 1998; 69: 467.
6 Overview
35 Uyama I, Sugioka A, Fujita J, et al. Laparoscopic total gastrectomy 52 Dion YM, Hartung O, Gracia C, Doillon C. Experimental laparoscopic
with distal pancreatosplenectomy and D2 lymphadenectomy for aortobifemoral bypass with end-to-side aortic anastomosis.
advanced gastric cancer. Gastric Cancer 1999; 2: 230–34. Surg Laparosc Endosc 1999; 1: 35–8.
36 Adachi Y, Suematsu T, Shiraishi N, et al. Quality of life after 53 Cuschieri A. Neue Technologien in der laparoskopischen Chirurgie.
laparoscopy-assisted Billroth I gastrectomy. Ann Surg 1999; 229: 49. Chirurg 2001; 72: 252–60.
37 Szinicz G, Riegler M, Müller W, Beller S. Minimally invasive surgery 54 Van der Peet DL, Berends FJ, Klinkenberg-Knol EC, Cuesta MA.
(MIC) in the area of the colon and rectum: technique of minimally Endoscopic treatment of benign esophageal tumors. Surg Endosc
invasive colorectal surgery. Chirurg 2001; 72: 362–7. 2001; 15: 1489.
38 Faranda C, Barrat C, Catheline JM, Champault GG. Two-stage 55 Ruurda JP, Broeders IAMJ, Simmermacher RKJ, et al. Feasibility of
laparoscopic management of generalized peritonitis due to robot-assisted laparoscopic surgery. An evaluation of 35 robot-
perforated sigmoid diverticula: Eighteen cases. Surg Laparosc assisted laparoscopic cholecystectomies. Surg Laparosc Endosc
Endosc Percutan Tech 2000; 3: 135–8. Percutan Tech 2002; 12: 41–5.
39 Milsom JW, Böhm B, Hammerhofer KA, Fazio V. A prospective 56 Seelig MH, Hinder RA, Floch NR, et al. Endo-organ and laparoscopic
randomized trial comparing laparoscopic versus conventional management of gastric leiomyomas. Surg Laparosc Endosc 1999;
techniques. In colorectal cancer surgery: a preliminary report. 9: 78–81.
J Am Coll Surg 1998; 187: 46. 57 Mittal SK, Filipi CJ. Indications for endo-organ gastric excision. Surg
40 Zacherl J, Scheuba C, Imhof M, et al. Long-term results after Endosc 2000; 14: 318–25.
laparoscopic unroofing of solitary symptomatic congenital liver 58 Allen JW, Finch RJ, Coleman MG, et al. The poor quality of
cysts. Surg Endosc 2000; 14: 59. information about laparoscopy on the World Wide Web as
41 Katkhouda N, Hurwitz M, Gugenheim J, et al. Laparoscopic indexed by popular search engines. Surg Endosc 2002; 16:
management of benign solid and cystic lesions of the liver. 170–72.
Ann Surg 1999; 229: 460. 59 Liberman MA, Greason K. Residency training in advanced
42 Intra M, Viani MP, Ballarini C, et al. Gasless laparoscopic resection laparoscopic surgery: how are we doing? Surg Laparosc Endosc
of hepatocellular carcinoma in cirrhosis. J Laparoendosc Surg Percutan Tech 1999; 9: 87–90.
1996; 6: 263. 60 Cottom D, Gorecki PJ, Curvelo M, Shaftan GW. Laparoscopic repair
43 Antonetti MC, Killelea B, Orlando R, 3rd. Hand-assisted laparoscopic of traumatic perforation of the urinary bladder. Surg Endosc 2001;
liver surgery. Arch Surg 2002; 137: 407–11. 15: 1488–9.
44 Montorsi M, Santambrogio R, Bianchi P, et al. Perspectives and 61 McKinley AJ, Mahomed AA. Laparoscopy in a case of pediatric blunt
drawbacks of minimally invasive surgery for hepatocellular abdominal trauma. Surg Endosc 2002; 16: 358.
carcinoma. Hepatogastroenterology 2002; 49: 56–61. 62 Howells GA, Uzieblo MR, Bair H, Boyer MD. Tension
45 Klingler PJ, Tsiotos GG, Glaser KS, Hinder RA. Laparoscopic pneumopericardium during laparoscopy for trauma. Surg Laparosc
splenectomy: evolution and current status. Surg Laparosc Endosc Endosc Percutan Tech 2000; 10: 44–6.
1999; 9: 1–8. 63 Langebrekke A, Istre O, Hallqvist AC, et al. Comparison of
46 Arca MJ, Gagner M. Minimal-invasive Verfahren am Pankreas. laparoscopy and laparotomy in patients with endometrial cancer.
Chirurg 1998; 69: 621–7. J Am Assoc Gynecol Laparosc 2002; 9: 152–7.
47 Walz MK. Minimal-invasive Nebennierenchirurgie. Chirurg 1998; 64 De Wilde RL. Goodbye to late bowel obstruction after
69: 613–20. appendicectomy. Lancet 1991; 338: 1012.
48 Turk I, Deger S, Winkelmann B, et al. Radical prostatectomy in 65 Gogenur I, Rosenberg-Adamsen S, Kiil C, et al. Laparoscopic
clinically localized prostate carcinoma. Pro laparoscopic approach cholecystectomy causes less sleep disturbance than open
[in German]. Urologe A 2002; 41: 48–54. abdominal surgery. Surg Laparosc 2001; 15: 1452–5.
49 Sirén J, Haglund C, Huikuri K, et al. Laparoscopic adrenalectomy for 66 Hawkins J, Dube D, Kaplow M, Tulandi T. Cost analysis of tubal
primary aldosteronism: clinical experience in 12 patients. Surg anastomosis by laparoscopy and by laparotomy. J Am Assoc Gynecol
Laparosc Endosc 1999; 1: 9–13. Laparosc 2002; 9: 120–24.
50 Maghraby HA. Laparoscopic varicocelectomy for painful varicoceles: 67 Campbell MR, Kirkpatrick AW, Billica RD, et al. Endoscopic surgery
merits and outcomes. J Endourol 2002; 16: 107–10. in weightlessness. Surg Endosc 2001; 15: 1413–18.
51 Silva L, Kolvenbach R, Pinter L. The feasibility of hand-assisted 68 Shalhav AL, Dabagia MD, Wagner TT, et al. Training postgraduate
laparoscopic aortic bypass using a low transverse incision. Surg urologists in laparoscopic surgery: the current challenge. J Urol
Endosc 2002; 16: 173–6. 2002; 167: 2135–7.
2
Technological and instrumentation
aspects of laparoscopic hernia surgery
GINA L. ADRALES AND ADRIAN E. PARK
Instrumentation 7 Ergonomics 13
Fixation 11 Conclusion 13
Videoendoscopic system 12 References 14
Other enabling technologies 12
Laparoscopic hernia surgery, like other types of minimally invasive approaches to a variety of surgical therapies. The
invasive surgery (MIS), has been shaped and impacted development of new dissecting tools and the incorpora-
by the emergence of new surgical techniques and the tion of various energy sources into laparoscopic proce-
assimilation of new and evolving medical technologies. dures have greatly enhanced the physician’s capability for
To address the technological and instrumentation aspects fine dissection and rapid hemostasis. Despite these achieve-
of laparoscopic herniorrhaphy comprehensively could ments, the basic design of laparoscopic instruments and
extend the discussion from a macro-perspective dealing the associated ergonomic constraints have evolved little
with issues of operative suite design and integration of over the past century. Laparoscopic instrument design is
technology to a micro-view focusing on, for example, the still based upon a template consisting of a handle con-
tines of a dissecting instrument. Such a dissertation is nected to a long, slender shaft, which then engages an end-
beyond the scope of this chapter. Instead, we will focus effector unit. Like all surgical instruments, laparoscopic
upon the instruments, equipment and material used in instruments should be cost-effective, low-maintenance,
laparoscopic hernia surgery and the related technological functional tools that achieve the intended purpose safely,
advances that have facilitated a widening adoption of easily and reliably, as Melzer has stipulated.1 Over the past
various laparoscopic hernia procedures. Some topics that two decades, an abundance of end-effectors with varied
are dealt with in greater detail in later chapters, such as functions has been developed. As a result, a wide array of
methods of mesh fixation and surgical energy sources, will instruments is currently available to the surgeon per-
receive more cursory mention in this chapter, in the con- forming laparoscopic hernia repair. A brief discussion of
text of specific instrument use and development. Ergono- the various characteristics and distinguishing features of
mic considerations in surgical instrument and equipment laparoscopic instrumentation relevant to hernia repair
design, so often overlooked yet so vital to optimal surgical follows.
performance, will also be addressed.
Disposable instruments
INSTRUMENTATION
Disposable instruments may increase operative efficiency
by eliminating the need for sterilization of reusable
The rapid expansion of available laparoscopic instrumen- instruments perioperatively. This convenience comes at a
tation has fueled the widespread application of minimally significant cost in terms of equipment expenditure and
environmental impact. In a cost-comparison of pro-
Supported in part by an educational grant from Tyco/US Surgical cedural equipment, the cost of disposable equipment
Corporation. exceeded that of reusable instrumentation by a factor of
8 Overview
10–20.2 Although reusable instrumentation is subject or ratcheted instruments may reduce muscular fatigue
to the wear and tear of repeated use and sterilization, during grasping, but they are not appropriate for dissec-
disposable instruments may be imprecise.3 Reposable tion, which requires more dynamic handling. Similarly,
instruments, which combine reusable and disposable single-action jaws, in which one jaw remains fixed, are
components, represent a compromise between the two effective for grasping but less so for dissection. Further-
instrument types. more, the symmetry of double-action jaws makes these
instruments better suited for fine dissection.
The diameter of the instrument also affects function
Laparoscopic dissecting and grasping and performance. Micro-instruments (2–3 mm diame-
instruments ter) have been applied to a variety of minimally invasive
procedures, including laparoscopic hernia repair.4,5 These
Although laparoscopic dissectors and graspers conform ‘needlescopic’ dissectors have relatively elastic shafts and
to a basic design, the configurations of the end-effectors short end-effectors with limited spread. Thus, limitations
vary in terms of size, shape and surface. Different types inherent in the design of 2-mm graspers and dissectors
of dissection (sharp or blunt dissection, micro- or have in turn limited the use of such needlescopic instru-
macro-exposure) require instruments with different dis- ments in laparoscopic hernia surgery.
secting tips. Sharp-tipped instruments, including laparo- Unique to laparoscopic totally extraperitoneal inguinal
scopic shears and needle-nose dissectors, facilitate fine hernia repair is the balloon dissector, commonly used in
spreading and micro-dissection. Blunt dissectors, such as North America to develop the pre-peritoneal plane. A
the Reddick-Olsen, may reduce the risk of inadvertent variety of balloon dissectors are available, most furnished
injury to adjacent structures, but their utility in fine dis- with a guiding trocar and obturator for initial placement
section and micro-exposure is limited. Tapered tips that beneath the rectus muscle. With inflation of the balloon,
fall somewhere in the continuum from sharp to blunt a pre-peritoneal working space is created. Although this
end-effectors constitute the majority of commonly used device provides a simpler and more timely alternative
dissectors. Tapered, narrow-tipped dissectors, such as the to manual dissection, it is imperative that the surgeon is
Maryland/Kelly or DeBakey laparoscopic instruments, familiar with the laparoscopic pre-peritoneal anatomy to
have proved useful during laparoscopic hernia repair, from recognize the appropriate plane of dissection and to avoid
dissection in para-esophageal herniorrhaphy to creation associated complications.
of the peritoneal flaps in transabdominal pre-peritoneal
inguinal herniorrhaphy. Additionally, the Maryland/Kelly
dissectors have curved jaws, which facilitate dissection Trocars
around structures. The curved tips of the Maryland/Kelly
dissector allow clear visualization of the operative target Careful consideration of trocar type and placement is
and the tip of the instrument, unlike the shadowing that imperative in the successful conduct of laparoscopic her-
may occur about the symmetrically tapered, flat-tipped, nia repair. Quite simply, trocars are the portals through
duckbill dissector. which the laparoscopic instruments are passed. At the
Effective tissue grasping is made possible by the surface same time, trocars represent potential weapons, and their
topography of the instrument tips. The fine ridges and misplacement can contribute to the morbidity and even
grooves provide friction during grasping, limiting slippage mortality of a laparoscopic procedure. The incidence of
and therefore tissue trauma. The delicate serrations of the trocar-related injury is low but significant. The incidence
DeBakey clamp provide atraumatic tissue handling. This of hollow viscus perforation varies between 0.04 and
curved instrument is thus ideally suited for the fine dissec- 0.14 per cent.6–13 Major retroperitoneal vascular injury has
tion and the gentle manipulation of the bowel required been reported in 0.03–0.1 per cent, carrying a substantial
during adhesiolysis and reduction of hernia contents. In mortality rate of nine per cent.9–12,14 Major vascular
contrast, ratcheted instruments with thick serrations are injury is a very common cause of death in laparoscopy,
poorly suited for bowel handling, but they are designed for second only to anesthetic complications.14 In an effort to
constant grasping, such as gallbladder retraction. Other increase the safety of trocar insertion, a variety of trocar
dissectors have tines that appose incompletely along the designs has been introduced.
proximal jaws of the instrument, allowing the instrument The previously stated pros and cons of reusable
to hold tissue atraumatically in that space. instrumentation also hold for trocars. Reusable, metal
The laparoscopic handle and the hinge mechanism trocars may provide better grip to the skin and abdomi-
of the jaws greatly impact the function of grasping and nal wall compared with plastic, disposable trocars.
dissecting instruments. Instruments with coaxial or Several trocar designs have been developed to prevent
articulating shafts provide the surgeon with greater free- slippage and leakage of pneumoperitoneum. The Hasson
dom of movement in restricted working spaces. Locking 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 has been implemented in trocar design to reduce insertion-
its shaft. Much like the configuration of a screw, these associated injury. The optical view trocar was developed as
threads assist in securing the trocar in the abdominal an alternative to Hasson trocar placement. This single-use,
wall. Balloon trocars utilize an attached, inflatable, intra- plastic trocar has a clear shaft and conical tip, allowing
abdominal balloon after insertion to bolster the trocar visualization of the abdominal wall layers as they are tra-
against the abdominal wall. While these balloons add versed while inserting the laparoscope. This trocar design is
security, they are subject to breakage and may decrease the well suited for insertion after pneumoperitoneum has been
radial mobility often required during ventral hernia repair established using a Veress needle.
to visualize and operate on the anterior abdominal wall. While the optical trocar capitalizes on the benefit of
Safe peritoneal entry is a particular concern during inci- direct visualization, other trocar designs are centered on
sional hernia repair, where there is a considerable risk of the tip configuration for injury prevention (Figure 2.1). In
injury to adherent loops of bowel. A variety of measures an effort to circumvent visceral damage, the shielded trocar
(a) (b) (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 Similarly, other non-bladed trocars have also been
a plastic shield that is released upon peritoneal entry to demonstrated to cause smaller abdominal wall defects
safely cover the cutting blade. Many disposable trocars that do not require closure.25 In contrast to cutting
incorporate this mechanism. Importantly, this feature does trocars, non-bladed trocars split the musculature rather
not guarantee protection against trocar entry injuries. than cut through the abdominal wall, a technique that
Pyramidal and conical trocar tips have also been may also be associated with less minor bleeding.16
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 Energy sources
inguinal herniorrhaphy, the reusable trocar resulted in a
lower complication rate.15 Trocar vascular and visceral Advances in the use of energy sources have increased the
injuries are thought to be related to the force required ease and feasibility of performing MIS. While energy
for trocar insertion. However, the size of the abdominal sources are used largely for hemostasis, increasingly they
wall defect created by the trocar has been shown to be are employed in tissue dissection as well. Available energy
inversely proportional to the entry force.16 In an animal sources include both thermal and mechanical energy
study, it was demonstrated that conical tips require devices.
greater entry force than pyramidal trocars yet subse-
quently produce smaller abdominal wall defects.
Electrosurgery
To decrease the insertion force and possibly reduce
visceral injury, innovative trocar designs have been Thermal energy sources rely on the passage of electrical
coupled with various energy sources. However, these new current through tissues and the subsequent production of
designs have not yet been proven in human application heat. Applying high-radiofrequency alternating current
in laparoscopic hernia surgery; studies have been limited results in the excitation of cellular ions and the conversion
almost entirely to animal models. Electrosurgical trocars of electrical energy to mechanical energy. The degree of
utilize thermal energy to create the abdominal wall open- the thermal response is directly proportional to the inhe-
ing for passage of the trocar. This has been found to rent resistance of the tissues, with little heat production
reduce the force required for entry without detrimental in plasma but significant heat production in bone. The
effects on wound healing at the trocar site after lap- electrical current can be applied with a bipolar or mono-
aroscopic cholecystectomy.17 Taking advantage of the polar electrode, the most common method in general
decreased thermal spread associated with ultrasonic dis- surgery.26 Bipolar electrosurgery confines the electrical
section, an ultrasonically activated trocar has been designed current to the tissue between the forceps and consequently
with an associated decrease in insertion time and force as offers the added safety of decreased thermal spread.
well as a smaller increase in abdominal pressure during Electrothermal injury is a substantial concern, with the
insertion compared with conventional conical trocars.18 incidence of laparoscopic electrosurgery-associated com-
The applicability of these trocars is yet to be seen in plications numbering two to five per 1000 cases.27
patients with multiple previous surgeries or with ventral
hernias, where the proximity of adhered bowel may
Ultrasonic dissection
predispose the patient to thermal visceral injury.
Another substantial concern in the treatment of Ultrasonic dissection is a form of mechanical dissection,
hernia patients is recurrent herniation. In a retrospective like scissor or water-jet dissection, that has gained
review of 320 patients (including two patients with popularity in laparoscopy. Mechanical energy is created
concomitant para-esophageal hernia repair), the overall by high-frequency sound-wave vibration. The high-
incidence of trocar site herniation after laparoscopic fun- frequency vibration produces denatured collagen and
doplication was found to be three per cent.19 As hernia- effectively vaporizes cells. The ultrasonically activated
tion at trocar sites has been reported repeatedly in the scalpel, the ultrasonic instrument used most commonly
literature,19–21 the size of the defect created by trocars is a in laparoscopy, has been shown to seal vessels at diameters
key factor. The size of the trocar site defect is influenced up to 5 mm. However, it is recommended that its use is
by the tip shape, trocar size, and mechanism of entry. limited to vessels 3 mm or less in diameter.28 At 80°C, the
The radially expanding trocar utilizes a needle puncture ultrasonically activated scalpel operates at a lower tem-
followed by insertion of a blunt, radially expanding perature than electrosurgery (100°C).3 Ultrasonic dis-
obturator through the needle tract. This alternative to section is reported to produce decreased lateral thermal
the traditional cutting trocar has been associated with spread when compared with traditional electrosurgery.29
less postoperative pain, improved postoperative patient- However, identification of intestinal or biliary duct
rated wound scores, decreased intraoperative and post- injury due to the ultrasonic dissector may be delayed.
operative complications, and smaller fascial defects.22–24 Anecdotally, the dissector may temporarily seal the
injury site, such as an enterotomy, only to open days later thin arm that is then covered by a retractable sheath
with devastating consequences. during insertion. The operation of this device is rather
In summary, electrosurgical and ultrasonic dissection counterintuitive, as retraction of the handle is required dur-
instruments minimize blood loss and may reduce opera- ing insertion. Proper handling of the device is essential to
tive time in a variety of laparoscopic procedures. However, protect the delicate mechanism responsible for securing the
very judicious and limited use of energy sources in ventral suture. A more cost-effective method of suture introduc-
and incisional hernia repair is encouraged. A higher toler- tion has been illustrated elegantly by Park and colleages31
ance for a small amount of oozing is accepted in exchange and Rosenthal and Franklin.32 Rather than employing a
for a reduced risk of intestinal, spermatic cord, or nervous suture passer, the suture is introduced on a Keith needle and
thermal injury. The morbidity of intestinal injuries, par- extracted through a large-gauge spinal needle.
ticularly missed enterotomies, is remarkably high, with a
mortality rate of at least 25 per cent.30
Fixation devices
In an effort to secure the prosthetic material and to facil-

FIXATION itate its incorporation, several fixation methods have
been developed. The need for prosthetic fixation by
Needle drivers and suture passers sutures, tacks and/or staples has been well demonstrated
for ventral and incisional herniorrhaphy, and it is now
The employment of needle drivers and suture passers dur- considered indispensable to the long-term durability of
ing laparoscopic hernia repair will be discussed in more the repair.33,34 The picture is less clear with regard to
detail in subsequent chapters. A variety of needle drivers inguinal herniorrhaphy, where data regarding the utility
and aids to suturing (e.g. Endostitch, Surg-assist) is avail- of tissue adhesives or even non-fixation continue to
able for use during laparoscopic hiatal hernia repair. These emerge. In contrast, primary suture closure is the most
devices were developed to assist the surgeon with intra- significant component of hiatal hernia repair, as pros-
corporeal suturing, an advanced laparoscopic technique. thetic mesh is seldom used.
Sutured mesh fixation is imperative in laparoscopic ven- The development of staples and spiral tacks has
tral hernia repair. This crucial component of ventral increased operative efficiency in ventral and incisional
herniorrhaphy can be accomplished via various suture- hernia repair. A variety of tacking devices is now avail-
passing devices. These reusable, low-profile, sharp instru- able, including a reusable device, the Salute™ (Onux
ments pierce the abdominal wall through small stab Medical, Inc.). This innovative device delivers a stainless-
incisions and transfer the suture to secure the mesh to the steel construct that is not preformed but assumes the
abdominal wall (Figure 2.2). The suture is held in place by a final shape of a keyring. Traditional spiral tacks are
approximately 3–4 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 rec-
ommended that tack or staple fixation of the mesh be
combined with nonabsorbable suture fixation in laparo-
scopic 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 pros-
thetic mesh in crural closure for large hiatal hernias.
Several adhesives have been studied. Fibrin sealant or fib-
rin 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 inflamma-
tory reaction compared with staple fixation.36 In another
animal study, the incorporation of fibrin glue in ventral
Figure 2.2 Gore suture passer (W.L. Gore & Associates, Inc.). hernia repair resulted in reduced intra-abdominal
12 Overview
adhesions.37 While an inflammatory reaction was also this distortion, but they remain cost-prohibitive in
noted in this study, the density of adhesions and the many institutions and may provide poorer resolution and
percentage of expanded polytetrafluoroethylene (ePTFE) movement lag.
prosthetic patch coverage by adhesions was decreased in Advances in imaging technology have led to the devel-
the fibrin glue cohort. The majority of fibrin sealant opment of new systems to address current optical and
studies associated with hernia repair have been con- ergonomic limitations. Head-mounted displays reduce
ducted in animal models. The hemostatic properties of the displacement associated with standard video towers
fibrin glue in hernia repair were notable in one of the few positioned at a distance from both the surgeon and the
published human studies. In patients with coagulopathic operative field. However, the results of head-mounted
disorders, fibrin glue was noted to reduce postoperative displays have been mixed; at least one report notes
bleeding after inguinal herniorrhaphy.38 decreased eyestrain and improved operative efficiency,
The cyanoacrylates, a class of tissue adhesives tradi- but another study fails to duplicate these results.40,41
tionally used in wound management, have been examined Three-dimensional imaging systems have also been
for use in laparoscopic hernia repair. Internal use constructed to provide stereoscopic perceptual cues.
of this tissue adhesive was previously limited due to However, the spacing between the component imaging sys-
the potential toxicity associated with early formulations. tems is generally limited and is significantly smaller than
However, newly designed formulations have been studied the normal interpupillary distance. This restriction limits
for their applicability in hernia repair, although these stud- the depth perception provided by the three-dimensional
ies remain limited to animal models. In an examination of optical systems. Additionally, the accompanying head-
octylcyanoacrylate tissue adhesive for fixation of ePTFE in mounted display results in degradation in image quality,
a rabbit incisional hernia model, less force was required for limiting the widespread incorporation of this innovative
displacement of adhesive-fixed mesh than for suture or system.
spiral tack fixation.39 In addition, the octylcyanoacrylate It is hoped that with the adoption of high-definition
adhesive stimulated an inflammatory reaction that television standards and new research in advanced
delayed cellular migration into the ePTFE interstices, so digital signal processing technology, many limitations of
the clinical implications of this finding are unclear. 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 ven-
VIDEOENDOSCOPIC SYSTEM
tral herniorrhaphy. These new systems could also correct
for perceptual distortion, such as the lack of shadowing
The videoendoscopic system has become the eyes of and other depth cues, and could facilitate the perform-
the laparoscopic surgeon. With the limited tactile feed- ance of more complex laparoscopic procedures.
back 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
OTHER ENABLING TECHNOLOGIES
are the result of optical distortion by the camera and
monitor systems, and the loss of monocular and stereo- Hand-assisted laparoscopy
scopic visual cues.
The current videoendoscopic system begins with a The technique of hand-assisted laparoscopy (HAL) has
rod-lens laparoscope with coaxial illumination and fiber- been applied to a variety of laparoscopic procedures, in
optic light bundles. Illumination is provided by a high- some cases avoiding certain laparotomy. With HAL, the
intensity but ‘cold’ broadband light source. Most systems surgeon’s hand is inserted into the peritoneal cavity to
employ a high-quality solid-state camera equipped with assist in dissection and retraction. Various port systems
a charged-coupled device and a three-chip array for that maintain pneumoperitoneum are used for hand
color separation (red, green, blue). This provides optimal placement. In HAL, the incision size is limited to the
color fidelity. Standard display systems utilize National surgeon’s hand size, and this incision may be later used
Television Committee Standard video with a resolution for specimen extraction.
of no less than 640 ⫻ 480 pixels. Improving upon stan- The application of the hand-assisted technique in
dard composite video systems, which combine luminance laparoscopic hernia repair has been limited. In 2000, Litwin
and chrominance signals, S-video separates the signals and and colleagues reported one repair of a post-traumatic
offers superior color saturation. Most cathode-ray tube left diaphragmatic hernia in a series of HAL cases.43 The
monitors in use are curved and are therefore associated patient was noted to have incarcerated colon, spleen and
with a degree of distortion. Flat-screen monitors eliminate small intestine. This repair was facilitated by the entry
of the surgeon’s 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, Cadiére and colleagues published a robotic-assisted
laparoscopic surgery series using the Da Vinci system (Intu-
itive Surgical), including three inguinal hernia repairs.44
Although the robotic articulating instruments facilitated
dissection in a variety of procedures, one system limita- Figure 2.3 Minimally invasive surgery often requires awkward
tion noted by the authors was the narrow field of vision positioning.
provided by the three-dimensional optical system.
the patient, the surgical staff, and the equipment. Within
the current ergonomic constraints of laparoscopy, changes
ERGONOMICS can and should be made to increase the comfort of the
surgeon and reduce muscular fatigue. Instrumentation
Research in the field of surgical ergonomics may have should be selected not only for function but also for ease of
a far greater impact on MIS than will some of the tech- use and proper individual surgical fit. Currently, this selec-
nological advancements addressed previously. In the tion may not be accomplished easily for surgeons with
manufacturing industry, it is well recognized that paying smaller hands. The operating table should be positioned
proper attention to postural mechanics and the health so that the instrument handles are at the surgeon’s elbow
impact of instrumentation and machinery can signifi- level.46 Similarly, the video monitor should be positioned
cantly increase the productivity, efficiency and longevity at or slightly above eye level. Suspended mobile monitors
of workers. There are comparatively few available data on may facilitate this adjustment. The monitor should be in
the ergonomic risk factors associated with surgery. The alignment with the operative target and the surgeon. Foot
performance of surgery can be both mentally and physi- pedals that control energy sources should be placed within
cally demanding, and there is an alarming incidence of a small radius from the surgeon’s feet to avoid stiffening
musculoskeletal complaints among laparoscopic sur- and straining to maintain balance.
geons.45 Ergonomic risk factors (prolonged static pos- Patient position is also crucial. The patient should
tures, awkward stances, extreme joint angles, pressure be positioned to allow gravity to assist with operative
points from instrumentation, etc.) are pervasive in MIS exposure, reducing the exertion needed from the surgeon
as a result of long instrumentation with reduced degrees and assistants for retraction. For example, the patient
of freedom and displaced imaging (Figure 2.3). More is placed in mild reverse Trendelenburg position dur-
specifically, there are ergonomic issues that are unique to ing para-esophageal hernia repair. Similarly, the patient’s
laparoscopic hernia repair, such as the strain of working arms should be tucked during ventral herniorrhaphy to
against the camera (mirror-image effect) and the com- provide freedom of movement by the surgeon and assis-
plex movements required to repair hernia defects from tants about the operating table. Attention to these details
underneath the anterior abdominal wall during ven- in positioning and operative set-up should greatly
tral herniorrhaphy. While changes in instrument design improve operative efficiency.
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
CONCLUSION
current operative environment and the selection of appro-
priate available instrumentation may improve operative
efficiency and protect the health of the surgeon. As with other types of MIS, laparoscopic hernia repair
The etiology of the ergonomic problem in laparo- evolved through the merger of innovative technology
scopy is multifactorial. Consideration should be given to and new surgical techniques. The wide array of available
instrumentation, image quality, and the positioning of instrumentation for tissue dissection, the development of
14 Overview
new tools for mesh fixation, and the application of novel 20 De Giuli M, Festa V, Denoye GC, Morino M. Large postoperative
techniques have all facilitated and expanded the role of umbilical hernia following laparoscopic cholecystectomy. A case
report. Surg Endosc 1994; 8: 904–5.
laparoscopy in the treatment of a variety of hernia defects. 21 Patterson M, Walters D, Browder W. Postoperative bowel
With continuing technological advances and attention to obstruction following laparoscopic surgery. Am Surg 1993; 59:
ergonomic factors, the outcome and efficiency of laparo- 656–7.
scopic hernia repair are certain to improve. 22 Bhoyrul S, Payne J, Steffes B, et al. A randomized prospective study
of radially expanding trocars in laparoscopic surgery. J Gastrointest
Surg 2000; 4: 392–7.
23 Yim SF, Yuen PM. Randomized double-masked comparison of
REFERENCES radially expanding access device and conventional cutting tip
trocar in laparoscopy. Obstet Gynecol 2001; 97: 435–8.
24 Lam TY, Lee SW, So HS, Kwok SP. Radially expanding trocar: a less
1 Melzer A. Endoscopic instruments: conventional and intelligent. painful alternative for laparoscopic surgery. J Laparoendosc Adv
In: Toouli J, Gossot D, Hunter J, eds. Endosurgery. New York: Surg Tech A 2000; 10: 269–73.
Churchill Livingstone, 1996: 69–95. 25 Liu CD, McFadden DW. Laparoscopic port sites do not require
2 Fengler TW, Pahlke H, Kraas E. Sterile and economic fascial closure when nonbladed trocars are used. Am Surg 2000;
instrumentation in laparoscopic surgery. Surg Endosc 1998; 12: 66: 853–4.
1275–9. 26 Tucker RD. Laparoscopic electrosurgical injuries: survey results and
3 Park AE, Mastrangelo MJ, Jr, Gandsas A, et al. Laparoscopic their implications. Surg Laparosc Endosc 1995; 5: 311–17.
dissecting instruments. Semin Laparosc Surg 2001; 8: 42–52. 27 Nduka CC, Super PA, Monson JR, Darzi AW. Cause and prevention
4 Tagaya N, Aoki H, Mikami H, et al. The use of needlescopic of electrosurgical injuries in laparoscopy. J Am Coll Surg 1994; 179:
instruments in laparoscopic ventral hernia repair. Surg Today 2001; 161–70.
31: 945–7. 28 Mueller W, Fritzsch G. Medicotechnical basics of surgery using
5 Ferzli G, Sayad P, Nabagiez J. Needlescopic extraperitoneal repair invasive ultrasonic energy. Endosc Surg Allied Technol 1994; 2:
of inguinal hernias. Surg Endosc 1999; 13: 822–3. 205–10.
6 Zaraca F, Catarci M, Gossetti F, et al. Routine use of open 29 Birch DW, Park A, Shuhaibar H. Acute thermal injury to the canine
laparoscopy: 1,006 consecutive cases. J Laparoendosc Adv Surg jejunal free flap: electrocautery versus ultrasonic dissection.
Tech A 1999; 9: 75–80. Am Surg 1999; 65: 334–7.
7 Catarci M, Carlini M, Gentileschi P, Santoro E. Major and minor 30 El-Banna M, Abdel-Atty M, El-Meteini M, Aly S. Management of
injuries during the creation of pneumoperitoneum: a multicenter laparoscopic-related bowel injuries. Surg Endosc 2000; 14:
study on 12,919 patients. Surg Endosc 2001; 15: 566–9. 779–82.
8 Bonjer HJ, Hazebroek EJ, Kazemier G, et al. Open versus closed 31 Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional
establishment of pneumoperitoneum in laparoscopic surgery. hernias. Surg Laparosc Endosc 1996; 6: 123–8.
Br J Surg 1997; 84: 599–602. 32 Rosenthal D, Franklin ME. Use of percutaneous stitches in
9 McMahon AJ, Baxter JN, O’Dwyer PJ. Preventing complications of laparoscopic mesh hernioplasty. Surg Gynecol Obstet 1993; 176:
laparoscopy. Br J Surg 1993; 80: 1593–4. 491–2.
10 Saville LE, Woods MS. Laparoscopy and major retroperitoneal 33 LeBlanc KA. The critical technical aspects of laparoscopic
vascular injury. Surg Endosc 1995; 9: 1096–100. repair of ventral and incisional hernias. Am Surg 2001; 67:
11 Loffer FD, Pent D. Indications, contraindications and complications 809–12.
of laparoscopy. Obstet Gynecol Surg 1975; 30: 407–27. 34 Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral
12 Deziel DJ, Millikan KW, Economou SG, et al. Complications of and incisional hernia repair in 407 patients. J Am Coll Surg 2000;
laparoscopic cholecystectomy: a national survey of 4,292 6: 645–50.
hospitals and analysis of 77,604 cases. Am J Surg 1993; 35 Dion YM, Charara J, Guidoin R. Bursting strength evaluation.
165: 9–14. Comparison of 0-Prolene sutures and endoscopic staples in an
13 Penfield AJ. How to prevent complications of open laparoscopy. experimental prosthetic patch repair of abdominal wall defect.
J Reprod Med 1985; 30: 660–63. Surg Endosc 1994; 8: 812–16.
14 Hashizume M, Sugimachi K. Needle and trocar injury during 36 Katkhouda N, Mavor E, Friedlande MH, et al. Use of fibrin sealant
laparoscopic surgery in Japan. Surg Endosc 1997; 11: 1198–201. for prosthetic mesh fixation in laparoscopic extraperitoneal
15 Leibl BJ, Schmedt CG, Schwarz J, et al. Laparoscopic surgery inguinal hernia repair. Ann Surg 2001; 1: 18–25.
complications associated with trocar tip design: review of 37 Toosie K, Gallego K, Stabile BE, et al. Fibrin glue reduces
literature and own results. J Laparoendosc Adv Surg Tech A 1999; intra-abdominal adhesions to synthetic mesh in a rat ventral
9: 135–40. hernia model. Am Surg 2000; 66: 41–5.
16 Bohm B, Knigge M, Kraft M, et al. Influence of different trocar tips 38 Canonico S, Sciaudone G, Pacifico F, Santoriello A. Inguinal hernia
on abdominal wall penetration during laparoscopy. Surg Endosc repair in patients with coagulation problems: prevention of
1998; 12: 1434–8. postoperative bleeding with human fibrin glue. Surgery 1999;
17 Waxman K, Birkett DH, Sackier JM, et al. Clinical and laboratory 125: 315–17.
evaluation of an electrosurgical laparoscopic trocar. Surg Endosc 39 Birch DW, Park A. Octylcyanoacrylate tissue adhesive as an
1994; 8: 1076–9. alternative to mechanical fixation of expanded
18 Gossot D, Validire P, Matsumoto S, et al. Development of an polytetrafluoroethylene prosthesis. Am Surg 2001; 67: 974–8.
ultrasonically activated trocar system. Surg Endosc 2002; 16: 40 Geis WP. Head-mounted video monitor for global visual access in
210–14. mini-invasive surgery. An initial report. Surg Endosc 1996; 10:
19 Bowrey DJ, Blom D, Crookes PF, et al. Risk factors and the 768–70.
prevalence of trocar site herniation after laparoscopic 41 Herron DM, Lantis JC, 2nd, Maykel J, et al. The 3-D monitor
fundoplication. Surg Endosc 2001; 15: 663–6. and head-mounted display. A quantitative evaluation of
advanced laparoscopic viewing technologies. Surg Endosc 1999; 44 Cadiére GB, Himpens J, Germay O, et al. Feasibility of robotic
13: 751–5. laparoscopic surgery: 146 cases. World J Surg 2001; 25: 1467–77.
42 Park A, Charash WF, Shaw M. The future of imaging in minimally 45 Berguer R, Forkey DL, Smith WD. Ergonomic problems associated
invasive surgery. Surg Endosc 2000; 14: 517–19. with laparoscopic surgery. Surg Endosc 1999; 13: 466–8.
43 Litwin DEM, Darzi A, Jakimowicz J, et al. Hand-assisted 46 Berguer R, Smith WD, Davis S. An ergonomic study of the
laparoscopic surgery (HALS) with the HandPort System: initial optimum operating table height for laparoscopic surgery. Surg
experience with 68 patients. Ann Surg 2000; 231: 715–23. Endosc 2002; 16: 416–21.
3
Prosthetic biomaterials for hernioplasty
KARL A. LEBLANC
Synthetic prosthetic biomaterials: flat, single-component Non-synthetic prosthetic biomaterials 22

products 17 Conclusion 24
Synthetic prosthetic biomaterials: preformed products 21 References 24
Synthetic prosthetic biomaterials: composite products 21
Almost all hernia repairs that are performed laparoscop- Table 3.1 Flat, single-component polypropylene biomaterials
ically utilize some form of prosthetic biomaterial. One and manufacturers
notable exception is the infrequent small hernias found
Biomaterial Manufacturer
during laparoscopic incisional and ventral hernioplasty,
which are merely sutured. The early pioneers in laparo- Angimesh Angiologica
scopic inguinal hernia repair generally used polypropy- Biomesh P1 Cousin Biotech
lene mesh (PPM) products, but a few attempted to use Biomesh P3 Cousin Biotech
Biomesh 3D Cousin Biotech
expanded polytetrafluoroethylene (ePTFE). Incisional
Hertra 1, 2 HerniaMesh
and ventral hernioplasty utilized ePTFE when it was first
Hermesh 3, 4, 5 HerniaMesh
described. Currently, PPM and ePTFE prostheses are Intramesh NK1, NK2, NK8 Cousin Biotech
the preferred biomaterials for the laparoscopic repair of Marlex C. R. Bard, Inc.
inguinal and incisional hernias, respectively. The pre- Parietene Sofradim International
ferences for each of these operations and the choice of Prolene Ethicon
prostheses are described in the following chapters. This Prolene Soft Mesh Ethicon
chapter will present the currently available materials that Prolite Atrium Medical Corp.
are used for the laparoscopic repair of hernias. Prolite Ultra Atrium Medical Corp.
The biomaterials can be subdivided into many classes. Surgipro (Monofilament) U.S. Surgical Corp., Inc./Tyco
The broadest distinction is between synthetic and non- Surgipro (Multifilament) U.S. Surgical Corp., Inc./Tyco
Trelex Meadox Medical Corp.
synthetic 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 itself (i.e. the weight of the mesh). These two factors influ-
above will be assumed. ence the thickness, stiffness, shrinkage rates, inflammatory
response, potential for development of adhesions to the
product, and resulting changes in the elasticity of the
SYNTHETIC PROSTHETIC BIOMATERIALS: abdominal wall. These products are listed in Table 3.1, and
FLAT, SINGLE-COMPONENT PRODUCTS the differences in the weave and pore sizes of some of them
are noted in Figure 3.1.
Most of these products are manufactured from poly- One of the problems that has been seen in the past
propylene. The major differences between the meshes are with the repair of incisional hernias is fistulization.1 This
the size of the monofilaments used in the structure of the has also been seen with laparoscopic inguinal repair.2
mesh and the size of the pores (interstices) of the mesh These real and potential complications of PPM may be
18 Overview
(a) (b) (c)
(e) (f)
Figure 3.1 Comparison of the weaves of PPM products: (a) Hetra 1, (b) Hetra 2,
(d) (c) Prolene, (d) Prolene Soft Mesh, (e) Marlex, and (f) NK Mesh.
related to the weight of the polypropylene within the Table 3.2 Polyester prostheses and manufacturers
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. Biomesh A1 Cousin Biotech
However, the lighter products are very soft and pliable, Biomesh A3 Cousin Biotech
and consequently the use of them within the pre-peri- Biomesh 3D Cousin Biotech
Mersilene Ethicon
toneal space created for the repair of inguinal hernias can
Parietex® TEC Sofradim International
be somewhat difficult. Manipulation can be particularly
Parietex® TECR Sofradim International
troublesome because of other difficulties, such as obtain- Parietex® TET Sofradim International
ing the correct spatial and linear orientation. To over-
come this, innovations such as Prolene Soft Mesh have
blue lines incorporated within the biomaterial, which
provides a degree of ease for laparoscopic inguinal hernia patches compromises about 85 per cent of the published
repair. reports on the repair of incisional and ventral hernias.
Although not as prevalent or plentiful as PPM, poly- The prevalence of use of ePTFE is based upon the fact
ester products are used in the repair of inguinal hernia in that there has never been a reported case of fistulization
several countries (Table 3.2). The use of polyester is gen- subsequent to the intraperitoneal placement of this
erally prescribed because of its pliability and conforma- product. In addition, ePTFE results in very minimal
bility to the inguinal floor. However, the use of polyester adhesions to itself. The currently available products
biomaterial has been associated with fistulas.3 Figure 3.2 are listed in Table 3.3 and shown in Figure 3.3. There
shows the differences between the polyester products. has been some concern regarding the extent and nature
The Parietex and Biomesh meshes are woven into a three- of tissue penetration into ePTFE. However, this was
dimensional weave rather than the two-dimensional based upon an earlier product that is no longer used in
weave that is most familiar to flat meshes. This is said to the laparoscopic arena. Recent studies have confirmed
make them even more pliable and to allow a greater that the level of tissue penetration and attachment
degree of tissue penetration. strength of the newer DualMesh® is superior to that of
As with other biomaterials, ePTFE products were PPM at only three days post-implant.4 Other postopera-
initially developed many years ago for open repair of tive data also support the inhibition of adhesions to
inguinal hernias. The use of these single-component ePTFE.5
Prosthetic biomaterials for hernioplasty 19
Table 3.3 ePTFE biomaterials and manufacturers
DualMesh W. L. Gore & Associates
DualMesh Emerge W. L. Gore & Associates
DualMesh Plus W. L. Gore & Associates
DualMesh Plus Emerge W. L. Gore & Associates
DualMesh with Holes W. L. Gore & Associates
DualMesh Plus with Holes W. L. Gore & Associates
Dulex C. R. Bard, Inc.
Mycromesh W. L. Gore & Associates
Mycromesh Plus W. L. Gore & Associates
(a) Reconix C. R. Bard, Inc.
Soft Tissue Patch W. L. Gore & Associates
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 pene-
tration 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 pur-
pose of preventing infection. Long-term data on the ben-
efits of impregnating these substances into the product
are difficult to document due to the low rate of infection
(b) that is associated with laparoscopic hernioplasty. The
brown color of the material does, however, present a sig-
nificant 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 com-
prise 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 dur-
ing 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
(c) evenly spaced intervals throughout the biomaterial. These
Figure 3.2 Comparison of polyester biomaterials: (a) Mersilene, products are 1.5-mm thick, compared with the DualMesh
(b) Parietex TEC, and (c) Parietex TET. products without holes, which are 1-mm thick.
20 Overview
(a)
(b)
(d)
Figure 3.3 ePTFE biomaterials: (a) DualMesh, (b) DualMesh Plus,

(c) (c) DualMesh Plus with Holes, and (d) Dulex.
(a) (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
Composix C. R. Bard, Inc.
Composix EX C. R. Bard, Inc.
Paritex® Composite Sofradim International
Paritene® Composite Sofradim International
Sepramesh® Genzyme Corp.
Figure 3.5 3D Max. Glucamesh Brennen Medical, Inc.
Glucatex 3D Brennen Medical, Inc.
SYNTHETIC PROSTHETIC BIOMATERIALS:

PREFORMED PRODUCTS
SYNTHETIC PROSTHETIC BIOMATERIALS:
COMPOSITE 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 The introduction of the laparoscopic approach to inci-
transabdominal or a totally extraperitoneal technique. sional hernioplasty has identified the need to protect the
The most common of these prostheses is the 3D Max intra-abdominal viscera from contact with the mesh
(C. R. Bard, Inc.) (Figure 3.5). This polypropylene prod- materials that are used in the repair. Table 3.4 lists the
uct is available in two sizes. Because of the curve within products that are composed of two different biomaterials.
the product, left and right prostheses are available for use The construction of these biomaterials is designed to allow
on the left and right sided inguinal hernia, respectively. the in-growth of tissue while protecting the opposite sur-
The orientation of this biomaterial is critical to ensure face from adhesion formation during the healing phase.
adequate coverage of the myopectineal orifice. The larger The concept differs in the individual products.
product may be used without the need for fixation; the The first of these to be manufactured was that of the
intra-abdominal pressure and the stickiness of the PPM Composix mesh (Figure 3.7a). A thin layer of ePTFE is
are said to allow for this.6 The smaller biomaterial does heat-sealed on to two layers of Marlex mesh. This is a very
require fixation because of its potential to migrate within thick product that requires at least a 12-mm trocar site
the pre-peritoneal space. hole in which to introduce it. There have been reports of
Another preformed device is the Anatomical Mesh adhesion formation and postoperative pain with the use
(Sofradim International) (Figure 3.6). The flat portion of of this biomaterial.7 A thinner product, Composix EX
the prosthesis is made of PPM, while the portion that is (Figure 3.7b), is comprised of one layer of Marlex and a
made to lie over the iliac vessels is made of polyester. The thicker layer of ePTFE. The ePTFE on this prosthesis is
sutures intertwined into the mesh are drawn together to sutured on to the PPM to provide secure fixation between
compress the product to ease its introduction through a the two products. There is an overlap of the ePTFE past
trocar. This is then cut to deploy the full surface of the the PPM to minimize the risk of exposure of the edges
biomaterial. At the time of writing, there are no long- of the PPM to the viscera. Therefore, one should avoid
term follow-up data on the use of this product. 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 writ-
ing, very new polypropylene and polyester biomaterials
that are impregnated with oat beta glucan. Oat beta glu-
can is a purified complex carbohydrate that is isolated
from the cell wall of oats. It is absorbed following intro-
duction of the product.
(b)
Figure 3.7 Comparison of (a) Composix and (b) Composix EX. NON-SYNTHETIC PROSTHETIC
BIOMATERIALS
which could expose the PPM. The products are available
in numerous sizes, so cutting will seldom be necessary. Several products based upon biological materials are
The last five products listed in Table 3.4 have absorbable now available (Table 3.5). The use of a non-synthetic
components. Parietex composite consists of a three- biomaterial for the repair of hernias may be the better
dimensional polyester mesh (listed in Table 3.3) that has approach. However, long-term studies and biocompati-
been incorporated by hydrophilic collagen. Paritene com- bility evaluations will be needed to confirm their useful-
posite uses the PPM that is listed in Table 3.1 and has the ness. All have been processed to eliminate the risk of
same collagen layer as Parietex composite. The absorbable transmission of viral or other diseases. These generally
collagen is no longer present by the fourteenth postoper- are pure or nearly pure collagen that will be incorporated
ative day. At the time of writing, long-term studies using and/or replaced by the patient’s own collagen over time.
these biomaterials are in progress. The hernia is repaired by the neofascia that subsequently
Sepramesh (Figure 3.8) is PPM coated on one surface develops. The majority of implantations of these bio-
with carboxymethylcellulose and hyaluronate foam. This materials have been via open operation, but their use
foam will be absorbed in about seven days to leave the with laparoscopic technique is undergoing evaluation.
Table 3.5 Biological prosthetic biomaterials and manufacturers
Surgisis ES® and Surgisis
Gold® Cook Surgical, Inc.
FortaPerm™ Organogenesis, Inc.
FortaGen™ Organogenesis, Inc.
Permacol™ Tissue Science Laboratories plc
Alloderm® 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.
Figure 3.12 Permacol.

Alloderm (Figure 3.9) is manufactured from cadav-
eric skin. Its width is limited by the size of the der-
matome that is used to harvest the material. Surgisis ES in appearance. They are five layers thick, the layers being
and Surgisis Gold (Figure 3.10) are four- and eight-ply, cross-linked together to provide greater strength. Fortagen
respectively, porcine small-intestinal submucosa. The will be replaced by the native collagen, similar to Surgisis,
manufacturing process causes the nodules that are seen but Fortaperm becomes a permanent prosthetic similar
on the Surgisis Gold. Fortagen and Fortaperm are also to that of the synthetic biomaterials described above.
processed porcine submucosa of the small intestine Permacol (Figure 3.12) is porcine dermis with indica-
(Figure 3.11). These latter two products are very similar tions similar to the other products.
24 Overview
At the time of writing, all of these biomaterials are rel- REFERENCES

atively new and clinical experience is generally limited.
There may be particular application in the site of infections
1 Losanoff JE, Richman BW, Jones JW. Entero-colocutaneous fistula: a
that are associated with tissue loss or following hernia late consequence of polypropylene mesh abdominal wall repair:
repair with synthetic meshes. These cannot be used in case report and review of the literature. Hernia 2002; 6: 144–7.
the presence of an intestinal fistula because the enteric 2 Klein AM, Banever TC. Enterocutaneous fistula as a postoperative
contents will dissolve the collagen in the product. complication of laparoscopic inguinal hernia repair. Surg Laparosc
Endosc 1999; 9: 60–2.
3 Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications
associated with prosthetic repair of incisional hernias. Arch Surg
1998; 133: 378–82.
CONCLUSION 4 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: 1542–6.
Laparoscopic hernioplasty is dependent upon the use of
5 Koehler RH, Begos D, Berger D, et al. Adhesion formation to
prosthetic biomaterial and the in-growth that ensues. A intraperitoneally-placed mesh: reoperative clinical experience after
variety of synthetic and non-synthetic biomaterials are laparoscopic ventral incisional hernia repair. Am J Surg; in press.
available for implant. Surgeons should be aware of all of 6 Pajotin P. Laparoscopic groin hernia repair using a curved prosthesis
the available products. The selection of the ideal prosthe- without fixation. J Coelio-Chir 1998; 28: 64–8.
7 LeBlanc KA. ‘Tack hernia’ – a new entity. JSLS 2003; in press.
sis should be based upon experimental, clinical and long-
8 Kramer K, Senninger N, Herbst H, Probst W. Effective prevention of
term follow-up data. Newer biomaterials will probably adhesions with hyaluronate. Arch Surg 2002; 137: 278–82.
be developed in the future that may enhance the repair of 9 Amid P. Hyaluronate does not prevent adhesions. Arch Surg 2002;
hernias. 137: 1313–14.
4
Fixation devices for laparoscopic hernioplasty
KARL A. LEBLANC
Early devices 25 Conclusion 28

Later devices 27 References 28
Latest devices 27
Laparoscopic hernioplasty requires the use of a pros- a series of 13 patients in whom he closed the peritoneal
thetic biomaterial. Consequently, a method of fixation opening of the sac using Michel clips. All but the last
will be necessary for all but the smallest of incisional and patient in this series were repaired through an open inci-
some of the inguinal hernia prostheses. The earliest sion. The thirteenth patient was repaired in 1979 under
attempts to repair inguinal hernias laparoscopically were laparoscopic guidance with a special stapling device. The
performed with the suture fixation of the mesh to the three-year follow-up of this patient revealed him to be
structures of the inguinal floor. This was a very tedious free of an identifiable recurrence. Ger and colleagues
task, which greatly hindered the adoption of this new continued their efforts to repair these hernias laparo-
technology. Manufacturers of instruments responded scopically. They reported the closure of the neck of the
with the development of different devices that delivered hernia sac using a prototypical instrument called the
metal fixation to secure the biomaterial to the inguinal Herniostat in beagles (Figure 4.1).2 This device was never
floor. The use of these devices is, of course, an integral produced commercially, but it was certainly ahead of
part of all laparoscopic hernia repairs. There have been a its time.
number of these products that have not been successful Schultz and colleagues published the first patient
or even brought to large-scale production. These and the series of laparoscopic herniorrhaphy in 1990.3 Rolls
newer instruments are discussed below. of polypropylene were stuffed into the hernial orifice,
The classification of these devices is arbitrary. Regard- which was then covered by two or three flat sheets of
less of the product that is used by the surgeon, it is criti- polypropylene mesh (2.5 ⫻ 5 cm) over the defect. These
cal that each is used properly. Few surgeons are afforded rolls of mesh were not secured to either the fascia or
the opportunity to use these instruments for the first time peritoneum. The peritoneum, however, was closed using
in the laboratory setting. Therefore, it is recommended clips that were commonly used for hemostasis. Corbitt
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 appli-
cation of these devices without exposing the patient to
untoward consequences.
EARLY DEVICES
Ger, in 1982, was the first to report the use of the laparo- Figure 4.1 Ralph Ger’s ‘Herniostat’. (Photograph used with
scope in the repair of an abdominal hernia.1 He reported permission of Ralph Ger, MD.)
26 Overview
Figure 4.2 Ethicon EMS stapler and the staples that it fired. Figure 4.3 Nanticoke Hernia Stapler and staples. These
devices are conformed into a more rounded shape than the
modified this technique by inverting the hernia sac and EMS staples.
performing a high ligation with sutures or with an endo-
scopic 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 polypropy-
lene patch material in a porcine model.5 They placed rec-
tangular pieces of the prosthesis against the abdominal
wall covering the internal inguinal ring and secured it
Figure 4.4 Endopath EMS stapler.
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 Figure 4.5 Endo-universal stapler of USSG.
their first ten patients repaired with the IPOM tech-
nique.6 They secured an expanded polytetrafluoroethyl-
ene (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 suc-
cessfully without adverse results in 20–30 patients. The
device did not become available commercially. A subse-
quent report of their first 75 patients was published in
1992.7 In this later series, the same prosthetic biomaterial Figure 4.6 Endopath EAS stapler.
was attached with the Endopath EMS® stapler (Ethicon
Endosurgery, Inc.) (Figure 4.4). After a follow-up of up device, however, allowed the articulation of the end of
to 20 months, the recurrence rate was 2.4 per cent. They the instrument, giving the surgeon the capability to place
noted a significant decrease in postoperative pain and an the staples more accurately against the abdominal wall
earlier return to normal activity compared with the open and the ligament of Cooper.
repair of the hernia defect. Ethicon responded with the release of the EAS device,
These early hernia repairs continued to become mod- which also has an articulating head (Figure 4.6). Both the
ified in many different aspects, including approaches to U.S. Surgical Corporation stapler and the Ethicon EAS
the inguinal area, prosthetic biomaterials, and fixation allowed 360-degree rotation of the shaft of the device
devices. The devices that followed, such as the EMS, and articulation of the end of the shaft to place staples. In
allowed the placement of multiple staples without the most cases, these movements in these two different planes
need to reload after each use. U.S. Surgical Corporation, allowed exact delivery of the staple to the prosthesis and
Inc. released its stapler, which was similar in concept tissue. At about this time, there was an increasing use of
(Figure 4.5). This device required a 12-mm trocar rather laparoscopic repair of not only inguinal but also inci-
than the 10-mm trocar used by the EMS staplers. The sional hernias subsequent to the first report in 1993.8 The
Fixation devices for laparoscopic hernioplasty 27
Figure 4.8 Origin Tacker.

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 Figure 4.9 ProTack.
Endosurgery (Figure 4.7). Despite its innovative design
and increased ability of accurate staple placement, this a part of the coil could remain exposed to the intestine.
product was never distributed widely. At least one report has documented the development of
a colocutaneous fistula that is presumed to be due to a
tack.9
LATER DEVICES
As laparoscopic surgery expanded into the many areas of

LATEST DEVICES
general surgery, there was an unsatisfactory realization
that hernias developed in trocar sites that were larger Newer products have recently been introduced into the
than 5 mm. Because of this, the trocar sites of the larger hernia repair market. Like their predecessors, these have
ports required fascial closure to prevent these hernias. In unique characteristics. Onux Medical, Inc. has produced
an effort to decrease this risk, the use of 5-mm instead the Salute fixation device (Figure 4.10). Unlike all of the
of 10-mm trocars, wherever possible, became more fre- products discussed above, which used titanium as the
quent. However, all of the instruments mentioned above metal for the device, this construct is made of stainless
required access with trocars that were at least 10 mm. steel. This is the only reusable fixation device that has
Further engineering refinements in all laparoscopic been available commercially. Unlike the other products,
instruments provided the surgeon with 5-mm instru- it does not deliver a preformed device into the tissues.
ments and laparoscopes. Origin Medsystems introduced A construct is formed into a keyring shape as the trigger
the first successful 5-mm fixation device (Figure 4.8). The is fired (Figure 4.11). This motion also cuts the wire at
method of fixation of this new helical coil was a signifi- the same time. While the device does require the use of
cant departure from the previous staples. Delivery with counter-pressure for placement, its method of delivery
the 5-mm size was accepted quickly. The apparent disad- makes it appealing for use in the upper abdomen, on
vantage of the inability to rotate or articulate the device the diaphragm or at the esophageal hiatus. Although the
did not prove to be important to the vast majority of sur- device does not seem to have as deep a penetration
geons. This method of fixation was quite secure. into the tissues as the tack, experimental evidence has
U.S. Surgical Corporation introduced a similar shown that it is an effective method of fixation.10 Two
product, the ProTack, shortly thereafter (Figure 4.9). The slightly different heads are available with this instru-
ProTack is almost identical, conceptually, to the Origin ment. Some surgeons find the use of one or the other
tacker. Both deliver a 5-mm titanium helical coil that preferable, in that the depth of penetration (depending
is screwed through the prosthesis and into the tissues. upon the particular surgeon’s technique) is affected by
The ProTack, however, allows the surgeon to unscrew the the shape of the head. Because of the shape of the head,
tack after it is introduced if the placement is deemed to the thickness of the wire is greater in the newer design.
be inadequate or inappropriate. Because the ends of Therefore, there are two different thicknesses of these
these devices cannot be manipulated, it is important to wires. Consequently, the spools of wire that are used
use significant counter-pressure during the implantation to deliver the coil are not interchangeable between these
of these tacks. If not, poor placement can result and 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
Laparoscopic hernioplasty requires fixation of the bio-

material. The devices described above are almost all in
use today. The effectiveness of the newer products will
Figure 4.12 EndoAnchor instrument. 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
The most recently developed product is the Endo- mechanism of delivery and the concept that is applied in
Anchor by Ethicon Endosurgery, Inc. (Figure 4.12). This the shape of the final delivered device is important.
allows the entire device to be loaded into either a Emerging technologies will continue to deliver newer
3-mm or a 5-mm shaft. To place this product into the products for this operation.
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 REFERENCES
end of the outer shaft (Figure 4.13). The anchor is con-
tained within the end of the needle. The anchor is released 1 Ger R. The management of certain abdominal herniae by
into the tissues as the trigger is released. Once this occurs, intra-abdominal closure of the neck of the sac. Ann R Coll Surg
the nitinol anchor assumes its shape after that movement Engl 1982; 64: 342–4.
(Figure 4.14). The upper protrusions of the shaft of the 2 Ger R, Monro K, Duvivier R, et al. Management of inguinal hernias
nitinol are the portion of the device that remains in by laparoscopic closure of the neck of the sac. Am J Surg 1990;
159: 370–73.
the tissues. The lower, larger hooks are positioned over 3 Schultz L, Graber J, Pietrafitta J, et al. Laser laparoscopic
the prosthesis to hold it in place. Currently, there is only herniorrhaphy: a clinical trial, preliminary results. J Laparoendosc
a limited release of this device. Surg 1990; 1: 41–5.
Fixation devices for laparoscopic hernioplasty 29
4 Corbitt J. Laparoscopic herniorrhaphy. Surg Laparosc Endosc 1991; preliminary findings. Surg Laparosc Endosc 1993;
1: 23–5. 3: 39–41.
5 Salerno GM, Fitzgibbons RJ, Filipi C. Laparoscopic inguinal hernia 9 DeMarie EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal
repair. In: Zucker KA, ed. Surgical Laparoscopy. St Louis: Quality polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral
Medical Publishing, 1991: 281–93. hernia. Surg Endosc 2000; 14: 326–9.
6 Toy FK, Smoot RT. Toy–Smoot laparoscopic hernioplasty. Surg 10 LeBlanc KA, Stout RW, Kearney MT, Paulson DB. Comparison of
Laparosc Endosc 1991; 1: 151–5. adhesion formation associated with Pro-Tack (US Surgical) versus
7 Toy FK, Smoot RT. Laparoscopic hernioplasty update. a new mesh fixation device, Salute (ONUX Medical). Surg Endosc
J Laparoendosc Surg 1992; 2: 197–205. 2003; in press.
8 LeBlanc KA, Booth WV. Laparoscopic repair of incisional
abdominal hernias using expanded polytetrafluoroethylene:
PART
2
Laparoscopic inguinal/femoral
hernioplasty
5 History 33 10 Femoral and pelvic herniorrhaphy 75

6 Anatomy and physiology 41 11 Results of laparoscopic inguinal/femoral
7 Intraperitoneal onlay mesh approach 47 hernia repair 83
8 Transabdominal pre-peritoneal approach 53 12 Complications and their management 89
9 Totally extraperitoneal approach 65
5
History
MICHAEL S. KAVIC AND STEPHEN M. KAVIC
Hernia paradigm 33 Laparoscopic hernia repair 37

Open hernia repair 33 Conclusion 39
Genesis of hernias 36 References 39
A hernia has been defined as the protrusion of a loop or the papyrus in 1875, which was later completed by
knuckle of an organ or tissue through an abnormal Bendix Ebbell, a Norwegian physician. Ebbell’s study of
opening.1 In their earliest state, hernias of the abdomen the papyrus suggested that the ancient Egyptians had
and pelvic side wall begin as a protrusion of peritoneum attained a high level of surgical skill and had developed
through a fascial defect. They are rarely symptomatic, procedures for hernia and aneurysm management.2
and typically they are undetectable on physical examina- Interestingly, then, in the first preserved written record of
tion. In order to understand the development of laparo- medical practice, the paradigm for hernia management
scopic hernia repair, it is necessary to review how the included surgical intervention.
approach to hernias and hernia repair has evolved Surgical intervention for hernia, and almost any other
throughout history. disease, was mercifully rare before the modern era.
Without anesthesia, operative pain was real and fearsome.
In addition, infection almost inevitably followed a surgi-
HERNIA PARADIGM cal procedure and frequently was life-ending. Because of
this, the religious proscriptions against human dissection,
and technological immaturity, progress in the surgical
Before recorded or written history, humans are thought
sciences stagnated. The discovery of anesthesia and the
to have managed hernia with taxis. From its Greek origin,
development of antiseptic methods in the mid-nineteenth
meaning ‘the drawing up in rank and file’, taxis for hernia
century revolutionized the practice of surgery. Operative
involved the use of finger or hand pressure to reduce the
intervention without the twin specters of agonizing opera-
displaced organ or tissue. Support after reduction, utiliz-
tive pain and postoperative infection became possible, and
ing a belt or girdle to maintain the herniated content,
the abdominal cavity no longer remained terra incognita.
would have been a logical extension of taxis. Thus the first
Along with that for many other diseases, the paradigm for
paradigm for hernia management is most likely to have
hernia changed.
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
OPEN HERNIA REPAIR
in one of the earliest written medical records, an ancient
Egyptian medical text known as the Ebers Papyrus. Henry O. Marcy (1837–1924), a surgeon from the USA
George Moritz Ebers (1837–98), a professor of Egypt- and a disciple of the English surgeon Joseph Lister,
ology at the University of Berlin, purchased an ancient described two cases of incarcerated hernia that he treated
papyrus while traveling in Egypt in 1873. The papyrus surgically in 1871.3 Marcy, using Listerian antiseptic
contained a collection of older works dating back to techniques, performed the standard operation of the day
3000–2500 BC. Ebers prepared a partial translation of 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 incar- USA, failed to appreciate the importance of dividing the
cerated hernia. However, Marcy went a step further and transversalis fascia to expose all layers, and a true triple-
expanded the hernia technique then in vogue. Rather layer repair was often not accomplished. Bassini’s opera-
than open the hernia sac, he reduced it and repaired the tion was modified and simplified by not dividing the
defect by closing the ‘constricting ring’ with carbolized transversalis fascia, but it was also diminished. Bassini
catgut suture. initially reported a recurrence rate of about three per cent.5
Marcy, in his report of these procedures, emphasized In the USA, experience with the Bassini repair, which was
the use of Lister’s antiseptic technique and a new form of frequently modified, differed from the Italian master, and
sterile (carbolized catgut) suture. He stressed that the recurrence rates ranged from five to ten per cent in most
two patients healed without infection. Almost as an hands.6
afterthought, he noted that both patients were ‘cured’ of Although Annandale, in 1876, was the first to enter
their hernias. In truth, Marcy may have been the first to the pre-peritoneal space for hernia repair,7 Cheatle, in
have closed the internal ring for hernia repair and prob- 1920, is generally credited with being the first to intro-
ably helped initiate the modern age of hernia repair.4 duce a pre-peritoneal (otherwise known as pro-peritoneal,
Although Marcy made significant contributions to extraperitoneal, or posterior) approach.8 Cheatle des-
herniology, it is generally agreed that the Italian surgeon cribed his procedure as follows: ‘an incision is made to
Eduardo Bassini (1844–1924) is the progenitor of mod- one side of the middle line, the rectus abdominus is split
ern hernia repair (Figure 5.1). Bassini, in 1884, devised a longitudinally and the abdominal wall is retracted to the
method of hernia repair that called for a three-layer side of the operation’. The hernia sac was ligated ‘as low
reconstruction of the inguinal floor.5 After division of the down as possible’ and the internal ring closed by sutur-
posterior wall of the inguinal canal and herniotomy (high ing ‘the muscle fibres and their sheath’.
ligation and excision of the sac), Bassini performed a For femoral hernia, Cheatle recommended that a
‘triple layer’ repair of the inguinal floor. He approximated flap of pubic bone periosteum be secured to Poupart’s
the internal oblique muscle, transversus abdominus ligament to secure the femoral orifice. In 1936, Arnold
muscle, and transversalis fascia to the inguinal ligament. Henry described a similar extraperitoneal approach to
According to Bassini, this herniorrhaphy technique (suture hernia repair in which he secured the femoral canal with
reinforcement of the floor of the inguinal canal) repaired a flap of pectineus fascia to Poupart’s ligament ‘without
the inguinal defect(s), re-established the obliquity of the tension’.9 The internal ring was repaired ‘from within’.
inguinal canal, and reconstructed the internal and external Nyhus and colleagues later adopted and further
inguinal rings, restoring all to competency. refined the open pre-peritoneal repair.10 They recom-
The Bassini repair was logical from an anatomic per- mended that the pre-peritoneum be approached via a
spective, and it worked in practice. It was also radical, as suprainguinal incision and that suture plasty (hernior-
the patient did not have to wear a truss after the proce- rhaphy) be performed to secure the defects of indirect,
dure as in other repairs popular at the time. sliding, and recurrent inguinal hernias.
Bassini’s operation was a marked improvement over Because of the significant recurrence rate after
what had preceded it. Unfortunately, the sound proce- herniorrhaphy, many surgeons recalled a quote attrib-
dure that Bassini devised became corrupted during its uted to Theodore Billroth (1829–94): ‘If we could artifi-
dissemination worldwide. Surgeons, particularly in the cially 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, investi-
Figure 5.1 Eduardo Bassini. gation of prosthetics for hernia repair was unfocused
History 35
until the seminal work of Francis Usher (1908–80). tissue disruption and hernia recurrence. He reported
Usher, in the 1950s, became interested in hernia recur- that tension-free repair with mesh prosthesis had been
rence and attempted to repair hernias with freeze-dried employed in more than 300 consecutive cases of direct
homographs and lyophilized dura mater.15 None of these and indirect inguinal hernia without complication or
materials proved satisfactory, so Usher turned his atten- recurrence.
tion to synthetic materials. Various forms of plastic had Lichtenstein’s genius was not that he introduced
been tried before, but because of their rigidity, tendency polypropylene mesh for inguinal hernia repair; he did
to fragment, and susceptibility to infection, none was not. Nor was his concept of a tension-free repair new; it
found to be satisfactory for hernia repair. Usher persisted was not. Usher deserves primacy in both of these matters.
in his investigation of plastic materials and learned of a Lichtenstein’s insight was in understanding the work that
new polyolefin plastic (polypropylene, i.e. Marlex) that had gone on before and building on it. He helped
could be extruded as a monofilament, did not fragment, popularize the concept of ambulatory hernia surgery and
and was inert. Usher worked closely with the company advocated a tension-free onlay of polypropylene mesh
that produced Marlex (Phillips Petroleum Co.), and had for all groin hernias, regardless of size or complexity. He
the material woven into a mesh and tested in animal stud- stressed the use of local anesthesia and the importance of
ies. He found that polypropylene mesh was tolerated well immediate resumption of normal activity. Lichtenstein
in sterile and infected fields, and he began to use Marlex and colleagues reported on the technique in 1989.23 They
mesh in humans in 1958.16,17 Usher made many original described over 1000 cases of hernias repaired with a
contributions to the field of hernia repair, which Read ‘tension-free hernioplasty’ technique and followed for
lists elegantly in a scholarly retrospective of Usher’s life:15 one to five years with no recurrences or mesh infections.
This paper described hernia repair with elegant simplicity
• The development of polypropylene mesh and
and took the surgical world by storm. Not only were the
suture for repair of abdominal-thoracic defects.
results excellent, but the operation was easy to perform
• Improved techniques for mesh placement. A
and patients underwent a rapid recovery. In a study of
prosthetic bridge was placed deep and under lapped
more than 16 000 tension-free mesh repairs performed by
the hernia defect.
72 surgeons, the recurrence rate was reported to be less
• Anterior, pre-peritoneal placement of the prosthesis
than 0.5 per cent and the incidence of infection was 0.6
for large, primary, direct or recurrent groin herniae
per cent.24 For the last quarter of the twentieth century, a
without suture closure of the defect.
mantra for hernia repair might have been ‘tension-free,
• Elimination of tension in hernia repair, which
tension-free, tension-free’.
facilitated early ambulation.
In referring to hernia procedures, Halsted noted that
• Demonstrated that infected prosthesis could remain
surgical skeptics at the turn of the nineteenth century
in situ and heal after open drainage.
exclaimed: ‘Why take so much trouble, when such good
• The use of unsplit groin mesh with overlap and
results, as are published, may be obtained by simpler
interrupted suture lateral to the internal inguinal
methods?’25 This at a time when William T. Bull, a
ring to allow extended pre-peritoneal obliquity of
prominent New York surgeon, reported recurrence rates
the spermatic cord. This provided a shelf for the cord
of 40 per cent in the first year after hernia repair and
to rest on and preserved the normal obliquity of
almost 100 per cent within four years.26 Indeed, many
the internal ring.
surgeons at the turn of the twentieth century held a sim-
• The use of bilaminar mesh to bridge a hernia defect
ilar view regarding a change of technique for open hernia
and suture of the two lamina and encompassed
repair: ‘If it ain’t broke, why fix it?’
tissue laterally to prevent the suture from tearing
Groin hernias originate in the abdomen and traverse
out weakened structures.
a myopectineal orifice between abdomen and thigh to
These contributions were significant advances in the present in the inguinal region (Figure 5.2). The myopec-
field of herniology.16–21 However, like so many other pio- tineal opening, as described by Fruchaud (Figure 5.3), is
neers, Usher did not receive the recognition he deserved. bounded by the rectus sheath medially, internal oblique
It remained for others to build on his work and advance and transversus abdominus muscles superiorly, the
the science of hernia repair. iliopsoas muscle laterally, and pubis inferiorly.27 It is an
In the 1986 edition of his textbook Hernia Repair irrefutable anatomic structure whose entire opening must
Without Disability, Irving L. Lichtenstein stated that he be addressed before a complete cure of inguinal-femoral
was performing a tension-free repair utilizing synthetic hernia can be anticipated.
mesh to bridge the hernia defect and that he had discarded The Lichtenstein operation is an excellent procedure.
older classical techniques of suture repair (herniorrha- However, it is not perfect. The Lichtenstein technique
phy).22 Tension, as noted by Lichtenstein, was ‘the bête of open anterior repair does not allow for the entire
noire of the hernia surgeon’ and could lead to suture or 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,
Stoppa’s revolutionary concept was to render the peri-
toneal envelope inextensible without mandatory repair of
the deteriorated abdominal wall and hernia defect. The
operation has become known as the giant prosthetic rein-
forcement of the visceral sac (GPRVS) or Stoppa proce-
dure, and has worked quite well, with low recurrence rates
reported for even very large, complex, recurrent hernias.
GENESIS OF HERNIAS
For thousands of years, adult groin hernias were thought

to result from a physical rupture or tear of the abdominal-
wall supporting tissues. In the late 1960s, Read noted that
Figure 5.2 Myopectineal orifice.
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 fol-
lowed 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-abdom-
inal 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 patient’s 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 proteo-
lytic enzymes disturb the normal protease/anti-protease
balance and contribute to the damage of elastin and colla-
Figure 5.3 Henri Fruchaud. gen in the fascia transversalis and rectus sheath of smok-
ers, which leads to direct inguinal herniation.34 It has been
shown that purified human neutrophil polymorpho-
limited exposure of the inferior aspect of the myopectineal nuclear leukocyte elastase can induce pulmonary emphy-
orifice. Moreover, it should be noted that performance of sema.35 There are other conditions of systemic illness and
an anterior repair requires the spermatic cord and its stress (pulmonary emphysema, ruptured abdominal aor-
structures to be mobilized circumferentially before the tic aneurysm, burns) that cause an enhanced leukocyte
mesh can be positioned. Circumferential cord mobilization count and the discharge of proteases and oxidants from
and manipulation can lead to spermatic venous throm- leukocytes. These conditions may, in part, be responsible
bosis, ischemia of the testicle, and testicular atrophy.28 for the biochemical changes that lead to damage of the
Lichtenstein in 1986 reported his incidence of testicular collagenous connective tissues in the groin and cause
atrophy to be one per cent.22 hernia formation in non-smokers in a manner similar to
During the latter third of the twentieth century, René smokers. Because of these findings and the work of others,
Stoppa and colleagues performed much of the innovative it was Cannon and Read’s opinion that: ‘The surgeon’s
work that ultimately formed the foundation for a suc- approach to inguinal herniation should consider more
cessful laparoscopic approach to hernia repair. Stoppa’s than the anatomic and technical detail. It must now
contribution to herniology was that he suggested manag- embrace biochemistry, because he is dealing with a local
ing hernias of the groin with a very large, permanent manifestation of a generalized lesion of connective tissue.’36
History 37
Both Schultz and Corbitt abandoned the technique of plug-

LAPAROSCOPIC HERNIA REPAIR and-patch repair because of excessive hernia recurrence
and changed their technique to one that utilized a large
With little fanfare and without much notice, Ger prosthesis of polypropylene mesh in the pre-peritoneal
reported the first laparoscopic hernia repair in a paper space that covered the entire myopectineal orifice.
published in 1982.37 This study conducted from August Toy and Smoot42 in 1991, along with Salerno and
through November 1977 examined the effectiveness of colleagues,43 took a somewhat different approach to
stainless-steel clips to secure the peritoneal opening of laparoscopic hernia repair. Both groups reported on an
known abdominal hernias during laparotomy for other intra-abdominal onlay technique subsequently dubbed the
major abdominal procedures. In the thirteenth and final intraperitoneal onlay of mesh (IPOM) procedure.42–44
case of the series, an operating laparoscope was used to This technique involved a transabdominal examination
visualize the peritoneal defect of a right indirect inguinal of the hernia defect and placement of synthetic mesh
hernia. The neck of the hernia sac was closed with a directly on the peritoneal surface about the hernia defect.
specially devised stapling device passed through a port Salerno and colleagues, in an animal model, investi-
placed in the right iliac fossa. The staple was constructed gated polypropylene as an onlay prosthesis.43 Toy and
of tantalum and measured 12.5 mm long in the open Smoot utilized a prosthesis of expanded polytetrafluoro-
position. Ger reported that the first patient to be treated ethylene (ePTFE) stapled to the peritoneal surface.42
by laparoscopic closure of the neck of the sac was under In the Toy–Smoot modification, no attempt was made
the care of Dr P. Fletcher of the University of the West to shield the graft from intra-abdominal content for
Indies, Jamaica.37 the reason that previous animal studies suggested that
Gynecologists have been responsible for many of the adhesions between ePTFE graft and abdominal viscera
innovations in laparoscopy, and hernia repair has been were thin and inconsequential. The IPOM procedure
no exception. In 1990, Popp published a report of the was satisfactory for small to moderately sized defects.
coincidental repair of an inguinal hernia during laparo- However, because staple bites were shallow (grasping
scopic uterine myomectomy.38 In this paper, Popp principally peritoneum) and because of difficulties in
related that the hernia margins were apposed and visualizing substantial pre-peritoneal structures (Cooper’s
secured by endosutures tied extracorporeally. A patch of ligament, iliopubic tract, transversalis fascia, transversus
dehydrated dura mater was applied to the sutured area to abdominus aponeurosis, etc.), larger hernias repaired
further cover the repair site. with this technique frequently recurred. With increased
Early on, several prominent laparoscopic surgeons intra-abdominal pressure, such as with coughing, strain-
advocated repair of inguinal hernia by ‘plugging’ the ing or exercise, the mesh (attached principally to peri-
hernia defect. At the annual meeting of the American toneum) would slide into the hernia defect and the repair
Association of Gynecological Laparoscopists (AAGL) in would fail.
1989, Bogojavlensky showed a video that demonstrated The early 1990s were a time of great intellectual
repair of an indirect inguinal hernia with a laparoscopic ferment in laparoscopic hernia surgery. While the intra-
stuffing technique.39 The hernia canal was filled with a abdominal onlay technique was being developed, several
plug of polypropylene mesh, and the internal ring was groups, led most notably by Arregui45 and Dion,46
closed with suture placed laparoscopically. reported on a transabdominal pre-peritoneal patch tech-
In 1990, Schultz and colleagues reported on a plug- nique that eventually became adopted widely. In no small
and-patch technique for hernia repair that expanded on measure, this technique relied on the principles of hernia
the initial work described by gynecologists.40 In their tech- repair established by Stoppa and his GPRVS.
nique, the sac of an indirect inguinal hernia was visualized After pneumoperitoneum was established, a laparo-
with a laparoscope and grasped on its superior margin scope was inserted into the abdominal cavity, typically
with forceps. The peritoneum was incised, and the sac was via an umbilical port, and both groin areas were exam-
removed from the musculofascial defect. The hole in the ined. Two additional ports, each placed lateral to the
muscle was then filled with rolls of polypropylene mesh rectus sheath and on a plane level with the umbilicus,
tied with dissolvable suture. It was thought that the rolled provided access for laparoscopic instrumentation. If an
polypropylene mesh would expand to completely fill the inguinal hernia was identified, then an incision was made
canal once the suture tie was absorbed. After the defect was into the peritoneum several centimeters above the supe-
filled with rolled mesh, one or two pieces of 1 ⫻ 2-inch rior margin of the inguinal hernia defect. The indirect or
mesh were laid over the defect, and the cut edges of peri- direct hernia sac was reduced, and wide dissection of the
toneum were brought together (over the mesh patch) and pre-peritoneal space was performed. No attempt was
secured with endoclips. In 1991, Corbitt independently made to obliterate the inguinal canal as in the plug-and-
described a similar technique; however, he further ligated patch technique. Rather, a large portion of mesh, com-
the inverted hernia sac with an endoscopic linear stapler.41 monly 8 ⫻ 13 or 10 ⫻ 15 cm in size, was used to cover
the myopectineal orifice of Fruchaud. The mesh was mesh, usually polypropylene, is then positioned to cover
fixed to the transverse abdominus aponeurotic arch and the femoral canal and the indirect and direct inguinal
Cooper’s ligament and lateral to the internal ring with spaces with a 3–5 cm overlap. The mesh is secured with
staples or tacks. The peritoneum was closed over the mesh suture, staples or tacks, and the pneumoperitoneum is
with suture or staples. deflated. No incision is made into the peritoneum, and the
The transabdominal pre-peritoneal application of mesh is completely shielded from intra-abdominal con-
synthetic graft, later dubbed the transabdominal pre- tent. Although an additional cost is engendered with the
peritoneal (TAPP) patch procedure, was elegant in concept. use of the balloon dissector, its employment has simplified
The entire opening between abdomen and thigh through the technique and encouraged many more surgeons to
which all hernias of the groin originate (the myopectineal perform laparoscopic repair. Additionally, recent long-
orifice of Fruchaud) was bridged in a tension-free manner. term outcome studies have suggested that laparoscopic
Intra-abdominal content was protected from contact with extraperitoneal hernia repair has outcomes similar to
the graft by placing the mesh in a pre-peritoneal position. open hernia repair.52
Several benefits were accrued with this technique, and One of the major frustrations encountered while
were summarized in a 1993 paper:47 performing laparoscopic abdominal wall repair has been
manipulation of the mesh prosthesis. A bitter lesson
• Expose and reconstitute the entire myopectineal
learned early on was that there must be adequate overlap
orifice.
of mesh (usually 3–5 cm) beyond the perimeter of the
• Examine both groin areas and repair bilateral
hernia defect. An adequate overlap demands a large por-
inguinal hernias as required.
tion of mesh, and the larger the mesh the more difficult it
• Perform repair with little disturbance of cord
is to manipulate in a laparoscopic environment. Several
structures with a likely reduction in the incidence
‘pearls’ have been developed to ease mesh deployment
of ischemic orchitis.
and assure adequate tension-free repair. Marking the
• Avoid transgression of the scarred tissue of a
mesh with a sterile pen has been of help in orienting the
recurrent hernia and the potential for nerve or
prosthesis. Rolling up the mesh like a cigarette and secur-
spermatic cord injury.
ing the rolled mesh with suture has simplified initial mesh
• Permit a thorough diagnostic abdominal
placement. Using this technique, an edge of the rolled
laparoscopic examination.
mesh is first secured with tacks or staples. The remainder
• Reduction in the incidence of hernias ‘missed’
of the mesh is then unfurled, finessed into position, and
on external physical examination.
anchored with tacks or staples.
Repair of an inguinal hernia from a transabdominal An intriguing use of mesh for groin hernioplasty, first
approach, however, exposed the patient to theoretical proposed by Felix and Michas, was that of a ‘double-
complications, including postoperative adhesions, postop- buttress’ repair using two sheets of polypropylene mesh.53
erative ileus, bowel obstruction, and intra-abdominal organ In this variation, the authors suggested using two pieces
injury.48 To reduce the potential for complications asso- of mesh, typically 8 ⫻ 13 cm (in a pre-peritoneal position),
ciated with a peritoneal incision or the intra-abdominal one overlying the other at an oblique angle, thus creating
application of a synthetic prosthesis, several authors, a ‘double buttress’ of mesh over the mid-portion of the
including McKernan and Laws,49 Dulucq,50 and Phillips,51 myopectineal orifice. While application of two layers of
discussed a totally extraperitoneal approach to laparo- mesh undoubtedly bolstered the mid-portion of the
scopic groin hernia repair. This method, which would orifice, this methodology had the additional benefit of
become known as the total extraperitoneal (TEP) patch increasing the diameter of the area repaired far in excess
procedure, deployed all laparoscopic instrumentation, of 8 ⫻ 13 cm, widely overlapping the entire myopectineal
cannulae, and camera in a working pre-peritoneal space orifice.
outside of the peritoneal cavity. Laparoscopic access has also been proposed for repair
The entire TEP procedure is performed in an extra- of ventral incisional hernias. In 1993, LeBlanc and Booth
peritoneal space, a pneumoextraperitoneum, between the described their experience with repair of incisional hernia
peritoneum and abdominal wall musculature. An initial using ePTFE prosthetic graft.54 Franklin and colleagues
incision is made at the umbilicus, and the anterior rectus reported on the use of open-weave polypropylene mesh
sheath on the side of the hernia defect is incised. A cannula for repair of ventral hernias.55 Notably, no fistula forma-
is inserted and passed caudally along the intact posterior tion or significant adhesive bowel complications were
rectus sheath, and the extraperitoneal space is developed found in their study. Kavic commented on the use of
with blunt dissection or a balloon dissector. Additional dual-mesh ePTFE (Gore-Tex) for abdominal-wall ventral
cannulae are placed in this pre-peritoneal space under hernia repair.56 Dual-mesh has a rough side and a smooth
direct laparoscopic vision, and extraperitoneal dissection side. The smooth side of the ePTFE graft is intended to
of the myopectineal orifice is completed. A large piece of interface with intra-abdominal content and to not excite
History 39
adhesion formation. The rough side is placed in apposi- complex pathophysiological, biochemical, molecular, and
tion to the abdominal wall, where its rough surface perhaps genetic derangements that are, even today, not
encourages tissue adhesion. The graft is fixed circumfer- well understood. Study of the groin by several generations
entially with staples or tacks and anchored with trans- of surgeon-scientists has provided an appreciation of the
fascial stay sutures placed at the four cardinal points of dynamic mechanisms that protect the myopectineal ori-
the graft. Carbajo and colleagues prospectively compared fice in the normal state. Current understanding suggests
laparoscopic with open prosthetic repair of large inci- that the entire myopectineal window must be secured if a
sional hernias.57 Their study suggested that laparoscopic complete cure of groin hernia is to be accomplished.56
repair reduces complication rates and hernia recurrence Achievement of the perfect operation may be an
compared with open methods. unobtainable goal, but pursuit of the perfect operation is
neither unreasonable nor undesirable.
CONCLUSION
REFERENCES
The successful repair of groin hernia can be accom-
plished in many ways. Conventional anterior hernior-
rhaphy, as described by Bassini and Shouldice, or 1 Dorland’s Illustrated Medical Dictionary, 28th edn. Philadelphia:
Saunders, 1994: 756.
anterior hernioplasty, as advocated by Lichtenstein, are 2 Ebbell B (transl.). The Ebers Papyrus. The Greatest Egyptian Medical
effective procedures. These repairs, however, limit their Document. London: H. Milford and Oxford University Press, 1937:
focus to the upper aspect of the myopectineal orifice and 17 and 123.
neglect the lower aspect. They have been successful in 3 Marcy HO. A new use of carbolized catgut ligatures. Boston Med
large measure because of the application of sound surgi- Surg J 1871; 85: 315.
4 Ponka JL. Significant contributions toward understanding and
cal principles to secure the hernia defect and because the sound treatment of hernias. In: Ponka JL, ed. Hernias of the
large majority of groin hernias pass through the indirect Abdominal Wall. Philadelphia: W.B. Saunders Co; 1980: 1–17.
or direct inguinal ring. 5 Bassini E. Nuovo metodo per la cura radicale dell’ernia inguinale.
Laparoscopic access has advanced the art of hernia Arch F Klin Chir 1890; 40: 429–76.
repair, as the entire myopectineal orifice with its multiple 6 Heydorn W. Hernia. In: James EC, Corry RJ, Perry JF, eds. Principles
of Basic Surgical Practice. St Louis: Mosby, 1987: 351–2.
openings can be approached and exposed. Bilateral groin 7 Annandale T. A case in which a reducible oblique and direct
hernias can be repaired without a large incision or multi- inguinal and femoral hernia existed on the same side and were
ple incisions. Hernias that may have been missed during successfully treated by operation. Edinburgh Med J 1876; 21:
anterior repair (contralateral inguinal, femoral, occult 1087–91.
hernias) can be examined and repaired.58 Surgical 8 Cheatle GL. An operation for the radical cure of inguinal and
femoral hernia. Br Med J 1920; 2: 68–9.
trauma to skin, subcutaneous tissue, fascia and muscle is 9 Henry AK. Operation for femoral hernia by a midline
reduced. Moreover, the spermatic cord is not manipu- extraperitoneal approach. Lancet 1936; 1: 531–3.
lated circumferentially, offering the possibility that 10 Nyhus LM, Stevenson JK, Listerud MB, Harkins HN. Preperitoneal
testicular vein thrombosis and testicular atrophy will be herniorrhaphy. A preliminary report in fifty patients. Western J
Surg 1959; 67: 48–53.
lessened. Hernias that recur after open procedures can be
11 Billroth T, ed. Czerny V. Beiträge zur Operativen Chirurgie.
repaired laparoscopically without transgressing scarred Stuttgart: F Enke, 1878.
tissue of the previous procedure. 12 Phelps AM. A new operation for hernia. N Y Med J 1894; 60: 291.
Over the past two decades, laparoscopic hernioplasty 13 Goepel R. Ueber die Verschliessung von Bruchpforten durch
has evolved from an experimental procedure to one of Einheilung geflochtener, fertiger Silberdrahtnetze
(Silberdrahtpelotten). Verh Dtsch Ges Chir 1900; 19: 174.
proven efficacy. Groin hernia repair is not a simple exer-
14 Witzel O. Ueber den Verschluss von Bauchwunden und
cise, and its practice requires skill and attention to detail. Bruchpforten durch versenkte Silberdrahtnetze (Einheilung von
Differing clinical situations demand different anatomic Filigranpelotten). Centralbl Chir Leipz 1900; 27: 257.
approaches. Anterior open repair should probably be 15 Read R, Francis C. Usher, herniologist of the twentieth century.
considered for pediatric patients and for patients with Hernia 1999; 3: 167–71.
16 Usher FC. Hernia repair with knitted polypropylene mesh. Surg
severe cardiopulmonary compromise, when repair may
Gynecol Obstet 1963; 117: 239.
be performed under local anesthesia. Bilateral inguinal 17 Usher FC, Gannon JP. Marlex mesh: a new plastic mesh for
hernias, recurrent hernias, and unilateral hernias with a replacing tissue defects: I. Experimental studies. Arch Surg 1959;
suspected contralateral hernia, however, suggest that a 78: 131.
laparoscopic approach be considered. 18 Usher FC, Cogan JE, Lowry TI. A new technique for the repair of
inguinal and incisional hernias. Arch Surg 1960; 81: 847.
The modern herniologist should be proficient in both
19 Usher FC. Hernia repair with Marlex mesh. Arch Surg 1962; 84: 73.
laparoscopic and open repair techniques. The myth that 20 Usher FC, Allen Jr, Crosthwait RW, et al. Polypropylene
the least skilled surgeon or resident can perform hernia monofilament: a new biologically inert suture for closing
repair should be laid to rest. Hernia genesis involves contaminated wounds. JAMA 1962; 179: 780.
21 Usher FC, Wallace SA. Tissue reaction to plastics; comparison of 40 Schultz L, Graber J, Pietrafitta J, Hickok D. Laser laparoscopic
nylon, Orlon, Dacron, and Teflon. Arch Surg 1958; 76: 997. herniorrhaphy: a clinical trial preliminary results. J Laparoendosc
22 Lichtenstein IL. Hernia Repair Without Disability, 2nd edn. St Louis: Surg 1990; 1: 23–5.
Ishiyaku Euroamaerica, Inc., 1986. 41 Corbitt JD. Laparoscopic herniorrhaphy. Surg Laparosc Endosc
23 Lichtenstein IL, Shulman AG, Amid PK, Montilier MM. The tension- 1991; 1: 23–5.
free hernioplasty. Am J Surg 1989; 157: 188–93. 42 Toy FK, Smoot RT, Jr. Toy–Smoot laparoscopic hernioplasty.
24 Shulman AG, Amid PK, Lichtenstein IL. A survey of non-expert Surg Laparosc Endosc 1991; 1: 151–6.
surgeons using the open tension-free mesh repair for primary 43 Salerno GM, Fitzgibbons RJ, Filipi C. Laparoscopic inguinal hernia
inguinal hernia. Int Surg 1995; 80: 35–6. repair. In: Zucker KA, ed. Surgical Laparoscopy. St Louis: Quality
25 Halsted WS. Bull Johns Hopkins Hosp 1903; 149: 211. Medical Publishing, 1991: 281–93.
26 Zimmerman LM, Zimmerman JE. The history of hernia treatment. 44 Fitzgibbons RJ. Laparoscopic inguinal hernia repair. New Frontiers
In: Nyhus LM, Condon RE, eds. Hernia, 2nd edn. Philadelphia: in Endoscopy, Nationwide Satellite Teleconference, May 1991.
JB Lippincott Co., 1978: 3–13. 45 Arregui ME, Davis CD, Yucel O, et al. Laparoscopic mesh repair of
27 Fruchaud HR. Anatomie chirurgicale des hernies de l’aine. Paris: inguinal hernia using a preperitoneal approach: a preliminary
G. Doin, 1956. report. Surg Laparosc Endosc 1992; 2: 53–8.
28 Wantz GE. Testicular atrophy as a risk of inguinal hernioplasty. 46 Dion YM, Morin J. Laparoscopic inguinal herniorrhaphy. Can J Surg
Surg Gynecol Obstet 1982; 154: 570–1. 1992; 35: 209–12.
29 Stoppa RE, Petit J, Henry X. Unsutured Dacron prosthesis in groin 47 Kavic MS. Laparoscopic hernia repair. Surg Endosc 1993; 7: 163–7.
hernias. Int Surg 1975; 60: 411–15. 48 MacFayden B, Arregui M, Corbitt J, et al. Complications of
30 Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron laparoscopic hernia. Surg Endosc 1993; 7: 155–8.
in the repair of hernias of the groin. Surg Clin N Am 1993; 49 McKernan BJ, Laws HL. Laparoscopic preperitoneal prosthetic
73: 571–81. repair of inguinal hernias. Surg Rounds 1992; 7: 579–610.
31 Read RC. Preperitoneal exposure of inguinal herniation. Am J Surg 50 Dulucq JL. Traitement des hernies de l’aine par mise en place d’un
1968; 116: 653–8. patch prothétique sous-péritonéal en rétropéritonéoscopie.
32 Read RC. Attenuation of the rectus sheath in inguinal herniation. Cahiers Chir 1991; 79: 15–16.
Am J Surg 1970; 120: 610–14. 51 Phillips EH, Carroll BJ, Fallas MJ. Laparoscopic preperitoneal
33 Read RC. The metabolic role in the attenuation of transversalis inguinal hernia repair without peritoneal incision. Surg Endosc
fascia found in patients with groin herniation. Hernia 1998; 1993; 7: 159–62.
2 (suppl 1): 17. 52 Wright D, Paterson C, Scott N, et al. Five-year follow-up of
34 Read RC. Blood protease/antiprotease imbalance in patients with patients undergoing laparoscopic or open groin hernia repair. Ann
acquired herniation. Prob Gen Surg 1995; 12: 41–6. Surg 2002; 235: 333–7.
35 Senior RM, Tegner H, Kuhn C, et al. The induction of pulmonary 53 Felix E, Michas C. The double-buttress laparoscopic herniorrhaphy.
emphysema with human leukocyte elastase. Am Rev Resp Dis J Laparoendosc Surg 1993; 1: 1–8.
1977; 116: 469–75. 54 LeBlanc KA, Booth WV. Laparoscopic repair of incisional
36 Cannon DJ, Read RC. Metastatic emphysema. A mechanism for abdominal hernias using expanded polytetrafluoroethylene:
acquiring inguinal herniation. Ann Surg 1981; 194: 270–8. preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41.
37 Ger R. The management of certain abdominal herniae by 55 Franklin ME, Heniford BT, Arca MJ, et al. Laparoscopic ventral and
intra-abdominal closure of the neck of the sac. Ann R Coll Surg incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9.
Engl 1982; 64: 342–4. 56 Kavic MS. Laparoscopic Hernia Repair. Amsterdam: Harwood
38 Popp LW. Endoscopic patch repair of inguinal hernia in a female Academic Publishers, 1997.
patient. Surg Endosc 1990; 4: 10–12. 57 Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic
39 Bogojavlensky S. Laparoscopic treatment of inguinal and femoral treatment vs. open surgery in the solution of major incisional and
hernia. Video presentation presented at the 18th Annual Meeting abdominal wall hernias with mesh. Surg Endosc 1999; 13: 250–2.
of the American Association of Gynecological Laparoscopists, 58 Crawford DL, Hiatt JR, Phillips EH. Laparoscopy identifies
Washington, DC, 1989. unexpected groin hernias. Arch Surg 1998; 64: 976–8.
6
Anatomy and physiology
B. PAGE AND PATRICK J. O’DWYER
View from the peritoneal cavity 41 Myopectineal orifice 44

Pre-peritoneal space 42 Femoral canal and sheath 45
Transversalis fascia 43 Nerves 45
Oblique muscles 44 Pathophysiology and conclusion 45
Inguinal canal 44 References 46
Spermatic cord 44
A thorough knowledge of the anatomy and function of the VIEW FROM THE PERITONEAL CAVITY
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 A starting point for any surgeon contemplating laparo-
certainly led to injuries to vessels and nerves in this region, scopic hernia repair is to view the normal anatomy of
which otherwise could have been avoided. In addition, the pelvis through the laparoscope (Figure 6.1) of a
failure to recognize the importance of the anatomy by sur- patient undergoing another laparoscopic procedure, e.g.
gical trainees and practicing surgeons has slowed progress cholecystectomy. With a head-down tilt of 15–30 degrees,
in minimal-access approaches to hernia repair via the first observe the natural boundaries between the pelvic
pre-peritoneal space. 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 Lateral fossa

(urachus)
Medial fossa
Medial umbilical ligament
Supravesical fossa
Lateral umbilical ligament
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 con-

densation 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 umbili-
cus. 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 liga-
ment. The inferior epigastric vessels are important land-
marks for the hernia surgeon, as indirect inguinal hernias
pass lateral to them on their way through the internal ring
Figure 6.2 The avascular plane immediately posterior to the
to the inguinal canal, while direct hernias pass medially
rectus muscle in a patient undergoing open surgery. Note
on their way through the transversalis fascia.
the transverse fibers pointed out with tissue forceps below
Posterior to the natural division between the abdomen
the arcuate line.
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 trans-
versalis sling, thus shutting the door to the inguinal canal.
Figure 6.3 The vascular plane between the pre-peritoneal fat

PRE-PERITONEAL SPACE 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 laparoscopic surgeon enters the pre-peritoneal space
either transperitoneally or totally extraperitoneally. Getting
into the right plane (i.e. immediately posterior to the rectus the midline, it is seen to fuse with the linea alba and can
muscle) is important (Figure 6.2), otherwise the space be difficult to separate from that structure when moving
between the pre-peritoneal fat and the deep layer of fas- to the contralateral side in bilateral hernia repair.
cia transversalis is entered (Figure 6.3). This space con- The pre-peritoneal space is in direct communication
tains numerous small blood vessels and is associated with with the retropubic space of Rietzius.1 Following the pubic
troublesome bleeding, while the space posterior to the arch around on either side, the pectineal (Cooper’s) liga-
rectus muscle is avascular. The deep layer of fascia trans- ment comes into view (Figure 6.4). This is usually crossed
versalis lies between the rectus muscle and the peritoneum, by the anastomotic pubic artery and vein, tributaries from
with pre-peritoneal fat sandwiched between them. The the inferior epigastric vessels, which course towards the
fascia transversalis extends laterally beyond the inferior obturator foramen, where they join with their respective
epigastric vessels and can be observed surrounding the pubic branch of the obturator vessels. An abnormal obtu-
sac of an indirect hernia. It is particularly strong lateral to rator artery arising from the inferior epigastric will be
the inferior epigastric vessels, and as it is pulled down to seen in a similar location; observed in about 30 per cent
open the space lateral to this it can be seen to inter- of cases, this is larger than the aforementioned vessels.
digitate with the fibers of transversus abdominus muscle. The pectineal ligament itself fans out over a broad area
Inferiorly, in the midline, the fascia transversalis fuses of the superior pubic ramus, where medially it forms
with the pubis, but it is quite flimsy here and breaks the lacunar ligament and anteriorly it continues as the
easily with posterior movement of the laparoscope. In iliopubic tract. The latter structure goes from the pubic
Anatomy and physiology 43
Medial limb of transversalis sling Inferior epigastric vessels Rectus muscle

Aponeurotic arch Transversus abdominus muscle
Hasselbach's triangle
Internal ring Ileopubic tract
Femoral branch of Deep circumflex iliac
genitofemoral nerve artery and vein
Iliacus muscle
Lateral cutaneous
Transversalis fascia
nerve of thigh
Genital branch of Femoral nerve
genitofemoral nerve Lacunar ligament
Psoas mucle
Femoral canal
Bladder Ileopsoas fascia (cut)
Anastomotic pubic artery and vein
Pectineal ligament
Testicular vessels
Vas deferens Obturator foramen
Obturator vessels and nerve 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 femoral branches at a variable distance along the psoas
of the anterior layer of fascia transversalis. The iliopubic muscle. The femoral nerve lies deep to the iliopsoas fas-
tract thus forms the posterior margin of both direct and cia and is again lateral to the iliac artery and runs along
indirect hernias while it is anterior to a femoral hernia. the lateral border of the psoas muscle. Further lateral is
The femoral canal is bounded by iliopubic tract anteri- the lateral cutaneous nerve of thigh, which can be seen
orly, the pectineal ligament posteriorly, the lacunar liga- crossing the iliacus muscle and which passes below the
ment medially, and the iliac vein laterally. Likewise, the iliopubic tract just medial to the anterior superior iliac
triangular area bounded by the deep epigastric vessels spine. The deep circumflex iliac artery and vein cross over
laterally, the lateral margin of the rectus muscle medially, the lateral cutaneous nerve on their course parallel and
and the iliopubic tract posteriorly (Hesselbach’s triangle) superior to the iliopubic tract. These vessels can easily
is the area through which direct hernias are formed. be injured at this site and cause some nuisance bleeding
More precisely, from the pre-peritoneal view, the medial during laparoscopic hernia repair.
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 abdomi-
TRANSVERSALIS FASCIA
nus muscle. The former can be seen easily at laparoscopic
surgery with a large direct hernia, where the defect This fascial layer, which is thought to invest the entire
extends lateral to the deep epigastric vessels. The fascia abdominal cavity, is a source of controversy for surgeons
transversalis forms a U-shaped sling around the cord, and anatomists. Some argue that it is a weak layer with no
with the two limbs extending anteriorly and laterally to intrinsic strength, while others regard it as essential both
fuse with the posterior aspect of the transversus muscle. in the origin and repair of groin hernias. It is likely that
This sling is responsible for the shutter mechanism, both of these statements are true and almost certainly
which, for practical purposes, closes off the inguinal represent observations from different groups of patients
canal with sudden increases in intra-abdominal pressure. or cadavers. Some regard it as a bilamellar structure with
The iliopubic tract is an important landmark for the a strong anterior layer and a membranous deep layer.2
surgeon, for as well as having the femoral canal posterior There is little doubt from the laparoscopist’s point of view
to it, the external iliac vein and artery pass behind the that a two-layer fascial structure exists. The anterior layer
iliopubic tract and inguinal ligament to become the of transversalis fascia can be seen easily when reducing a
femoral vessels. Both run on the medial aspect of the psoas direct hernia as an attenuated fascial structure that lines
muscle and can be seen easily during a totally extra- the defect. The deep layer is observed when entering the
peritoneal laparoscopic hernia repair. It goes without pre-peritoneal space subumbilically and immediately
saying for surgeons who continue to use staples or other posterior to the rectus muscle (Figure 6.3). Both struc-
fixation methods for laparoscopic hernia repairs that tures appear strong and difficult to break through in the
placement of these devices in this area should be avoided. young patient with an indirect hernia; in older patients,
As stated already, the vas deferens runs over the iliac both are flimsy, presumably because of a deficiency of col-
vessels on its course from the prostatic urethra to the lagen.3 Some regard the deep layer as a distinct structure
internal ring. The testicular artery and vein course just from the transversalis fascia. However, as it is followed
lateral to the iliac artery, while the genitofemoral nerve laterally it appears to interdigitate with the abdominal
runs a similar course, having split into its genital and muscles, making it likely that it is attenuated posterior
rectus sheath and will thus contain a fascial contribution INGUINAL CANAL
from the transversalis fascia.4 It is also likely that the so-
called anterior layer of transversalis fascia is merely an
attenuation of the aponeuroses of the internal oblique The inguinal canal is an oblique intermuscular slit about
and transversus abdominus muscles. Evidence for this 6 cm long, lying above the medial half of the inguinal
comes from children and young adults, in whom this ligament. It begins at the deep (internal) ring and ends at
layer is mainly muscular or musculotendinous.5 the superficial (external) ring. It transmits the spermatic
The transversus abdominus muscle is the deepest cord and the ilio-inguinal nerve in the male, and the round
of the three abdominal muscle layers and the one seen by ligament and the ilio-inguinal nerve in the female. The
the laparoscopic surgeon. It arises from the costal carti- anterior wall is formed by the external oblique aponeuro-
lages of the lower six ribs, the vertebral column and the sis medially and the internal oblique laterally. Its floor is
iliac crest. Its fibers run transversely, except in the lower made up of the rolled edge of the inguinal ligament. The
abdomen, where they arch over the inguinal canal as an lower edges of the internal oblique and the aponeurotic
aponeurotic arch, which is inserted into the pubic crest arch of the transversus muscle form the roof of the canal.
and iliopectineal line. The transverse fibers proceed hor- These muscles arch over from in front of the cord laterally
izontally to their insertion in the rectus sheath and linea to behind the cord medially. In adults, the posterior wall is
alba. Below the aponeurotic arch, the posterior wall of thus strong medially and weak laterally, where it is formed
the inguinal canal is closed by transversalis fascia only in by the transversalis fascia only. In children, however, the
adults and is the site through which direct hernias occur. inguinal canal is short (1–1.5 cm) and the internal and
When the aponeuroses of the transversus and the inter- external rings are almost superimposed on each other.
nal oblique muscle are fused lateral to the rectus sheath,
the term ‘conjoined tendon’ is used. This is a variable SPERMATIC CORD
structure, however, and does not exist in all patients.6
The spermatic cord leaves the abdominal cavity via the

OBLIQUE MUSCLES superficial ring. The coverings of the spermatic cord are
formed by the local muscles and fascia. The internal sper-
In addition to the transversus abdominus muscle, the matic fascia is derived from fascia transversalis, cremas-
abdominal wall is composed of the internal and external ter muscle from internal oblique muscle, and external
oblique muscles. The external oblique arises from the lower spermatic fascia from external oblique aponeurosis. The
eight ribs. From its fleshy origin, the muscle spans widely to spermatic cord contains the testicular artery and vein, the
an aponeurotic insertion. Superiorly, the aponeurosis is ductus deferens and its accompanying vessels, the cremas-
very thin and is attached to the xiphoid process. Inferiorly, teric artery, lymphatics, and the genital branch of the
it is thick and inserts into the anterior superior iliac spine genitofemoral nerve. Until birth, the processus vaginalis,
and pubic tubercle as the taut inguinal ligament. In the the portion of the peritoneum that accompanies the testis
midline, the aponeurosis forms the anterior rectus sheath on its descent into the scrotum in embryonic life, remains
and is inserted into the linea alba. Posteriorly, the external opened. In some children, delay in closure may result in
oblique is not attached and forms part of the lumbar trian- the development of a pediatric hernia. Although patent in
gle. This, on occasion, may be a site for a lumbar hernia. some adults, the role of the processus vaginalis in the
The internal oblique muscle arises from the lumbar development of an indirect inguinal hernia is not certain.
fascia, from the anterior two-thirds of the iliac crest, and It is likely that failure of the sphincter mechanism of the
from the lateral part of the inguinal ligament. The muscle inguinal region, the transversalis U-sling, combined with
fibers run parallel to the costal cartilages until they reach contraction and flattening of the transversalis arch and
the ninth rib, where they become aponeurotic. Above the internal oblique muscle, which essentially closes the
umbilicus, the tendinous aponeurosis of the internal inguinal canal, is more important.
oblique splits to encircle the rectus muscle. At a point
2.5 cm below the umbilicus lies the arcuate line, the pos-
MYOPECTINEAL ORIFICE
terior 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 fas- Fruchaud emphasized that all groin hernias originate from
cial structure to a more attenuated membranous struc- a single weak area (Figure 6.5).7 This area is formed by the
ture (Figure 6.3). The lower fibers of the internal oblique abdominal wall muscles above, the arching fibers of the
originate at the inguinal ligament and arch downward transversus abdominus, the internal and external oblique
and medially with the fibers of transversus abdominus to muscles, the bony pelvis below, ilium covered by the pec-
insert into the pubic crest anterior to the rectus muscle. tineal ligament, the rectus muscle medially, and the fascia
Ilio-hypogastric nerve
Ilio-inguinal nerve
Inferior epigastric vessels
Cremasteric vessels
Spermatic cord
Genital nerve
Inguinal ligament
Ileopsoas muscle
Figure 6.6 Position of the nerves in the right inguinal canal.
Inguinal ligament
region. It passes obliquely through the substance of the
Femoral vessels
psoas major muscle and emerges from this crossing deep
to the peritoneum and the ureter. It splits behind the
Spermatic cord
deep inguinal ring into the genital and femoral branches.
The genital branch lies on the floor of the inguinal canal
Myopectineal orifice behind the spermatic cord and supplies the cremasteric
Figure 6.5 The myopectineal orifice.
muscle via its motor branches and the scrotal skin via its
sensory branches. The femoral branch contributes to the
covering the iliopsoas muscle laterally. The myopectineal sensation of the anterior thigh. The lateral cutaneous
orifice is divided into two levels by the inguinal ligament. nerve of the thigh crosses the iliacus muscle after emerg-
The superior, inguinal level provides a passage for the ing from the lateral border of the psoas muscle. It passes
spermatic cord or round ligament; the inferior, femoral beneath the iliopubic tract just medial to the anterior
level provides a passage for the femoral vessels. superior iliac spine and innervates the skin on the ante-
rior and lateral surface of the thigh. The femoral nerve is
the largest of the three nerves and lies deep to the iliop-
FEMORAL CANAL AND SHEATH soas fascia. It can be seen emerging between the psoas
and iliacus muscle, passing beneath the iliopubic tract,
and innervating the muscles in the anterior compart-
The femoral canal contains fatty tissue, lymph nodes and ment of the thigh and the skin of the anteriomedial
lymphatics. The boundaries of the canal include the femoral aspect of the lower thigh and leg.
vein and connective tissue laterally, the aponeurotic inser- Also of importance to the hernia surgeon are the ilio-
tion of the transversus abdominus and lacunar ligament inguinal and ilio-hypogastric nerves (Figure 6.6). The
medially, the iliopubic tract and inguinal ligament anteri- former is usually smaller than the latter and is sometimes
orly, and the pectineal ligament posteriorly. The entrance to absent. These are both sensory nerves that arise from
the canal, the femoral ring, is a little over 1 cm in diameter, the first lumbar nerve. The ilio-inguinal nerve passes
while the canal itself is 1–2 cm long with its apex at the fossa through the inguinal canal and becomes superficial at the
ovalis. The femoral sheath is an extension of the transver- external ring to innervate the skin of the scrotum and the
salis fascia and envelops the femoral artery, vein and canal. medial upper thigh. Damage to the ilio-inguinal nerve in
The sheath is divided into three compartments by septa of the inguinal canal causes sensory loss as the motor fibers
connective tissue between each compartment. are already given off to the conjoint tendon. The ilio-
hypogastric nerve emerges through the external oblique
aponeurosis to innervate the suprapubic skin.
NERVES
PATHOPHYSIOLOGY AND CONCLUSION

The nerves of most importance to the laparoscopic sur-
geon are the genitofemoral nerve, the lateral cutaneous
nerve of the thigh, and the femoral nerve. The genito- A better understanding of the physiology of the inguinal
femoral nerve comes from the first and second lumbar region may lead ultimately to novel methods of preventing
nerves and completes the innervation of the groin and treating inguinal hernias. In children, fusion of the
processus vaginalis is thought to be hormone-related.8 muscle to its aponeurosis on the rectus sheath. This sug-
This is supported by the fact that inguinal hernias are gests an inherited anatomical variation that predisposes
associated with an undescended testis and gonadotropin certain individuals to the development of an inguinal
administration results in a significantly higher rate of hernia and helps explain why one-third of patients will
closure of the processus vaginalis. Since androgen recep- have or develop a contralateral hernia while a similar
tors are not present in the processus vaginalis, it has been number will have a family history of a hernia.16
postulated that their effect is on the genitofemoral nerve. Although we have made significant progress in the
This releases calcitonin gene-related peptide (CGRP), understanding of the anatomy and physiology of the
which has been shown to fuse the inner mesothelial layer inguinal region, there is still a lot to learn. Advancements
of the processus vaginalis.9 Hepatocyte growth factor/ in these areas will undoubtedly lead to the prevention of
scatter factor (HGF/SF) has also been found to induce some groin hernias and better treatment of existing
fusion of the processus, suggesting that local administra- symptomatic hernias in the future.
tion 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 REFERENCES
key element in the development of pediatric hernias, its
role in adults is less certain. Autopsy studies reveal that
15–35 per cent of adults have a patent processus vaginalis 1 Bouchet Y, Voilin C, Yver R. The peritoneum and its anatomy. In:
Bengmark S, ed. The Peritoneum and Peritoneal Access. London:
without ever developing a hernia.10 A more likely cause, Wright, 1989: 1–13.
given the increasing incidence with age, is a relative 2 Cooper A. The Anatomy and Surgical Treatment of Abdominal
reduction in connective tissue in the inguinal region.11 In Hernia. London: Longman, 1804.
addition, there is evidence that altered collagen synthesis 3 Wagh PV, Read RC. Collagen deficiency in rectus sheath of patients
may weaken the fascia transversalis in patients with an with inguinal herniation. Proc Soc Exp Biol Med 1971; 37: 382–4.
4 Arregui ME. Surgical anatomy of the preperitoneal fascia and
inguinal hernia. In a study by Klinge and colleagues, posterior transversalis fascia in the inguinal region. Hernia 1997;
immunohistochemical and Western blot analysis showed 1: 101–10.
that the ratio of type I to type III collagen was decreased 5 Bendavid R. The transversalis fascia: new observations in
significantly in the fascia transversalis of patients with an abdominal wall hernias. In: Bendavid R, Abrahamson J,
inguinal hernia.12 The tensile strength of tissues depends Arregui ME, et al., eds. Abdominal Wall Hernias: Principles and
Management. New York: Springer-Verlag, 2001: 97–100.
on the proportion of type I and III collagen, and the 6 Sorg J, Skandalakis JE, Gray SW. The emperor’s new clothes or the
authors postulated that the relative increase in type III myth of the conjoined tendon. Ann Surg 1979; 45: 588–9.
collagen, thin, immature fibers might be responsible for a 7 Fruchaud H. Anatomie chirurgicale des hernies de l’aine. Paris:
reduction in mechanical strength of the collagen matrix G Doin, 1956.
of the abdominal wall. 8 Clarnette TD, Hutson JM. The development and closure of the
processus vaginalis. Hernia 1999; 3: 97–102.
The lack of strength in the supporting structures is 9 Sugita Y, Uemura S, Hasthorpe S, Hutson JM. Calcitonin gene-
probably only part of the puzzle that leads to failure of the related peptide (CGRP) – immunoreactive nerve fibre and receptors
inguinal region in adults. Anatomically, Hessert’s triangle in the human processus vaginalis. Hernia 1999; 3: 113–16.
is a weak area that has the internal ring as its apex, the rec- 10 Read RC. Historical survey of the treatment of hernia. In:
tus abdominus as its base, and the inguinal ligament and Nyhus LN, Condon RE, eds. Hernia, 3rd edn. Philadelphia:
JB Lippincott, 1989: 3–17.
aponeurotic arch of the transversus abdominus and inter- 11 Conner WT, Peacock EE. Some studies on the aetiology of inguinal
nal oblique as its sides.13 This area is normally closed by hernia. Am J Surg 1973; 126: 732–5.
the contraction of the transversus and internal oblique 12 Klinge U, Zheng H, Si Zy, et al. Altered collagen synthesis in fascia
muscular arch, which flattens out this arch and causes it to transversalis of patients with an inguinal hernia. Hernia 1999;
approach the inguinal ligament. This essentially occludes 4: 181–7.
13 Hessert W. Some observations on the anatomy of the inguinal
the triangle and is referred to as the inguinal shutter by region, with special reference to absence of the conjoined tendon.
Keith.14 Recent evidence indicates that in patients with an Surg Gynecol Obstet 1913; 16: 566–8.
inguinal hernia, this triangle is larger than usual and thus 14 Keith A. On the origin and nature of a hernia. Br J Surg 1973; 11:
closure of the shutter may be incomplete.15 The authors of 455–75.
the latter study concluded that the greater area was a cause 15 Abdalla RZ, Mittlestaedt WE. The importance of the size of Hessart’s
triangle in the aetiology of inguinal hernia. Hernia 2001; 5: 110–23.
and not a consequence of inguinal herniation because the 16 Hair A, Paterson C, Wright D, et al. What effect has the duration
reason for the increase in this area was a higher intersec- of an inguinal hernia on patient symptoms? J Am Coll Surg 2001;
tion of the internal oblique and transversus abdominus 193: 125–9.
7
Intraperitoneal onlay mesh approach
MORRIS FRANKLIN
Patient selection 48 Postoperative management 51

Operating room set-up 48 Conclusion 51
Operative technique 49 References 51
It has been over 100 years since Bassini ushered in a new The three most popular procedures to emerge were the
era of hernia surgery with the introduction of his triple- transabdominal pre-peritoneal (TAPP) patch, the totally
layer technique to repair the inguinal floor. Since then, extraperitoneal (TEP) patch, and the intraperitoneal
surgeons have developed a myriad of new methods of her- onlay mesh (IPOM) repairs. In the TAPP technique,
nia repair in an attempt to improve the results. However, the peritoneum is incised intra-abdominally and a pre-
despite a century of advances in hernia surgery, recur- peritoneal space is developed. A prosthetic mesh is then
rence continues to plague the general surgeon and is the introduced into this space, placed over the abdominal wall
primary reason why no single technique of herniorrhaphy defect, and stapled into place. The peritoneum is then
has become universally accepted. The repair of inguinal re-approximated over the mesh so that there is no exposure
hernias has probably produced more variety in technique of synthetic material to the intra-abdominal contents.
than any other operation performed by the general sur- In the TEP approach, the peritoneal space is never
geon today. Complexity of the anatomy, the variety in size entered. Dissection is carried out in the extraperitoneal
and location of the defect, and the multiplicity of the space just below the fascia of the abdominal wall. A
presentations of a hernia have contributed to this pre-peritoneal space is created using blunt dissection
uncertainty regarding the optimal repair.1 and carbon dioxide insufflation. Synthetic mesh is then
After minimally invasive surgery proved to be success- placed over the defect and fixed into place with staples or
ful in the treatment of biliary, gastric and colon diseases, tacks, as in the TAPP procedure.
surgeons attempted to find a method of successfully The potential drawback of both the TAPP and the TEP
repairing inguinal hernias laparoscopically. It was felt that procedures is that they require considerable dissection to
the attendant benefits of decreased postoperative pain and create the pre-peritoneal space, which can result in periop-
disability seen in other minimally invasive procedures erative discomfort and complications, such as hematoma
could be realized in hernia patients as well. The first report formation or injury to the vas deferens, vascular structures,
of a laparoscopic technique of inguinal herniorrhaphy was or nerves. The TEP technique in particular is technically
by Ger and colleagues in 1990,2 who advocated simple clo- more demanding, and the pre-peritoneal dissection can
sure of the neck of the hernia sac. This was soon followed be very difficult to perform, particularly in large inguino-
by reports of plugging of the inguinal canal or direct defect scrotal hernias. As a result, a third laparoscopic repair
with a prosthetic mesh, as described by Schultz and col- was developed, which involves placing the mesh on the
leagues3 in 1990 and by Corbitt4 in 1991. After unaccept- intra-abdominal side of the peritoneum, rather than pre-
able early recurrence rates, these methods were abandoned peritoneally, thus avoiding the radical dissection of the
in favor of newer techniques that combined the advan- pre-peritoneal space. This method of repair – the IPOM
tages of a tension-free repair utilizing a synthetic mesh technique – was concurrently investigated in the Laboratory
with the transabdominal approach of laparoscopy. for Experimental Laparoscopic Surgery at Creighton
University and at the Texas Endosurgery Institute, San PATIENT SELECTION

Antonio.5 Yorkshire cross-feeder pigs with congenital
indirect inguinal hernias underwent intraperitoneal
herniorrhaphy with placement of Prolene mesh either All adult patients with inguinal hernias and who are fit
laparoscopically or via laparotomy. At six weeks, all pigs for general anesthesia are considered candidates for a
were sacrificed and an intra-abdominal exploration was laparoscopic IPOM procedure. Those patients with an
carried out to confirm the success or failure of the repair, to obliterated pre-peritoneal space secondary to radiation
stage the development of any adhesions to the mesh, to or previous surgery (radical retropubic prostatectomy,
examine the prostheses for infection, and to evaluate the bladder surgery, vascular procedures, cesarean section,
erosion of the prosthesis into neighboring structures. All etc.) are particularly good candidates in that a laparo-
hernia repairs in both groups were successful. In addition, a scopic TAPP or TEP procedure would be technically
significant reduction in adhesion formation was noted difficult or even impossible in this setting. Additionally,
when the mesh was placed laparoscopically rather than by those patients with a failed TAPP or TEP are ideal candi-
laparotomy. There was no evidence of intra-abdominal dates for this approach, which allows for recurrent hernia
infection or erosion of the prosthesis into adjacent struc- repair in virgin territory.
tures in either group. These findings parallel those of Relative contraindications include severe intra-
Franklin6 and Layman and colleagues,7 who found that the abdominal adhesions due to prior surgery, ascites, coagulo-
use of intraperitoneal material in swine models resulted pathy, severe underlying medical illness precluding general
in good in-growth of peritoneum over the mesh with anesthesia, and lack of appropriate laparoscopic skills.
minimal adhesion formation.
We performed the first IPOM procedure in a human
patient at the Texas Endosurgery Institute in 1990. Since
OPERATING ROOM SET-UP
then, we have repaired over 550 direct, indirect, and recur-
rent inguinal hernias using the IPOM technique, with
an overall complication rate of 7.5 per cent and a recur- The operating room set-up for the IPOM procedure on a
rence rate of 0.96 per cent.8 These results are compar- left-sided inguinal hernia can be seen in Figure 7.1. The
able to those of Toy and colleagues,9 who reported 441 operating surgeon stands on the contralateral side of the
IPOM repairs with a complication rate of 8.0 per cent table from the hernia, while the assistant is positioned on
and a recurrence rate of 3.8 per cent, and Fitzgibbons the side ipsilateral to the hernia site. With the patient
and colleagues,10 who detailed 217 IPOM repairs with a under general anesthesia, a catheter is placed in the blad-
recurrence rate of 5.1 per cent. der and a nasogastric tube is introduced into the stomach.
Anesthesia
Suction
irrigation
Cautery
Camera
holder
Assistant
surgeon
Laparoscopy
Surgeon
table
Scrub
nurse
Mayo
stand
Hot plate
sequential
Primary Secondary compression
Figure 7.1 Operating room set-up
video cart video cart devices
for left-sided hernia repair.
Intraperitoneal onlay mesh approach 49
After insufflating the peritoneal cavity to 14 mmHg using space. Division of the sac also gives access to the properi-
a Veress needle, a 5-mm trocar is introduced into the toneal area where a ‘lipoma’ of the cord, if present, can be
abdomen on the side opposite the hernia, just lateral to the excised. When operating for left-sided hernias, we often
rectus sheath at the level of the umbilicus. After a general- find it necessary to divide the embryonic adhesions that
ized inspection of the abdominal cavity and lysis of adhe- the sigmoid colon maintains with the parietal peritoneum
sions if necessary, a 10/12-mm trocar is placed at the adjacent to the hernia defect. We excise the sac using
umbilicus and a 5-mm trocar is placed on the ipsilateral laparoscopic scissors connected to an electrosurgical unit.
side of the hernia, exactly opposite the initial trocar. Trocar First, the sac is inverted progressively into the peri-
placement is outlined in Figure 7.2. For bilateral repairs, toneal cavity using gentle traction. Once the inversion is
the same configuration of trocar placement is utilized. completed, the sac is incised, starting 1 or 2 cm from its
base at the 12 o’clock position and proceeding clockwise to
about the 4 o’clock position. The incision is then restarted
at the ‘top’ and carried in an anticlockwise fashion until
OPERATIVE TECHNIQUE approximately the 8 o’clock position. The inversion of an
indirect inguinal hernia sac drags within it the fatty areo-
After inspection of the entire peritoneal cavity and lysis lar tissue in which the gonadal vessels and the vas may be
of any remaining adhesions, the hernia site and the con- embedded. This tissue must be bluntly and carefully swept
tralateral inguinal area are evaluated carefully. For proper away from the sac anteriorly. Once separated fully from
orientation, the surgeon should recognize the median, the elements of the cord, the sac can then be safely excised
medial and lateral umbilical ligaments. Just below the circumferentially and removed through a 10/12-mm port.
posterior parietal peritoneum, the external iliac vein Small or capillary vessel bleeding during this phase of
and artery, the gonadal vessels, and, in males, the vas the operation is controlled easily by pinpoint electro-
deferens should be identified. The hidden course of the coagulation. Large inguinoscrotal sacs and sacs in multi-
genitofemoral nerve and the approximate course of the ple recurrent hernias are ringed at the neck (incision of
lateral femoral cutaneous nerve should be recalled and the peritoneum circumferentially) and are left in place.
care taken to avoid rough dissection in this area. The exact Bleeding and extensive edema may ensue if these sacs are
location of the ureter bilaterally should also be noted. pursued aggressively.
We now routinely remove direct and indirect hernia Once the sac is removed, a piece of Polypropylene
sacs, since in our experience leaving the sac may perpetu- mesh is prepared. The size of the mesh should be such
ate a bulge in the groin – a bulge that patients and inexpe- that it covers the hernia defect and extends 3 cm beyond
rienced surgeons interpret as an operative failure despite its rim in all directions at a minimum. We have found that
repeated assurances that no bowel can enter the sac or a 12 ⫻ 15-cm portion of mesh covers most defects ade-
quately. The folded mesh is introduced into the abdomi-
nal 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 one’s finger and visualizing the inden-
tation laparoscopically can establish the spot where the
1 mm incision is to be made and where the needle is to
10/12mm port 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
5 mm port 5 mm port
needle is passed through the abdomen and mesh, it is
grasped, turned through 180 degrees, and pushed back
Hernia 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
Figure 7.2 Trocar configuration for IPOM inguinal hernia repair. tightly against the abdominal wall. The same procedure is
Figure 7.5 Mesh stapled securely to Cooper’s ligament.

Figure 7.3 Keith needle passing through mesh and abdominal
wall adjacent to 13-gauge spinal needle.
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
1–1.5 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
(a)
should be placed lightly and further apart (2 cm) to avoid
damage to the iliac vessels and the vas deferens. A few
13G needle staples are also used to fix the superior and central por-
tion of the mesh to the anterior abdominal wall. Medi-
ally, every effort should be made to secure the mesh
to Cooper’s ligament (Figure 7.5). The anteriorly posi-
tioned inferior epigastric vessels, immediately beneath
the peritoneum, should be avoided in the stapling pro-
cess. Staples should not be used near the inferior or infero-
Skin lateral 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
Mesh
incisions through which the Prolene sutures were placed
Peritoneum 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 Cooper’s ligament prevents dis-
(b)
placement of the mesh when the abdomen is deflated and
when the patient assumes the erect position. We firmly
Figure 7.4 (a) Keith needle being passed back through abdominal believe that recurrent herniation is the result of early
wall via 13-gauge needle. (b) Diagrammatic representation. migration of the mesh away from its intended position.
To repair a contralateral hernia, the same procedure
repeated at both upper corners of the mesh. This method is performed on the opposite side. Initially, we did not
of percutaneous fixation of mesh for inguinal hernia repair combine this type of surgery with operations on the bowel
was first described by Rosenthal and Franklin in 1993.11 We or biliary tree. However, these are no longer contraindi-
do not rely solely on staples, which grasp only mesh and cations to the simultaneous repair of these hernias with
peritoneum, to hold the prosthesis in place. bowel or biliary surgery subsequent to the development
Intraperitoneal onlay mesh approach 51
of biosynthetic mesh materials such as Surgisis™ anesthesia, higher costs, the potential problems inherent
(Cook Surgical), which have demonstrated high resist- to laparoscopy, and the need for technical expertise in
ance to infection, even in contaminated fields.13 (See laparoscopic surgery. Potential complications due to the
Chapter 4.) mesh’s direct contact with abdominal viscera have yet to
As the trocars are sequentially removed, the trocar be realized in the laboratory or in clinical practice.
sites are examined to ensure that no bleeding is present. The laparoscopic IPOM technique of hernia repair
Finally, the umbilical insertion site is observed by slowly is a safe and relatively easy procedure to perform, with
withdrawing the camera and its cannula in unison. To good results and low morbidity. It can be a particularly
prevent potential herniation, all 10-mm trocar sites are effective technique for laparoscopic repair of recurrent
closed by repairing the underlying fascia or aponeuro- inguinal hernias or for hernia repair in the setting of an
sis with the aid of a Carter-Thomason®suture passer obliterated pre-peritoneal space.
(Louisville Laboratories) using 0 Vicryl®(Ethicon) or
Polysorb®(U.S. Surgical) sutures. The skin edges are then
re-approximated with 3-0 Monocryl®(Ethicon) subcuti-
REFERENCES
cular sutures or Steri-strips®(3M Health Care).
1 Ramshaw R, Shuler FW, Jones HB, et al. Laparoscopic inguinal

hernia repair: lessons learned after 1224 consecutive cases. Surg
POSTOPERATIVE MANAGEMENT Endosc 2001; 15: 50–54.
2 Ger R, Monroe K, Duvivier R, Mishriek A. Management of indirect
inguinal hernia by laparoscopic closure of the neck of the sac.
Patients are generally discharged the evening of surgery Am J Surg 1990; 159: 370–73.
or after a 23-hour observation period, depending on age, 3 Schultz L, Graber J, Pietrafitta JJ, Hickok D. Laser laparoscopic
herniorrhaphy: a clinical trial preliminary results. J Laparoendosc
comorbidities, and difficulty of operation. They are
Surg 1990; 1: 41–5.
scheduled for follow-up office visits one to two weeks 4 Corbitt JD. Laparoscopic herniorrhaphy. Surg Laparosc Endosc
following discharge and are instructed to be aware of uri- 1991; 1: 23–5.
nary retention, neuralgia (from damage to the lateral 5 Fitzgibbons RJ, Salerno GM, Filipi CJ, et al. A laparoscopic
femoral cutaneous nerve), and scrotal swelling in men. intraperitoneal onlay mesh technique for the repair of an indirect
inguinal hernia. Ann Surg 1994; 219: 144–56.
We ask that they avoid heavy lifting (⬎9 kg) for five
6 Franklin ME. Animal studies and rationale for intraperitoneal
to seven days following surgery. However, after this repair. In: Arregui ME, Nagan RF, eds. Inguinal Hernia: Advances
brief time period, they are allowed to perform activity as or Controversies? Oxford: Radcliffe Medical Press Ltd, 1994:
tolerated. 241–4.
7 Layman ST, Burns RP, Chandler KE, et al. Laparoscopic inguinal
herniorrhaphy in a swine model. Am J Surg 1993; 59: 13–19.
8 Franklin ME, Diaz-Elizondo JA. The intraperitoneal onlay mesh
CONCLUSION procedure for groin hernias. In: Fitzgibbons RJ, Greenburg AG,
eds. Nyhus and Condon’s Hernia. Philadelphia: Lippincott Williams
& Wilkins, 2002: 269–76.
The transabdominal approach to inguinal hernia repair 9 Toy FK, Moskowitz M, Smoot RT, Jr, et al. Results of a prospective
multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic
is not a new concept. Advocated by Marcy14 in 1887 and
inguinal hernioplasty. J Laparoendosc Surg 1996; 6: 375–86.
by LaRoque15 in 1932, the transabdominal approach for 10 Fitzgibbons RJ, Camps J, Comet DA, et al. Laparoscopic inguinal
inguinal herniorrhaphy allows greater ease in identifica- herniorrhaphy: results of a multicenter trial. Ann Surg 1995;
tion of groin anatomy, determination of the type of her- 221: 3–13.
nia defect, and separation of incarcerated and adherent 11 Rosenthal D, Franklin ME, Jr. Use of percutaneous stitches in
laparoscopic mesh hernioplasty. Surg Gynecol Obstet 1993; 176:
structures to the sac.16,17 However, the morbidity asso-
491–2.
ciated with a laparotomy is far too great for repair of 12 Eubanks S, Newman L, Goehring LM, et al. Meralgia paresthetica:
an uncomplicated inguinal hernia. With the advent of a complication of laparoscopic herniorrhaphy. Surg Laparosc
laparoscopic surgery, the benefits of the intra-abdominal Endosc 1993; 3: 381–5.
approach to inguinal herniorrhaphy can be enjoyed 13 Franklin ME, Gonzalez JJ. Preliminary experience with new
bio-active prosthetic material for repair of hernias in infected
without the morbidity of a laparotomy.
fields. Presented at the American Hernia Society meeting,
The IPOM procedure is relatively simple to perform Tucson, AZ, USA, May 8–12, 2002.
and carries with it all the potential advantages of a mini- 14 Marcy HO. The cure of hernia. JAMA 1887; 8: 589–92.
mally invasive procedure with respect to the open inguinal 15 LaRoque GP. The intra-abdominal method of removing inguinal
hernia repair, including less postoperative pain, earlier and femoral hernia. Arch Surg 1932; 24: 189–203.
16 Read RC. Preperitoneal herniorrhaphy: a historical review. World J
return to normal activities, ability to clearly visualize
Surg 1989; 13: 532–40.
and repair all hernia defects bilaterally, easier repair of 17 Nyhus LM, Condon RE, Haskins HN. Clinical experiences with
recurrent hernias, and improved cosmesis. Disadvantages preperitoneal hernia repair for all types of hernia of the groin.
of the IPOM technique include the necessity for general Am J Surg 1960; 100: 234–44.
8
Transabdominal pre-peritoneal approach
REINHARD BITTNER, CLAUS-GEORG SCHMEDT AND BERNHARD JOSEF LEIBL
Principles 53 Special remarks 61

Preoperative management 54 Postoperative management 63
Instrumentation 55 Conclusion 63
Operative room set-up 55 References 63
Operative technique 56
The introduction of laparoscopic operating techniques sufficiently large, then laparoscopic pre-peritoneal hernio-
opened up the possibility of using this method to plasty can be seen as a completely tension-free method of
implant mesh into the pre-peritoneal space to repair an hernia repair, which dispenses with any and all kinds
inguinal hernia. By sparing the patient a large abdominal of fixation. In contrast to this, the success of an anterior
incision in the inguinal region1 or in the midline,2 one mesh implant (Lichtenstein) depends on a strong external
can expect a decrease in the number of wound complica- oblique aponeurosis and on a row of well-placed fixation
tions, less postoperative pain, and consequently a faster sutures.
recovery of normal physical activity and return to work. Laparoscopic hernioplasty can be used on any type of
In contrast to pre-peritoneal mesh insertion via a mini- hernia, with the exception of huge, non-reducible scrotal
mized anterior approach,3 the laparoscopic method hernia (more than double the size of a man’s fist). In our
provides clear visibility when dissecting the inguinal patient pool of more than 1100 hernia repairs yearly,
region with safe, wrinkle-free placement of a large mesh.4 TAPP is used in 99 per cent of repairs.5 Conventional her-
Laparoscopic hernioplasty with pre-peritoneal placement nia repair operations are carried out only in young
of a large mesh (transabdominal pre-peritoneal (TAPP) patients (⬍20 years of age), in patients at high cardiopul-
repair) represents a synthesis between proven conven- monary risk where a general anesthetic is refused, and in
tional operative techniques and the advantages of a mini- patients who decline to accept implantation of prosthetic
mally invasive approach. materials.
Preferred indications are hernias recurring after con-
ventional operations (with the advantage of avoiding
anterior scar areas),6 bilateral hernia (both sides can be
PRINCIPLES treated through the same three trocar incisions), and
hernias with extensive destruction of the rear wall of the
Indications hernial canal (Nyhus type 3 with a defect diameter of
more than 3 cm, pantaloon hernia).7,8 Other accepted
The mode of operation of TAPP follows the law of indications are inguinal pain in athletes,9 after eliminat-
physics according to Pascal.2 As a result of pre-peritoneal ing other possible causes, and hernias in patients who
placement of the prosthesis, i.e. between abdominal wish to return to normal physical activity as quickly as
pressure and the weak point in the abdominal wall, the possible.
pressure that initially caused the hernia now acts as a Pain in the inguinal area with no clinically or sono-
stabilizer for reconstruction. If the mesh chosen is graphically proven hernia sac or lipoma of the spermatic
cord is not seen as an indication for laparoscopic hernio- between anterior and posterior implant techniques.10 The
plasty. Painstaking neurological (inguinal nerve neural- same meta-analysis confirmed that in comparison with
gia?) and orthopedic investigation is necessary. Strong anterior mesh implants, laparoscopic/endoscopic tech-
selection for operation is the only way to reduce signifi- niques provide a clearly higher patient comfort and a
cantly the frequency of postoperative chronic pain for significantly faster resumption of normal physical activity.
these patients. However, a clinically proven hernia, even It was observed, however, that the risk of severe complica-
though a hernia sac may not have been identified laparo- tions is higher when using the laparoscopic technique
scopically, does necessitate complete dissection of the (4.7/1000 v. 1.1/1000). Furthermore, the laparoscopic
inguinal region. As a rule, very often one will find a cir- technique means longer operating times and significantly
cumscribed lipoma of the inguinal canal or a fatty mass higher costs. There is no doubt that the laparoscopic tech-
that has moved into the inguinal canal. The operation is nique is more difficult to learn. This is, to some extent,
then identical to a hernia repair. related to the fact that many clinics do not routinely
Advantages of the TAPP technique over the totally perform videoendoscopic operations, and therefore there
extraperitoneal (TEP) approach include the following: is no structured training curriculum available. In the
authors’ hospital, with the experience that comes from
• After insertion of the laparoscope, one can assess
more than 8000 hernia repairs, a median operating time of
immediately the hernial situation on both sides and
40 minutes is sufficient for experienced surgeons, while
recognize the landmarks that are important for
trainees need 55 minutes. These times are completely in
dissection.
the range of those for open repair.5 A decisive factor con-
• Intestinal adhesions in the hernial sac (sliding hernia)
cerning the costs is whether disposable or non-disposable
can be recognized immediately.
instruments are used, and whether, or how, the mesh is
• Control of any bleeding is possible by appropriately
fixed in place. A high potential cost-saving is possible here.
aimed electrocoagulation, thereby avoiding injury to
The experience of our clinic is that the costs for the oper-
the adherent intestinal wall.
ating theatre alone (personnel and instruments) are only
• It is possible to diagnose accompanying pathological
about $75 higher than those of the Lichtenstein operation,
conditions as well as to carry out additional surgery
assuming that an anesthetist is required for the local
in the abdominal space (e.g. cholecystectomy)
anesthesia. Furthermore, the total costs for employees are
without conversion to an open procedure.
lower with the laparoscopic technique when the costs of
lost work days are factored into overall expense.11 All in all,
Contraindications the literature and our own results show that a well-trained
surgeon can perform a cost-effective laparoscopic hernio-
The only absolute contraindication is for patients at high plasty in a period of time that is well within the range of
cardiopulmonary risk who cannot be subjected to general that for conventional open surgery.
anesthesia or a pneumoperitoneum. A relative contraindi-
cation is seen in patients after extensive abdominal surgery,
especially after a lower abdominal laparotomy through a PREOPERATIVE MANAGEMENT
midline incision as well as after surgery in the space of
Retzius (transabdominal prostate resection, bladder resec-
tion), after previous laparoscopic or endoscopic hernio- Anatomy/pathology
plasty with mesh implant, and in patients with large, old,
irreducible scrotal hernia. Patients who have undergone the Clinical examination of the patient is indispensable. An
above operations tend to develop extensive adhesions in experienced examiner can diagnose correctly inguinal her-
the abdominal space as well as substantial scarring between nia with a total accuracy rate of 0.93. An additional sono-
the retroperitoneal structures. These patients present a risk graphic examination can increase this figure to 0.94.12
not only of increased bleeding but also of injury to the Classification of the hernia into medial or lateral, or in
intestinal organs and the bladder, as well as the large respect to the size of the defect, can be estimated only
abdominal vessels. approximately, both clinically and sonographically, achiev-
ing a total accuracy rate of correct diagnosis of only 0.62
and 0.53, respectively. Exact classification of the hernia is
Laparoscopic versus open repair therefore only possible intraoperatively.
Precise knowledge of anatomy is indispensable for
According to a meta-analysis of the EU Hernia Trialists a successful laparoscopic hernia operation, especially
Collaboration covering a total of 58 randomized studies, concerning the course of the epigastric vessels, the large
recurrence rates can be reduced by about 50 per cent by pelvic vessels, the corona mortis, and the inguinal nerves
implanting prosthetic materials, with no difference noted (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 Reddick–Olsen atraumatic forceps to push an
umbrella-like mesh through the 12-mm trocar. The han-
dles of the instruments mentioned above should not be
lockable; the dissection forceps (Kelly) is the only excep-
tion, 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 OPERATIVE ROOM SET-UP
important anatomical structures are visible.
The patient is supine and flat on the operating table. After
Preoperative testing setting up the pneumoperitoneum, the patient is placed
into the Trendelenburg position and turned at an angle of
In patients who are old (⬎60 years) or who have an about 15 degrees towards the surgeon, so that the surgeon
increased cardiopulmonary risk, an electrocardiogram can approach the inguinal region without being hindered
(ECG) and thoracic X-ray are essential. Additionally, if by intestinal loops. The patient’s arms are at his or her side,
necessary, blood and clotting tests should be run. Patients so that the operator can change sides easily in cases of a
should be asked whether they have taken aspirin and, if bilateral hernia. The surgeon stands on the side opposite
necessary, platelet function assay (PFA) values should be the hernia; the camera operator is positioned on the ipsilat-
determined. eral side of the hernia. The monitor is placed at the foot of
Some authors recommend evaluation of the colon for the patient. The assisting nurse with the instruments is
pathology to eliminate a symptomatic hernia, especially always to the left of the patient, between the surgeon and
in older patients. If the patient’s history is uneventful, the camera operator. The anesthetist looks after the patient
however, this is not considered a routine examination. as usual, from the head of the operating table, so that each
A preoperative urethral catheter is not necessary. It member of the team can follow the progress of the opera-
is usually sufficient to request that the patient empties tion on the monitor at any time (Figures 8.2–8.4).
their bladder before being transported to the operating
theater. Should a full bladder be found during laparo-
scopy, however, a suprapubic urinary catheter can be laid MCL MCL
via percutaneous puncture.
INSTRUMENTATION
The following instruments are needed for a laparoscopic

hernioplasty: Assistant
Surgeon (camera)
• Veress needle for creating a pneumoperitoneum;
10 mm
• 10-mm trocar at the navel for insertion of the optics; 5 mm
• 5-mm trocar in the left mid-abdomen for insertion 12 mm
of the Endo-grasper (Overholt); Scrub
• 12-mm trocar in the right mid-abdomen for the hernia nurse
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.
Monitor
All the trocars and operating instruments are reusable
instruments. It is important that the trocars do not Figure 8.2 Localization of ports for TAPP repair of left-sided
cut through the tissues; our preference is to use trocars inguinal hernia. MCL, medioclavicular line.
MCL MCL abdominal surgery, then we prefer the Veress needle tech-
nique. 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 monitor-
ing, as described by Semm.13 At the beginning of insuffla-
Assistant tion, the intra-abdominal pressure and the rate of gas flow
Surgeon
(camera) must be monitored carefully. Pressure must initially be
10 mm 0 mmHg and the gas flow must be 2–3 liters CO2/min. If
12 mm
the pressure is initially too high or the gas flow too low,
5 mm
then the position of the needle must be checked and/or an
Scrub open approach into the abdominal space should be chosen.
nurse If the patient has an umbilical hernia, we make a
2–3-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
Monitor
space through the hernial gap (fascial closure in these
patients follows at the end of the operation in the same
Figure 8.3 Localization of ports for TAPP repair of right-sided way as for umbilical hernias). If intra-abdominal pressure
inguinal hernia. MCL, medioclavicular line. 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
MCL MCL
is then inserted into the abdominal cavity in the direction
of the center of the navel with slightly rotating move-
ments, the most effective way to avoid slipping on the
fascia. By using this technique, the danger of inadvertent
Assistant changes Surgeon changes
injury to the small or large intestines or large vessels is kept
position for repair position for repair at a negligible minimum.
of contralateral side of contralateral side
If intra-abdominal adhesions are expected, especially
after prior median laparotomy, then the open technique
Assistant Surgeon according to Hasson should be chosen to insert the opti-
(camera) cal trocar. After the somewhat larger skin incision has
10 mm been made, the linea alba is dissected and opened up far
12 mm
5 mm enough between two Kocher clamps to allow insertion of
a finger. After opening the peritoneum, the finger is
Scrub inserted into the abdominal space to check for and/or
nurse
eliminate possible adhesions. The optical trocar can then
be inserted and the pneumoperitoneum created.
Now the further steps of the operation are under direct
Monitor view. In cases of a bilateral hernia, both the working tro-
cars, 5 mm left, 12 mm right, are introduced into the mid-
Figure 8.4 Localization of ports for TAPP repair of bilateral clavicular line at the level of the umbilicus. If the hernia is
inguinal hernias. MCL, medioclavicular line. unilateral, then we recommend inserting the ipsilateral
working trocar about 1–2 cm above the navel area and/or
the contralateral working trocar about 1–3 cm below the
navel region (Figures 8.2–8.4). In this way, collisions with
OPERATIVE TECHNIQUE
the optical trocar can be avoided. In order to dissect the
inguinal region, the surgeon uses the right hand to oper-
The operation begins with the creation of the pneumo- ate the Metzenbaum Endo-scissors, which are connected
peritoneum and insertion of the camera trocar. The to monopolar electrocautery. The left hand operates the
pneumoperitoneum can be installed with the help of the Endo-Overholt.
Veress needle or after open insertion of the optical trocar The transabdominal technique allows immediate assess-
(Hasson technique). If a patient has had no previous ment of the hernia situation. The operative procedure is
Figure 8.6 Partly blunt, partly sharp dissection in the mostly

Figure 8.5 Generous arcuate incision of the peritoneum about avascular, cobweb-like tissue layer between the peritoneum and
3–4 cm above the transverse arcade and the inner inguinal ring, the abdominal wall.
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 omen-
tum 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 abdomi-
nal 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 fin-
ger of the left hand on the outside, the tip of the scissors
on the inside. Regardless of the type and size of the her-
nial orifice, starting at this point a generous curving inci-
sion of the peritoneum is performed, well above the
internal inguinal ring and above the rear wall of the Figure 8.7 In very obese patients, early preparation of the
inguinal canal as far as the median umbilical ligament anatomical landmarks (e.g. epigastric blood vessels, symphysis)
(Figure 8.5). It is usually not necessary to divide this liga- is very important. Dissection then follows these landmarks
ment, even in the case of a prominent ligament, i.e. when strictly, which have to be prepared absolutely free of fatty tissue.
this structure projects far into the abdominal space or has
a large component of adipose tissue, nor if the hernial sac During this phase, early identification of some anatom-
is found to be located very medially. Division of this liga- ical structures (landmarks), including the epigastric ves-
ment can lead to unnecessary bleeding from umbilical sels, symphysis and Cooper ligament, and iliopubic tract,
vessels that remain patent. If the peritoneal incision needs is important, especially in obese patients or in unclear
to be extended, then this is carried out parallel to the hernia situations (Figure 8.7). Only when these structures
ligament in the cranial direction. The peritoneal and/or have been identified properly can dissection continue, fol-
subperitoneal small blood vessels are coagulated immedi- lowing the structures in the direction of the hernial orifice/
ately with monopolar current, so that the site is always hernial sac. Special attention must be paid to dissection
absolutely free of blood and has a yellowish-pink color. underneath the iliopubic tract, in order to avoid injury to
Dissection continues strictly in the mostly avascular, nerves (N. cutaneus femoris lateralis, N. genitofemoralis)
cobweb-like zone, whereby the procedure is mainly blunt, or vessels (Figure 8.8). Clumsy and obscure use of electro-
and the peritoneum with its surrounding pre-peritoneal coagulation and placement of clips are strictly prohibited.
fatty tissue can be pushed away from the fascia transver- Any bleeding that occurs must be controlled immedi-
salis and the rectus muscle (Figure 8.6). The few blood ately to keep the site clearly visible and to avoid increased
vessels that may be encountered are coagulated. light absorption, which would cause insufficient lighting
Figure 8.10 Dissection of the medial compartment has to be

carried beyond the middle of the symphysis so that a supra-
Figure 8.8 Avoiding rough dissection in the lateral caudal symphytic defect, especially in recurrent hernias, is not missed.
compartment, below the iliopubic tract and lateral to the
testicular blood vessels, endangering the inguinal nerves, which
may have a very variable course. 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
Figure 8.9 Dissection of a direct hernia in a case of bilateral conventional anterior approach should be selected
hernias, where the opposite mesh is already in place. In order from the start.
to avoid the formation of seroma, generous use of 2 In a lateral direction, the medial compartment
electrocoagulation in hemostasis is recommended. 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
of the operative field. Control of any bleeding can be
avoid injury not only to the iliac vessels but also
carried out with the aid of a dissection swab in the right
to the corona mortis, which is found in about
hand or with a small gauze that is inserted easily via the
20–30 per cent of patients (Figure 8.11).
12-mm trocar. The electrocoagulator is then connected
to the Endo-Overholt in the left hand, allowing accurate Dissection of the lateral compartment is significantly
coagulation. more difficult, especially in patients with a large amount
In most cases of direct herniation, the lipomatous her- of adipose tissues with a large indirect hernial sac and in
nial content will be dissected from the extended transver- patients with severe scar contractions between hernial sac
salis fascia and removed from the hernial orifice during and cremaster muscle. These problems are not uncom-
dissection of the Hesselbach triangle, i.e. the level between mon, especially in recurrent hernias after previous con-
epigastric vessels, the transversus arcade, and the liga- ventional operation. A basic consideration in an indirect
mentum inguinale/tractus iliopubicus (Figure 8.9). This hernia is that the hernia sac should be located cranially
dissection is almost completely blunt. Careful hemostasis and laterally to the spermatic cord, whereas the vas defer-
is important to ensure that the part of the fascia transver- ens should be most caudal, stretching over the iliac ves-
salis that forms the hernial sac is totally free of even the sels 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 8.13 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 possi-
ble 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 iliop-
Figure 8.12 Tip of the hernia sac clearly visible in front of the
ubic tract and epigastric vessels. It can sometimes be
left Endo-Overholt. Strong adhesions to the cremasteric bundle
helpful to create a dorsocaudal window between hernial
(in front of the right Endo-Overholt) can be removed after
sac and spermatic cord, especially in the case of a scrotal
careful electrocoagulation.
hernia. If complete removal of a hernial sac may seem
too difficult regarding risk of injury to the spermatic
be followed in a lateral direction. Detachment of the her- cord, then the hernial sac can be severed. If the hernial
nial sac from the internal inguinal ring in the region of its sac stays in situ, however, the risk of postoperative hydro-
upper circumference can therefore be carried out rela- cele may be higher.
tively quickly, as there is usually no danger of injury to Our experience in more than 450 scrotal hernias
the spermatic cord (Figure 8.12). If an accompanying shows that the hernial sac can almost always be removed
lipoma of the spermatic cord is present, this can usually completely without risk of injury to the testicular vessels
be mobilized out of the inguinal canal relatively easily; or extensive postoperative hematoma, as long as the fol-
sometimes, only then is it possible to make an approach lowing principles are observed:14 early identification of
to the hernial sac. the testicular vessels laterally and caudally of the hernial
Dissection is mainly blunt, adhering strictly to the sac, dissecting from caudal-lateral to ventral-medial, care-
hernial sac with careful hemostasis. If there are irremov- ful hemostasis, strict dissection while the hernial sac is
able adhesions between the hernial sac and the cremaster held under tension, and severing stronger adhesions with
tube or spermatic cords, then these are electrodissected the aid of electrocoagulation. Once the point of the top of
Figure 8.14 Partly blunt, partly sharp removal of the hernia sac Figure 8.15 End of dissection: the peritoneal sac is removed
towards the abdomen while performing meticulous hemostasis beyond the middle of the psoas muscle. All anatomic structures
of the spermatic structures (parietalization). are recognizable and freed of fatty tissue.
the hernial sac has been reached, the rest of the procedure
is simple (Figure 8.14). Partly blunt, partly sharp (electro-
coagulation) 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 retroperi-
toneum and the spermatic cord) is performed in the direc-
tion 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 posi-
tion 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 peri-
toneum is closed, any adhesions that may be left behind Figure 8.16 A 10 ⫻15-cm polypropylene mesh is placed
do not displace the mesh into a position that could lead to without folds. All potential hernia openings are overlapped by
a recurrence. If extensive parietalization is not possible, at least 3 cm.
which does happen very rarely (sometimes in a patient
with a recurrence after TAPP), then a slitted mesh can be out wrinkles, overlapping all possible hernial orifices
introduced, causing the dorsal portion of the mesh to take by at least 3 cm (Figure 8.16). Using such a large mesh
up a position behind the spermatic cords. means that fixation is necessary only to facilitate posi-
After this dissection, the entire myopectineal orifice is tioning (e.g. in very shallow curved inguinal areas or to
free of peritoneum and fatty tissue, thereby allowing com- avoid mesh dislocation in the immediate perioperative
plete identification of the epigastric vessels, the internal phase). Fixation is carried out with a few clips or staples.
inguinal ring, Hesselbach’s triangle, Cooper’s ligament, We recommend using two clips in both the areas of the
the iliopubic tracts, the testicular vessel bundle, and the symphysis and/or Cooper’s ligament, two clips to fix the
vas deferens (Figure 8.15). A 10 ⫻ 15-cm polypropylene upper border of the mesh to the rectus muscle medial to
mesh can now be inserted. The mesh is folded like an the epigastric vessels, and two clips lateral to the epi-
umbrella over the Reddick–Olson Endo-forceps and gastric vessels into the fascia transversalis (Figure 8.17).
pushed through the 12-mm working trocar into the Before the clips are fixed at the ligament of Cooper, a
inguinal region, where, due to the memory effect, it can possible corona mortis and/or the iliac vessels should be
be spread out easily. The mesh should be positioned with- identified. After the iliopubic tract is identified, the lateral
Clip position in
TAPP technique
Figure 8.17 Presentation of clip
⫽ Clip position positions and the endangered
regions: triangle of pain and triangle
⫽ Forbidden area of doom. (a) Medial defect;
(b) lateral defect; (c) femoral defect.
clips are placed, keeping a minimum cranial distance

of about 2–3 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 peri- Figure 8.18 The peritoneal fold should be 1–2 cm proximal to
toneal fold should be at least 1–2 cm above the upper end the caudal edge of the mesh.
of the mesh (Figure 8.18). Finally, the peritoneal inci-
sion is closed carefully with resorbable sutures (PDS,
Lahodny). To facilitate tension-free closure, the intra- Suturing of the lateral fascial openings is not neces-
abdominal pressure should be reduced to 6–8 mmHg. sary when blunt, radially expanding trocars are used,
When using this technique, a tight and secure seal is pos- because the rectus muscle covers these openings. The
sible even with scarred peritoneum, a task that is occa- fascial opening for the camera trocar should always
sionally difficult when clips are used. The suture closure be closed with suture to avoid the occurrence of a late
is technically more difficult, however, and needs practice. postoperative trocar hernia.
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, bleed-
SPECIAL REMARKS
ing from the epigastric vessels does occur on occasion
and must be recognized and controlled. In such cases, A drain is generally not necessary, but in the case of large
hemostasis is simple to carry out with electrocoagulation scrotal hernias, a retroperitoneal closed suction drain
and can be performed with an Endo-Overholt intro- ought to be used, placed between the mesh and the
duced via the contralateral trocar. abdominal wall.
Bilateral hernia vessels, so that the former is displaced medially and the
latter are displaced in a very lateral direction. Very rarely,
The identical standard technique is used separately the testicular vessels may be looped around the sper-
for each side, with implantation of a 10 ⫻ 15-cm poly- matic cord in a medial and ventral direction. Whereas
propylene mesh on each side.15 these problems occur mostly in indirect recurrent her-
nias, operation of a direct recurrent hernia is much eas-
ier because, as a rule, there are no structures nearby that
Recurrent hernia after conventional may be injured. It must be taken into account, however,
operation that the tranversalis fascia should not be perforated dur-
ing dissection, as one would then enter into the inguinal
An essential advantage of the laparoscopic technique in canal and possibly damage the testicular vessels.
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 Recurrent hernia after pre-peritoneal
almost standard primary hernia technique. The results patch hernioplasty
(operating time, morbidity, return-to-work times, recur-
rence rate) are consequently not significantly different to Laparoscopic operation of a recurrent hernia after
those of a primary hernia operation (Table 8.1). The only pre-peritoneal hernioplasty is technically possible, but
exception is the situation after previous hernioplasty operation time will be significantly longer, and there will
according to Lotheisen. In this case, significant scarring be a risk of higher morbidity.16 However, the time needed
can be expected at Cooper’s ligament, and it is difficult to to regain physical activity is the same as for the standard
operate laparoscopically in this area. This situation can be technique in primary hernias.
overcome by choosing a peritoneal incision caudal to Operation of a recurrent hernia after pre-peritoneal
the Cooper ligament. After the usual dissection of the hernioplasty is extremely difficult and should be carried
peritoneum, which has been described above, in an area out only by very experienced laparoscopic hernia sur-
somewhat medial to the Cooper ligament a whetstone-like geons. As a rule, extensive scarring can be found between
incision is made around the ligament itself at the peritoneal the abdominal layer and mesh, and/or mesh and peri-
level. This method allows renewed access to the scar-free toneum, and can only be dissected sharply. Dissection
pre-peritoneal space caudally, where further dissection can begins in the scar-free areas, with early identification of
now take place undisturbed. Although this leaves a small, the landmarks (epigastric vessels, symphysis, Cooper’s
scarred peritoneal section on the Cooper’s ligament, the ligament). Medial dissection should adhere strictly to the
polypropylene mesh can nevertheless be anchored safely. rectus muscle and/or the fascia transversalis in order to
In the area of the internal inguinal ring, it is not avoid damage to the bladder. In 80 per cent of cases, we
uncommon to find scar formation 1–2 mm thick sur- found a dissection layer between abdominal wall and
rounding both the hernia sac and the spermatic cord. mesh, and in about 20 per cent of cases between peri-
Once this cuff-like scarred ring of tissue is cut with elec- toneum and mesh. As noted earlier, reoperation upon a
trocautery in the neighborhood of the epigastric vessels direct hernia is significantly easier than on an indirect her-
(which may involve the cremasteric muscle), standard nia. Operation of an indirect hernia is extremely compli-
dissection can continue. cated, but once the scar areas have been overcome and
It must be taken into consideration that the previous direct access gained to the hernial sac, the rest of the oper-
operation may have resulted in an atypical localization of ation is not too different to that of a primary hernia. The
the spermatic cord. The recurrent hernia can occasion- mesh is usually left in place; parietalization, however, is
ally develop between the vas deferens and the testicular possible in only the rarest of cases. As a rule, a slitted mesh
Table 8.1 Operative results in 8050 consecutive laparoscopic hernia repairs
Median Median
operation Morbidity Reoperation Recurrence return to
time (min) rate (%) rate (%) rate (%) work (days)
Unilateral primary hernia (n ⫽ 4222) 47 3.0 0.4 0.8 14
Bilateral primary hernia repair (n ⫽ 1341)* 35 2.2 0.5 0.6 15
Recurrent hernia (n ⫽ 1146) 45 4.5 1.0 1.1 21
Scrotal hernia (n ⫽ 440) 65 4.8 1.1 2.7 19
*Results related to 2682 repaired hernias.

will have to be inserted. In such cases, we do, however, simple. Sometimes external pressure may be required. The
secure the slit with a second, smaller mesh using the hernial content can now be reliably assessed for viability.
so-called double-buttress technique. In case of a direct The further procedure again correlates to the standard
hernia and stable conditions in the area of the lateral technique. If the intestine shows signs of gangrene, then
compartment, lateral dissection is not necessary. It suf- a primary mesh implant is not recommended due to the
fices to implant a piece of mesh that is appropriately sized risk of infection. Thorough rinsing of the inguinal region
so that it overlaps the hernial defect by at least 3 cm and and the insertion of a drain is recommended. Defect
can be anchored to the original mesh, which is located reconstruction, however, should not be performed; an
laterally. option here is open repair with sutures.
Scrotal hernia
POSTOPERATIVE MANAGEMENT
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 On the evening after the operation, the patient is allowed
the hernial sac, so that trauma to the wall of the bowel to get up and use the toilet. The patient may drink freely
(e.g. by electrocoagulation on the hernia sac) can be and may have a light meal if desired. A diclofenac 100 mg
avoided completely. The operation is performed strictly suppository is provided as needed. A one-night stay in
according to the standard technique, as mentioned above, the hospital is obligatory for insurance reasons in
almost exclusively using the two Endo-Overholt tech- Germany, where the authors of this chapter work. On the
nique and the rope-ladder principle. Especially important following morning, we recommend that the patient
in this kind of hernia is the fat-free dissection of the moves around freely and begins light stretching exercises
internal inguinal ring, the detachment of all lipomatous for the inguinal region. The patient should decide when
masses from the inguinal canal, the spermatic cord and to be discharged. As a rule, patients leave the hospital
the hernial sac, early preparation of testicular vessels, and between the second and fourth postoperative day. Before
carefully controlled hemostasis.14 In the case of a very discharge, sonography of both inguinal regions and
large internal inguinal ring, a 10 ⫻ 15-cm standard mesh scrotum is performed routinely. Sutures are removed (as
may be too small because it is not possible to overlap the an outpatient) on the sixth postoperative day. From the
upper border of the hernial ring by the required mini- eighth to the tenth postoperative day, we recommend
mum 3 cm. Therefore, in these patients we prefer to use a return to work and resumption of normal physical activ-
15 ⫻ 15-cm mesh. ity. 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.
Irreducible/incarcerated inguinal hernia
Irreducible and especially acute incarcerated hernias

present a good indication for the laparoscopic tech- CONCLUSION
nique.17 An exception, however, is the very large, chroni-
cally irreducible scrotal hernia, as the relationship Laparoscopic hernia repair is a well-standardized repair
between operative effort and result are out of propor- technique, suitable for all types of inguinal and femoral
tion. Although an open approach is also difficult in such hernias. The procedure combines highest patient comfort
patients, the few cases that do come into question should with low morbidity and recurrence rates. However, fun-
opt for this technique. In contrast, the laparoscopic tech- damental training in laparoscopic surgery is an important
nique offers advantages in acute incarcerated hernias. It prerequisite for good results. When laparoscopic proce-
may be possible to avoid resection of the intestine, as dures are established in a surgical department, this tech-
there is more time available to observe how the damaged nique can be performed on a routine basis, even as a
intestinal wall recovers. If a resection does prove neces- teaching operation.
sary, 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 REFERENCES
aim of completely exposing the hernial ring in the pre-
peritoneal space. Reduction of the hernial contents via 1 Rives J, Nicaise H, Lardennois B. A propos du traitment chirurgical
traction should be avoided. If the exposed hernial ring des hernies de l’aine. Orientation nouvelle et perspectives
is split in a ventral-cranial direction, then reduction is thérapeutiques. Ann Med Reims 1965; 2: 193–200.
2 Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron in 11 Heikkinen TJ, Haukipuro K, Hulkko A. A cost and outcome
repairs of hernias of the groin. Surg Clin N Am 1984; 64: 269–85. comparison between laparoscopic and Lichtenstein hernia
3 Ugahary F, Simmermacher RKJ. Groin hernia repair via a gridiron operations in day-case unit. A randomized prospective study. Surg
incision: an alternative technique for preperitoneal mesh insertion. Endosc 1998; 12: 1199–203.
Hernia 1998; 2: 123–5. 12 Bittner R, Kraft B, Kuckuk B, et al. Ultrasound examination in
4 Arregui MD, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair laparoscopic/endoscopic hernia surgery. In: Fitzgibbons RJ, Jr,
of inguinal hernia using a preperitoneal approach: a preliminary Greenburg AG, eds. Nyhus and Condon’s Hernia, 5th edn.
report. Surg Laparosc Endosc 1992; 2: 53–8. Philadelphia: Lippincott Williams & Wilkins, 2002: 95–102.
5 Bittner R, Leibl BJ, Kraft K, et al. Laparoscopic transperitoneal 13 Semm K. Operative Manual for Endoscopic Abdominal Surgery –
procedure for routine repair of groin hernia. Br J Surg 2002; 89: Operative Pelviscopy – Operative Laparoscopy. Chicago: Year Book
1062–6. Medical Publishers, 1985.
6 Felix EL, Michas C, McKnight RL. Laparoscopic repair of recurrent 14 Leibl BJ, Bittner R, Schmedt CG. Scrotal hernias: a contraindication
groin hernia. Surg Laparosc Endosc 1994; 4: 200–4. for an endoscopic procedure? Surg Endosc 2000; 14: 289–92.
7 Nyhus LM. Individualization of hernia repair: a new era. Surgery 15 Schmedt CG, Däubler P, Leibl BJ, et al. Simultaneous bilateral
1993; 114: 1–2. laparoscopic inguinal hernia repair: an analysis of 1336
8 Schumpelick V, Treutner KH, Arlt G. Inguinal hernia repair in consecutive cases at a single center. Surg Endosc 2002; 16: 240–4.
adults. Lancet 1994; 344: 375–9. 16 Leibl BJ, Schmedt CG, Kraft K, et al. Recurrence after endoscopic
9 Ingoldby CJH. Laparoscopic and conventional repair of groin transperitoneal hernia repair (TAPP): causes, reparative techniques
disruption in sportsmen. Br J Surg 1997; 84: 213–15. and results of the reoperation. J Am Coll Surg 2000; 190: 651–5.
10 EU Hernia Trialists Collaboration. Repair of groin hernia with 17 Leibl BJ, Schmedt CG, Kraft K, Bittner R. Laparoscopic
synthetic mesh – meta-analysis of randomized controlled trials. transperitoneal hernia repair of incarcerated hernias: is it feasible?
Ann Surg 2002; 235: 322–32. Surg Endosc 2001; 15: 1179–83.
9
Totally extraperitoneal approach
ED FELIX
Principles 65 Postoperative management 73

Preoperative management 66 References 74
The surgical approach to inguinal hernia repair has method, and the potential complications and their
undergone a slow evolution since Bassini introduced the management will be described.
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
PRINCIPLES
demonstrated that tension-free reinforcement of the
abdominal wall with mesh eliminates one of the major
causes of recurrence, the intrinsic or acquired weakness A surgeon must be experienced in conventional anterior
of the groin; the emphasis of hernia repair then switched approaches as well as both laparoscopic approaches
dramatically. Ten years later, laparoscopic surgeons took (TAPP and TEP) in order to make a rational decision on
the tension-free repair one step further by introducing a which hernioplasty best fits an individual patient and her-
repair that reinforced the groin, avoided missed hernias, nia. The laparoscopic approach that is chosen depends
and reduced postoperative recovery. upon the surgeon’s level of experience, the type of hernia
Many early attempts at a laparoscopic approach, how- present, and the patient’s past history. For most patients, I
ever, fell quite short of this lofty target. There seemed to be favor the TEP approach because it avoids entering the
a wide variability in the results reported by surgeons. peritoneal cavity, it requires less operative time, and it has
Many complications as well as early failures were reported. less potential for complications than the TAPP approach.
It quickly became apparent, however, that success with this There are, however, a few exceptions. The TAPP approach
approach was dependent upon the level of laparoscopic is preferred if the patient has an incarcerated hernia,
expertise of the surgeon and the ability of the surgeon to because this approach allows for an accurate analysis of
apply proper techniques to appropriate patients.4 what is incarcerated and its viability, as well as safe and
At first, the majority of surgeons were limited to a single usually easy reduction of the contents of the hernia.
laparoscopic approach, the transabdominal pre-peritoneal When the hernia is incarcerated, balloon dissection of the
(TAPP) approach, but soon the totally extraperitoneal extraperitoneal space may lead to a large tear in the
(TEP) approach became a viable alternative. Arguments peritoneum or injury to incarcerated omentum, bowel or
between laparoscopic surgeons on which approach was bladder. The extraperitoneal approach and especially the
better were common, but now most surgeons realize that use of a balloon dissector should be avoided if the hernia
each approach works well when applied appropriately in cannot be reduced after the induction of anesthesia.
the hands of an experienced laparoscopic surgeon.5 In female patients with abdominal pain, the etiology
The purpose of this chapter is to describe an approach of the pain may be in question. When a surgeon needs to
to the laparoscopic TEP repair of inguinal hernias that has differentiate between pain secondary to a groin hernia
resulted in a recurrence rate of less than one per cent in and other possible causes, such as endometriosis, one
over 2000 repairs in our center. The indications and should perform a diagnostic laparoscopy followed by a
contraindications to the use of the approach, the operative TAPP repair when indicated. For female patients where
the diagnosis is certain, a TEP technique is preferred. The elected in children. At the other extreme are patients over
presence of a Pfannenstiel incision is common in many 70 years of age. Some have suggested that laparoscopic
female patients because of a previous cesarean section or repair should be limited to working younger adults. It is
pelvic surgery, but this should not interfere with the TEP our experience, however, that patients of all ages benefit
dissection because a Pfannenstiel incision is really a mid- from the laparoscopic approach, especially regarding the
line fascial incision. rapid recovery and return to normal activity.
Some previous operations, abdominal incisions, or We recommend that patients who are not candidates
treatments may preclude adequate or safe dissection of for general anesthesia should have an open hernioplasty
the extraperitoneal space. Previous pelvic irradiation or under a local anesthetic. Although several centers have
radical prostatectomy can prevent separation of the peri- reported success using local and regional anesthesia for
toneum from the abdominal wall. Balloon dissection of extraperitoneal repairs,7 it has been our experience that
the extraperitoneal space may result in injury to the blad- some patients will become anxious if carbon dioxide
der or a large rent in the peritoneum. A lower-abdominal enters the peritoneal cavity, necessitating conversion to a
incision crossing the rectus sheath can obstruct the safe general anesthetic. We would reserve laparoscopic repair
passage of the dissector. If the dissector is forced through for patients who are candidates for general anesthesia,
the obstruction, the peritoneum will tear and an intra- even if the case is to be performed using a local or regional
abdominal visceral injury may result. A transverse incision technique. An absolute contraindication to laparoscopic
is not a contraindication to the use of the extraperitoneal hernioplasty is the presence of infection. Neither the
approach, but if resistance is experienced when passing the TAPP nor the TEP approach should be used in the face of
dissector, then the procedure should be converted to a local or systemic infection because of the risk of infecting
TAPP approach. A midline incision is usually not a prob- the mesh.
lem 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 manu-
PREOPERATIVE MANAGEMENT
ally after the trocars are placed. If bilateral repairs are
planned, however, then there is a small chance that a Anatomy and pathology
previous midline incision will prevent dissection of the
opposite side. In this case, the surgeon may initiate the Understanding the anatomy of the groin has never been
procedure as a TEP approach and convert to the TAPP easy, but it has always been important to the performance
approach when, or if, this becomes necessary. of a successful inguinal hernia repair. Because the post-
The laparoscopic approach is ideally suited for recur- erior anatomy of the groin is being viewed in an unfamil-
rent hernias. The surgeon’s view of the posterior wall is iar way, it can be even more difficult to understand it.
unobstructed and allows for complete identification of Consequently, without a complete knowledge of the
the site of recurrence and repair of the entire posterior normal and pathological anatomical structures of the
floor. The decision of whether a TAPP or TEP approach posterior groin, any laparoscopic posterior repair will
should be employed is dependent upon the expertise of be doomed to failure. (See Chapter 6 for an overview of the
the surgeon. The dissection of the recurrent indirect sac anatomy/physiology of the inguinal region.) The easiest
can be difficult using the extraperitoneal technique and way to learn the normal anatomy of the posterior wall is to
requires more skill than that of a primary repair. With first view it through a transabdominal route (Figure 9.1).
experience, however, this difference in degree of diffi- Once the surgeon understands the normal and pathologi-
culty disappears, and the surgeon should base the hernio- cal aspects of the posterior anatomy via a TAPP approach,
plasty choice on other factors. then dissection of the extraperitoneal space and exposing
The extraperitoneal dissection of large scrotal hernias the anatomy of the posterior space via a TEP approach can
is similar to that of recurrent hernias, in that the separa- be undertaken. Because the anatomical structures are not
tion of the indirect sac can be quite difficult.6 To avoid obvious until the dissection is completed, it is key that the
problems, the surgeon should use the TAPP approach surgeon understands what is being dissected in order to
until he or she has adequate mastery of some of the spe- prevent becoming lost or confused. Serious complications
cial maneuvers required to deal with a long scrotal sac. to major vessels and nerves can occur, especially when
The age of the patient may influence the type of there is a large indirect or femoral hernia.
hernioplasty chosen. In general, laparoscopic hernio- To proceed without injuring normal structures,
plasty should be reserved for adults. In a few cases, the the surgeon must identify certain landmarks. Once the
patient that is a minor by chronological age may be fully extraperitoneal space is developed, identification of the
mature and have an adult-type hernia or even a recurrent pubis will allow proper orientation of the other struc-
hernia. Only then should the laparoscopic approach be tures. 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.
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
Figure 9.2 Extraperitoneal view of the groin. C, cord; DIR, direct tract (Figure 9.4). The identification of this is essential to
hernia; IL, iliac vessels; IND, indirect hernia; INF, inferior avoid injury to several cutaneous nerves and dissection
epigastric vessels. of any cord lipoma that may be present.
Figure 9.5 Balloon dissector and Hasson trocar.

Figure 9.4 Recognizing the iliopubic tract. CL, Cooper’s
ligament; DIR, direct hernia; INF, inferior epigastric vessels; to ligate an indirect sac or a peritoneal tear are suggested.
IPT, iliopubic tract. Rarely, a suction irrigator will be needed to clear blood
from the extraperitoneal space and decrease groin and
Preoperative testing perineal ecchymosis postoperatively.
A full laparotomy set-up is not required, but a Mayo or
Inguinal hernia repair does not require extensive pre- 6–8 inch curved clamp is needed to dissect the fat and
operative testing, but it does require determination of muscle at the umbilicus. A number 11 scalpel blade is used
whether the patient is a candidate for general anesthesia. to incise the fascia, and two ‘S’ retractors facilitate the dis-
If general anesthesia is thought to be safe, then the sur- section and retraction of the fascia and muscle. Two 5-mm
geon’s next step is to make sure that there are no other trocars are used for the placement of the instruments that
contraindications to laparoscopic hernia repair. If there are used in the dissection of the pre-peritoneal space.
are none, then the most appropriate laparoscopic Polypropylene mesh is the mainstay of the laparo-
approach can be selected, as outlined earlier. Before scopic repair. Usually, a 15 ⫻ 15-cm mesh is used and
proceeding to the operating room, however, a complete trimmed to fit the posterior wall. The mesh is anchored to
examination of both groins by the operating surgeon is the abdominal wall with 5-mm tacks supplied in a multi-
essential. If the surgeon actively looks for a possible fire gun. Recently, however, we have used a preformed
hernia on the contralateral side, then we have shown in a mesh that does not require fixation of any kind. The recur-
prospective study that very few contralateral hernias will rence rate remains the same, but the risk of nerve injury is
be missed.8 It is not necessary to expose the opposite side lowered. In a small number of cases in which we feel fixa-
to look for a second hernia during a TEP repair if the sur- tion is required, such as multi-recurrent hernias or where
geon has performed a proper preoperative examination. the mesh will not lay flat against the wall, we use a regular
In addition, the surgeon should determine whether the mesh and cut it to fit the space.
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 Operative room set-up
sac. The TAPP approach also allows the surgeon’s ability
to evaluate the viability of the incarcerated contents. The room set-up is simple, requiring one surgeon, a
nurse and a video monitor. The patient is positioned
Instrumentation with both arms tucked at his or her side and with a slight
head-down position. The surgeon stands on the side of
TEP hernioplasty does not require many specialized the patient opposite the hernia and the scrub nurse/assis-
instruments. A balloon dissector and balloon Hasson tant stands on the opposite side. The monitor is placed
trocar (Figure 9.5) make the extraperitoneal dissection at the foot of the operative table and the Mayo stand is
easier and simpler for most surgeons, but they are not over the legs. The insufflator should also be in plain view
mandatory. We use a straight 10-mm endoscope, but of the surgeon. A single light is positioned directly over
some surgeons prefer an angled scope. Unipolar scissors the periumbilical incision to help with the initial expo-
for dissection and a bipolar coagulator to control bleed- sure of the fascial layers.
ing are useful. At least two atraumatic graspers are Very few instruments are required for extraperitoneal
needed to perform the dissection, and endoloop sutures dissection and hernia repair. They should be set up on the
Mayo stand so that either the surgeon or the nurse can the procedure should be converted to a TAPP approach.
reach them readily. If a preformed mesh is used, then both When the pubis is palpated with the dissector, the balloon
left- and right-sided meshes must be kept in the room. is inflated. The operator views the progress of the dissec-
tion directly via the laparoscope in the dissector. After com-
pleting the balloon dissection, the balloon is removed and
Operative technique replaced with a specialized Hasson trocar that seals the
extraperitoneal space. The dissected space is then insuf-
We begin the procedure with a small transverse skin inci- flated with carbon dioxide up to 12 mmHg. We use lower
sion 2.5 cm lateral to and just below the umbilicus on the pressures (8–10 mmHg) if the patient is thin or elderly.
side of the hernia (or the dominant hernia if bilateral The anterior and posterior rectus sheaths create a tunnel
hernias are present). By avoiding the midline of the that opens into the dissected extraperitoneal space. When
fascia, we avoid entering the peritoneal cavity where the the tunnel is short, it does not interfere with exposure or
anterior and posterior rectus sheaths merge. We choose placement of the other midline trocars; if it is very long,
the side of the dominant hernia because we use a balloon the available space will be limited and the exposure will be
dissector that will dissect more completely on the side poor. In this case, the sheath should be cut back with
that it is placed. This makes the rest of the dissection sim- laparoscopic scissors. This maneuver will open up the
pler. We identify the anterior rectus sheath by carefully exposure, greatly facilitating the rest of the repair.
spreading the subcutaneous fat with a Mayo clamp. The Three trocars are placed in the midline: a 10-mm
small vessels in the fat should not be torn at this point, Hasson just below the umbilicus for the camera, a 5-mm
because bleeding in the tiny hole will make identification trocar just above the pubis, and a second 5-mm trocar
of the anterior rectus sheath difficult. Two ‘S’ retractors between these two trocars in the midline. The second
are placed in the wound and used to expose the white trocar is positioned as close as possible to the subumbili-
fibers of the fascia. An 11 blade is used to incise the fascia cal camera trocar in order to leave space between the
exposing the rectus muscle. One of the ‘S’ retractors is lowest trocar and the pubis. The inferior trocar is posi-
placed under the muscle like a shoehorn; the muscle is tioned approximately three fingers below the middle
elevated, thereby allowing visualization of the posterior trocar to prevent ‘sword fighting’ of the instruments and
sheath. A finger is used to dilate the space in preparation still allowing the lowest trocar to be above the level of the
for the placement of a balloon dissector. mesh. The surgeon must watch the entry of each trocar
Because the posterior rectus sheath usually ends at the into the extraperitoneal space in order to prevent the lac-
line of Douglas, an instrument such as the balloon dissec- eration of a small branch of the inferior epigastric vessels
tor can be passed on top of the sheath, allowing it to auto- or penetration into the peritoneal cavity. We anchor each
matically fall into the extraperitoneal space. The dissector is trocar to the skin with a specialized adhesive strip to
placed behind the rectus muscle with its tip on the poste- prevent them from slipping in and out of the abdominal
rior rectus sheath. Aiming it slightly upward, we gently slide wall during instrument manipulation.
on top of the sheath toward the pubis until the pubic bone The exposure of Cooper’s ligament begins with the
is palpated. If resistance is encountered, then the dissector dissection of the posterior aspect of the abdominal wall
must not be forced into the space because it will tear the by the gentle sweeping off of any tissue remaining on the
peritoneum. A second attempt to pass the instrument can pubis. If a direct hernia is present (Figure 9.6), it is com-
be tried after dilating the space with a finger, but if that fails pletely reduced at this point. This can be accomplished
(a) (b)
Figure 9.6 Reducing the direct hernia. INF, inferior epigastric vessels.
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 peri-
toneum must also be dissected off the vas deferens, as orig-
inally 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 recur-
rence. A short or small sac is easily delivered out of the
Figure 9.7 Lipoma of the cord. internal ring, but it may be difficult and traumatic to com-
pletely dissect off the cord a very long sac that descends
with gentle traction on the peritoneal attachments to the into the scrotum. In the latter case, the sac should be
defect. The peritoneum usually peels away from the trans- transected. The superior lateral edge of the peritoneum is
versalis fascia, allowing it to balloon into the direct defect. incised first because the testicular vessels and the vas def-
When the direct hernia is not reduced by these maneu- erens may be quite adherent to the undersurface of the sac.
vers, we incise the fascial defect on the superior aspect to The vas deferens will be on the medial side and the testic-
release the incarcerated hernia contents. The direct sac ular vessels on the lateral side. To avoid injury to these cord
should not be ligated because the bladder may make up structures, they must be identified before the inferior peri-
the medial aspect of the sac. In this situation, ligation of toneal surface is cut. A mass ligation of the sac should be
this sac could result in an injury to the bladder. avoided because the spermatic cord could be inadvertently
After dissection of the direct floor, the femoral area incorporated into the ligated tissue.
must be examined. The iliac vein will be visible just lateral After the proximal sac is completely separated from
to Cooper’s ligament. If it is not visible, then an incarcer- the distal sac, it is dissected off the cord structures and
ated femoral hernia is probably covering the vein. The ligated with an endoloop. If the intraperitoneal carbon
surgeon must reduce the hernia carefully so that the small dioxide causes the peritoneum to balloon outward into
vessels in the femoral canal are not avulsed. If the hernia the operative field, the surgeon can usually dissect the
is stuck in the canal, then an incision in the medial and peritoneum further cephalad in order to hold it out of
superior edge of the femoral ring will release the hernia. the field of vision. Before ligating the indirect sac, it is
The dissection of the lateral floor is initiated with probably better to wait until the mesh is in place because
identification of the inferior epigastric vessels. The fat this will allow the peritoneal pressure to be in equilib-
and loose connective tissues are dissected off the poste- rium with the extraperitoneal space and exposure will
rior abdominal wall just lateral to these vessels until the not be compromised. At the end of the procedure, the
peritoneum is identified. If there is a lipoma of the cord, indirect sac and any other tears in the peritoneum are
then it will be lateral to the peritoneal sac and cord closed to prevent the development of internal hernias or
(Figure 9.7). It is pulled out of the internal ring and left adhesions to the mesh. If carbon dioxide is trapped in the
in the retroperitoneum, out of the operative field. peritoneal cavity, it is vented with a Veress needle to pre-
Sometimes, only a slip of fat will be covering the ilio- vent postoperative shoulder discomfort at this point.
pubic tract, but it may lead to a very large lipoma in the At the onset of a TEP repair, one cannot tell whether
scrotum. The fibers of the iliopubic tract must be identi- there is an indirect component to the hernia until the
fied to prevent leaving behind a lipoma. Cautery should lateral dissection is completed. This is in contrast to the
be avoided in this part of the dissection because the TAPP approach, in which an indirect hernia is almost
lateral femoral cutaneous nerve and femoral branch of always obvious on the initial inspection of the pelvic
the genitofemoral nerve are directly under the lipoma. floor. Because of this, it is mandatory that the entire
Dissection of the cord and possible indirect hernia is posterior floor be dissected in every TEP repair, even if a
now started. If there is no indirect hernia, then the peri- direct or femoral hernia is not immediately apparent.
toneal edge will be set back from the internal ring. The This is critically important because up to 30 per cent of
edge of the peritoneum is lifted off the testicular vessels patients will have an indirect hernia in addition to the
with atraumatic graspers and dissected cephalad as far 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 poten-
tial 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
Cooper’s 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 extraperi-
toneal space by removing the laparoscope, grasping the Figure 9.9 Mesh placement.
mesh on one end with a 5-mm instrument, and dragging
it into the extraperitoneal space via the 10-mm port. We mesh is large enough to cover all three potential hernia
do not find it necessary to roll up the mesh tightly before sites in every patient. The total size of the mesh must be
placing it, as some have described. The laparoscope is tailored to the size of the patient’s pelvis. When the mesh
replaced and the mesh pushed gently through the 10-mm is smoothed out, it overlaps the pubic bone and crosses
port the rest of the way into the pelvis with the scope. the midline (Figure 9.9). Folds or wrinkles in the mesh
Once the mesh is fully in the extraperitoneal compart- should be avoided because they lead to increased scar or
ment, it is rotated using two graspers until the tagged adhesion formation and can be the cause of chronic pain
corner is in place below Cooper’s ligament or pubis. The 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 (a)
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 uti-
lized.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 Cooper’s 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 (b)
repair of the direct and femoral areas.
Figure 9.10 TAPP double-buttress mesh approach.
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 genito-
femoral, 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 Figure 9.11 Mesh anchored with tacks.
press so hard as to force the staples (or other fixation
device) deep into the muscle layers because this can that any wrinkles or folds are removed. If aberrant obtu-
result in an injury to a more superficial nerve, such as the rator vessels are present coursing over the pubis, they
ilio-inguinal. must be avoided otherwise serious bleeding can result.
The first tacks or staples are placed through the mesh Other anchors are placed into the mesh and transversalis
into Cooper’s ligament to stabilize the mesh, which allows fascia medial to the inferior epigastric vessels, whereupon
the surgeon to fan out the mesh in a lateral direction so 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 Postoperative management for patients undergoing
described above, so that damage to the neural structures laparoscopic inguinal hernioplasty is fairly standardized.
below the iliopubic tract is prevented. The purpose of the The surgery is usually performed under general anesthe-
fixation is not to strengthen the repair but rather to keep sia and patients are observed for approximately two to
the mesh in place until natural in-growth occurs. The three hours before discharge. They are allowed to resume
number of fixation points has therefore decreased as our normal activities as soon as they feel that they are
understanding of this repair has grown. capable. No restrictions are placed upon the patients. We
More recently we have begun using a preformed mesh allow patients to return to work and physical activity as
that does not require fixation (Figure 9.12) (see Chapter 3). soon as their pain tolerance allows them to do so. On
The results over the last two years equaled our earlier average, patients are back to 80 per cent of full activity in
results with anchors. In the newer technique, the mesh, less than a week and are able to perform fairly physical
which has a molded contour, fits into the pelvis and is activity, such as riding a bicycle, by the second week.
not fixed with anchors. Care must be taken to use a mesh Some patients develop a seroma at the site of the hernia.
that is large enough to be held in place once the carbon This, in fact, may mimic a recurrence, but it will reabsorb in
dioxide is removed. 90 per cent of patients by six weeks. If it is not uncomfort-
The final phase of the procedure is evacuation of the able for the patient, it is observed and then aspirated only
carbon dioxide. It is released slowly through one of the if it is present after six weeks and if it appears that it is
5-mm ports while the lateral inferior corner of the mesh not resolving. We have not found it necessary to use
is held against the wall with a grasper in the other 5-mm ultrasonography to diagnosis a seroma, but rather have
port. This procedure ensures that the peritoneum will been able to rely on physical exam alone. On only one occa-
cover the mesh rather than lift the inferior edge. The sion did we misinterpret the findings as a recurrent hernia
peritoneum will rest on top of the mesh, holding it in when it was actually a contained fluid collection.12
place. If the peritoneum lifts the mesh, the mesh must be Using our extraperitoneal technique with and, more
manipulated or trimmed until it is covered properly by recently, without anchors, we have maintained a recur-
peritoneum. If there are bilateral hernias, we release the rence rate of less than 0.5 per cent over the last ten years.
gas very slowly while watching both meshes and holding Short- and long-term morbidity, convalescence and sat-
the corners of each mesh with a grasper as needed. The isfaction of all patients have been excellent. Because the
small trocars are removed, and the rest of the extraperi- procedure can be performed rapidly and in an outpatient
toneal gas is evacuated through the umbilical port. If car- setting, the overall cost has remained comparable to
bon dioxide is trapped within the peritoneal cavity, it is other methods of hernia repair. The keys to a successful
evacuated from the peritoneal cavity with a Veress laparoscopic technique are an understanding of the
needle. The fascia of the 10-mm port is re-approximated posterior anatomy, perfection of the laparoscopic skills
with absorbable suture. Gas trapped in the scrotum can required to perform advanced laparoscopic surgery,
also be eliminated with a small needle at the end of the and knowledge of the limitations of the laparoscopic
procedure, if deemed necessary. approach to inguinal hernia repair.
REFERENCES 7 Ferzli G, Sayad P, Huie F, et al. Endoscopic extraperitoneal

herniorrhaphy. A 5 year experience. Surg Endosc 1998; 12:
1311–13.
1 Bassini E. Nuovo me todo cura radicale dell’ernia inguinale. Arch 8 Felix E. Laparoscopic approach to bilateral hernias. Sages abstracts
Soc Ital Chir 1887; 4: 380. 1999.
2 Lichtenstein IL, Shulman AL, Amid PK, et al. The tension-free 9 Felix E, Michas C, Gonzalez H. Laparoscopic hernioplasty: why it
hernioplasty. Am J Surg 1989; 157: 188–93. works. Surg Endosc 1997; 11: 36–41.
3 Stoppa R, Rives JL, Walamount C. The use of Dacron in the repair 10 Felix EL, Michas C. Double-buttress laparoscopic herniorrhaphy.
of hernias of the groin. Surg Clin N Am 1984; 64: 269–85. J Laparoendosc Surg 1993; 3: 1–8.
4 Felix E, Scott S, Crafton B, et al. Causes of recurrence after 11 Felix E, Michas C, Mcknight R. Laparoscopic herniorrhaphy.
laparoscopic hernioplasty – a multicenter study. Surg Endosc 1998; Transabdominal preperitoneal floor repair. Surg Endosc 1994;
12: 226–31. 8: 100–3.
5 Felix E, Michas C, Gonzalez H. Laparoscopic hernioplasty. Tapp vs. 12 Felix E. A unified approach to recurrent laparoscopic hernia
Tep. Surg Endosc 1995; 9: 984–9. repairs. Surg Endosc 2001; 15: 969–71.
6 Felix E, Michas C, Gonzalez H. Laparoscopic repair of recurrent
hernia. Am J Surg 1996; 172: 580–4.
10
Femoral and pelvic herniorrhaphy
CHRISTINE A. ELY AND MAURICE E. ARREGUI
Demographics 75 Rare and unusual hernias 77

History of repair 76 Conclusion 81
Techniques 76 References 82
Postoperative care 77
Femoral and pelvic hernias are much less common than In this chapter, we will focus on our technique of
inguinal hernias. If these hernias are diagnosed pre- repair of femoral and obturator hernias, since the obtu-
operatively, they are certainly amenable to laparoscopic rator hernia is by far the most common of the pelvic
repair. However, if they are not diagnosed preoperatively, hernias (Figure 10.1). Our technique and postoperative
these cases are the perfect situation for the application of care will be reviewed. In addition, we will comment on
diagnostic laparoscopy followed by laparoscopic repair. 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
Inguinal ligament
Spigelian hernias.
Less common
Femoral hernia
(anatomically
less weak) DEMOGRAPHICS
Most common
Inguinal hernia Femoral hernias are much less common than inguinal
(Anatomically hernias, with an incidence of two to four per cent of all
weakest)
groin hernias.1 They are more common in women, with
reported male/female ratios of 1 : 1.6 to 1 : 3.1,2 The inci-
dence 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
Pectineus muscle 0.05–0.07 per cent of all groin hernias. They typically
occur in an emaciated, dehydrated, multiparous female
Rare patient. The patients may have a positive Howship–
Obturator hernia Romberg sign or a palpable upper-thigh mass. The
(Anatomically least weak)
Howship–Romberg sign is positive when medial thigh and
Figure 10.1 Surgical anatomy of the obturator and inguinal hip pain is created or exacerbated by adduction and
region. Lateral view of the right side of the pelvis, showing the medial rotation of the thigh and relieved by thigh flexion.3
sites of inguinal, femoral and obturator hernias. From Carter JE. More often, however, symptoms are vague, and patients
Hernias. In: Howard FM, Perry CP, Carter JE, et al., eds. Pelvic frequently present with small-bowel obstruction with
Pain: Diagnosis and Management. Philadelphia: Lippincott either intermittently incarcerating or strangulated small
Williams & Wilkins, 2000: 385–413, with permission. bowel. One’s level of suspicion, therefore, needs to be high.
These vague symptoms and small-bowel obstructions can

occur with both femoral and obturator hernias.
d b
HISTORY OF REPAIR
Femoral hernias have been repaired anteriorly with and

without mesh, or with a mesh plug, as well as via the e
a
suprainguinal ligament approach or the infrainguinal
approach. They have been repaired posteriorly via open c
pre-peritoneal approaches and, most recently, laparoscop-
ically 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.4–8 Reports are
now emerging regarding the success of the laparoscopic Figure 10.2 Transperitoneal view of (a) indirect inguinal hernia,
repair of these hernias.8 (b) direct inguinal hernia, (c) femoral hernia, (d) inferior
A variety of approaches for repair of the obturator epigastric vessels, and (e) median umbilical ligament.
hernia has been used. The abdominal, inguinal (extraperi-
toneal or retroperitoneal), retropubic, and obturator
approaches have been described, as well as different com-
binations of these incisions. The abdominal approach has
seemed to be the best approach because it provides simul- b
taneous diagnosis and repair and allows the resection of
compromised bowel if necessary. The obturator defect has a
been closed with sutures or mesh, or with tissue, such as a
flap of adductor longus, the round ligament, or a portion c
of the bladder wall.9,10 Most recently, the laparoscopic
approach has been applied to these hernias (Figures 10.2 d
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.
TECHNIQUES
Figure 10.3 Intraoperative view of obturator foramen. (a) Plug
If the hernia is discovered preoperatively, our approach of fat in obturator foramen, (b) Cooper’s ligament, (c) obturator
of choice is the extraperitoneal approach. If the hernia is nerve, and (d) obturator artery.
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 with a 5-mm, 30-degree viewing laparoscope. Using the
may be used, as described below. transperitoneal view, an additional 5-mm trocar is
We perform extraperitoneal repair of indirect and placed on the ipsilateral side about one finger’s breadth
direct inguinal hernias. Femoral hernias and obturator below the level of the umbilicus over the lateral aspect of
hernias are repaired in a similar fashion. As we will point the rectus muscle just above the arcuate line of the poste-
out, the most important concept is wide coverage of all rior rectus sheath. The trocar is introduced carefully into
hernia orifices with mesh to prevent recurrence. the posterior rectus space to avoid perforation of the
General endotracheal anesthesia is used. After infil- peritoneum. Dissection of this space is then carried out
trating with 0.5 per cent bupivacaine with epinephrine with a long, blunt grasper inserted through the trocar.
(adrenaline), a 5-mm incision is made in a skin fold in For unilateral repair, a second 5-mm trocar is inserted in
the inferior portion of the umbilicus. A Veress needle the midline at the midpoint between the symphysis pubis
is introduced for insufflation of carbon dioxide to a and umbilicus. For bilateral repair, the second trocar is
pressure of 15 mmHg. A 5-mm trocar is then inserted, placed on the opposite side, in the lateral rectus space,
followed by a general inspection of the peritoneal cavity again just above the arcuate line.
Femoral and pelvic herniorrhaphy 77
After dissection with the blunt grasper, an additional are given a prescription for propoxyphene for pain con-
5-mm incision is made below the umbilicus, through trol. The patient is restricted only from driving for two to
which a 5-mm trocar is placed. The 5-mm, zero- or 30- three days, or until they are pain-free and not requiring
degree viewing laparoscopes are then used. The dissection narcotic analgesics. Patients may bathe the same day and
of the pre-peritoneal space is carried beyond Cooper’s lig- may return to work or full activity without restrictions
ament into the space of Retzius below the obturator fora- when they feel ready.11
men. Once dissection is complete, the symphysis pubis,
the rectus muscle medially, the anatomic landmarks
surrounding Hesselbach’s triangle (including Cooper’s RARE AND UNUSUAL HERNIAS
ligament and the medial iliopubic tract), the transversus
abdominus musculo-aponeurotic arch, and the inferior
In this section, we will mention some unusual hernias
epigastric vessels will be identified. Laterally, the dissec-
that may be encountered and the principles and tech-
tion will have exposed the cord structures, the underlying
niques for their management and repair.
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 Sciatic hernia
Cooper’s ligament.
Subsequent to the reduction of the herniated contents Sciatic hernias are very rare. A literature search on
and sac, the femoral hernia defect and the entire Medline from 1966 to 1996 generated only 57 reported
myopectineal orifice of Fruchaud will be covered with cases of sciatic hernias.12 A sciatic hernia is a protrusion
Mersilene mesh. A 15 ⫻ 15-cm mesh is trimmed to of a peritoneal sac and its contents through the greater or
13 ⫻ 15 cm. It is introduced by rolling it, grabbing one lesser sciatic foramen. They may be congenital or, more
end with grasping forceps, and pushing it through the commonly, acquired. The defect usually results from
5-mm trocar. The mesh is unrolled and positioned over weakness of the piriformis muscle from a chronic
the entire area, thereby covering the hernia defect and increase in the intra-abdominal pressure, such as in preg-
all other potential sites of herniation. The mesh is not nancy, severe constipation, surgery or trauma. It can also
sutured or tacked into place. In the case of an obturator occur because of atrophy of the muscle caused by neuro-
hernia, the mesh can be smaller and limited to a wide muscular or hip disease.13 The hernia sac can protrude
coverage of the obturator foramen with or without fixa- through one of three openings: the greater sciatic fora-
tion. We would choose to fashion the size of the mesh so men above the piriformis muscle, the greater sciatic fora-
that it overlaps the defect by 3–4 cm. Others have fixated men below the piriformis muscle, or the lesser sciatic
the mesh, which can be done with either sutures or tacks. foramen (Figure 10.4). Typical symptoms include inter-
Based on the above principles, however, we would not mittent pain radiating to the buttocks and/or posterior
fixate the mesh. After making sure that the prosthesis is thigh, with or without a palpable mass deep to the glu-
lying flat and in the correct space, the pre-peritoneal tro- teus maximus muscle. The most common contents of a
cars are removed and the pre-peritoneal space is desuf- sciatic hernia are small bowel, ovary (with or without the
flated. The laparoscope is then placed in the peritoneal adjacent fallopian tube), and ureter.13
cavity and the mesh is observed as the peritoneum lies on The sciatic hernia has traditionally been approached
top of it, making sure that there is no buckling of the transabdominally, with reduction of the hernia, excision
mesh. Then, while still under direct vision, the peritoneal of the sac, and either suture closure or mesh coverage of
cavity is desufflated and the final trocar is removed. The the defect. Alternatively, if it is diagnosed preoperatively
positive intra-abdominal pressure that took part in and it is easily reducible, the hernia could be repaired
creating the hernia itself is now used to secure the mesh from a transgluteal approach.
in place, obviating the need for fixation of the prosthetic The largest series of patients who underwent laparo-
biomaterial. The subcutaneous tissue at all trocar sites is scopic repair of a sciatic hernia consisted of 20 women
closed with 3-0 Vicryl (Ethicon). Collodian is applied to who underwent diagnostic laparoscopy for pelvic pain
the skin for dressing.11 and were found to have a sciatic hernia, which was then
repaired via laparoscopic approach.14 When a sciatic her-
nia was identified, the contents were reduced. The peri-
toneum was elevated and transected transversely with
POSTOPERATIVE CARE endoscopic scissors. The obturator internus and coc-
cygeus muscles were identified with the use of blunt dis-
The patient is observed in the recovery room for one to section. A 6.0 ⫻ 12.5-cm piece of Surgipro mesh (U.S.
two hours. The majority of electively repaired patients Surgical) was then folded and placed into the space that
are then discharged home on the same day. Most patients had been created by the atrophic piriformis muscle.
The authors do not describe it exactly as a ‘plug’; this is contained an ovary and/or the fallopian tube, which left
the only description that they gave. A second, smaller little room for the distention of the peritoneum con-
piece of mesh, trimmed to the size of the peritoneal defect, tained within the hernia sac by the intra-abdominal car-
was placed over the folded mesh. The second piece of mesh bon dioxide. However, the authors felt that in other cases
was secured to the obturator internus fascia laterally and the increased intra-abdominal pressure could be helpful
the coccygeus medially with a stapler. The peritoneum in the detection of sciatic hernias because of the actual
was then closed over the mesh.12 If the peritoneum is stretching of the peritoneum to its limit of support, such
not closed, then an inert mesh, such as DualMesh® as the bone or muscle.12
(W. L. Gore & Associates) could be used to prevent mor-
bidity due to adhesions.15 The repair was very successful,
with 14 patients reporting complete pain relief, and the Supravesical hernia
other six individuals noting continuing improvement
over a median follow-up of 13 months. Supravesical hernias are rare hernias that herniate
Laparoscopy is a great adjunct in the diagnosis of this through the supravesical fossa of the anterior abdominal
hernia because of the excellent view of the pelvis that wall. They are classified as either external (those that pass
it affords. In this series of patients, all of the hernias downward through the supravesical fossa to become
Anterior sacroiliac ligament
Piriformis muscle
Sacrospinous ligament
b
Sacrotuberous ligament
c
Ischial tuberosity and spine

(a)
Posterior sacroiliac
Posterior inferior
ligament
iliac spine
Greater sciatic foramen Piriformis muscle
Sacrospinous ligament Capsule of hip joint

Figure 10.4 Sites of potential hernias
through the sciatic foramina:
Sacrotuberous ligament (a) suprapiriformis sciatic hernia,
Greater trochanter
(b) infrapiriformis sciatic hernia, and
(c) subspinous sciatic hernia through the
Lesser sciatic foramen
lesser sciatic foramen. From Carter JE.
Quadratus femoris Hernias. In: Howard FM, Perry CP, Carter JE,
Ischial tuberosity muscle
et al., eds. Pelvic Pain: Diagnosis and
Management. Philadelphia: Lippincott
Sciatic nerve Williams & Wilkins, 2000: 385–413, with
(b) permission.
direct inguinal or femoral hernias) or internal (those may be especially well suited for the laparoscopic approach
that pass downward to enter the space of Retzius) because of the better visualization of the entire pelvis.16
(Figure 10.5). While the external hernias may be much
easier to diagnose, an internal hernia may present with
Perineal hernia
non-specific clinical findings, such as pelvic pain or blad-
der symptoms, or, as in other hernias, it may present as
Perineal hernias are very rare true hernias, which are usu-
small-bowel obstruction with its attendant symptoms.
ally found in women. These defects are characterized by a
Open repair has been described for these hernias, either
peritoneal sac that has herniated between the muscles and
with or without mesh, particularly for the external her-
fascia of the perineal floor.16 They can be categorized as
nias. Laparoscopic repair, however, is again applicable
either anterior or posterior to the superficial transverse
to such hernias, using the same technique as described
perineus muscle. Anterior perineal hernias pass through
above for sciatic hernias. The internal supravesical hernia
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
e unique to women and may contain intestine or bladder.
Posterior perineal hernias pass directly through the
d components of the pelvic diaphragm. Their content is
a usually omentum or small bowel, which lie between the
rectum and uterus. The hernia usually remains lateral to
c the uterosacral ligament and posterior to the broad liga-
b ment. There are two possible locations, an upper poste-
rior hernia between the pubococcygeus and iliococcygeus
muscles, and a lower posterior hernia between the ilio-
coccygeus and coccygeus muscles, below the lower
margin of the gluteus maximus muscle. Posterior perineal
Figure 10.5 External supravesical hernia: (a) external hernias may occur in men or women, but they are more
supravesical hernia orifice, (b) Hesselbach’s triangle, common in men.13,17
(c) transversus abdominus aponeurotic arch, (d) rectus muscle, Laparoscopic repair of these hernias has been
and (e) inferior epigastric vessels. described as an approach for maximum visualization of
Ischiocavernous muscle
Bulbocavernosus muscle
Superficial transverse
perineal muscle
a
External anal sphincter
b Levator ani muscle
c Coccygeus muscle
Gluteus maximus muscle
d
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: 385–413, with permission.
the pelvic cavity. The hernia is identified, the hernia eight-year period, ten (9.5 per cent) of the hernias were of
contents are reduced, and a pre-peritoneal dissection is the prevascular type.20 Repair of these hernias can be dif-
performed to define the boundaries of the hernia ring. ficult because, if repaired anteriorly, the iliopubic tract
Permanent prosthetic mesh is used to cover and overlap must be sutured to the vascular adventitia, which obvi-
the defect. The mesh is tacked or stapled in place, and ously holds inherent danger. The pre-peritoneal approach
reperitonealization is performed.16 has therefore been recommended as the safest and pre-
ferred approach.20 In the previously mentioned study,
all ten of the prevascular hernias were repaired using
Prevascular hernia the TEP laparoscopic technique, with good results, no
complications, and no recurrences to date.
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 Lipoma of the cord
them as in the ‘usual’ fashion.18 This hernia was origi-
nally described by Teale in 1846. Other related hernias A lipoma of the spermatic cord or the round ligament is an
have been described that protrude through the femoral isolated discrete collection of fatty tissue arising from the
sheath in strict continuity with the femoral vessels but in retroperitoneal tissue, which protrudes through the inter-
various locations and are separated from the vessels only nal ring and is easily separated from the cord structures
by adventitia (Figure 10.7). There is one report of a (Figure 10.8). These tissues can cause symptoms similar to
patient who simultaneously had two bilateral femoral a true hernia. Lipomas can occur with or without a coex-
hernias (total of four femoral hernias).18 isting peritoneal defect. In a retrospective review of 280
This group of hernias is rare, with a reported incidence hernia repairs, the incidence of lipoma of the cord was
of 1.7–2.5 per cent of all femoral hernias.19 However, found to be 22.5 per cent (63/280).21 Eighteen of these
recent reports suggest that these hernias may be more lipomas were found in groins without hernias. Fourteen
common than originally recognized. In a retrospective of the patients with lipomas presented with groin pain,
study in which 105 femoral hernias were identified in an and four were asymptomatic. The authors believe that
a lipoma can be the cause of a patient’s groin pain, and
also can be a predisposing factor to formation or recur-
rence 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 symp-
tomatic patients and documenting in detail those found
incidentally in asymptomatic patients because of the pos-
sibility 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: Figure 10.8 Laparoscopic view of lipoma of the cord. Cord
415–16, with permission. structures can be seen medially.
Contrary to the advantage that laparoscopy adds in all aponeurosis. This aponeurosis, or fascia, is defined as the
of the above-mentioned hernia surgeries, lipomas of the region between the semilunar or Spigelian line (the tran-
cord or round ligament are more difficult to visualize sition from muscle to aponeurosis in the transversus
with the laparoscope. A maneuver that is useful to help abdominus muscle) and the lateral border of the rectus
visualize the lipoma is external compression with the muscle. The usual Spigelian hernia refers to a hernia
hand at the inguinal canal, thus pushing back the lipoma located above the inferior epigastric vessels. Hernias that
through the internal ring. This should be done in any penetrate the Spigelian fascia inferior to the inferior epi-
patient who is undergoing laparoscopic evaluation for gastric vessels are called low Spigelian hernias (Figure
groin pain when a hernia is not found.21 Herniated pre- 10.9). These hernias are actually traversing through
peritoneal fat can also be found in the femoral canal, Hesselbach’s triangle, which includes part of the
Hasselbach’s triangle, or obturator foramen, or alongside Spigelian aponeurosis caudal and medial to the inferior
the pre-peritoneal nerves. We have seen small herniations epigastric vessels. One can easily appreciate that these
along the lateral femoral cutaneous nerve, which, when hernias are very easily confused with direct inguinal her-
reduced, relieved the patient of the preoperative pain over nias and most likely are underreported because of mis-
the distribution of that nerve. representation as direct inguinal hernias. Low Spigelian
When a lipoma is discovered and requires removal, it is hernias, if diagnosed properly, are usually diagnosed
not always easy to pull it through a 5-mm or 10-mm trocar. intraoperatively. The hernial orifice is usually small and
The available options are piecemeal removal of the lipoma has rigid, sharply defined edges. These hernias may also
(which can be tedious), allowing it to remain attached at be repaired laparoscopically, which can be done in a pre-
the base and placing it between the mesh and the peri- peritoneal fashion, as described for repair of a direct
toneum, or separation of the lipoma from the cord, leaving inguinal hernia.22,23
the lipoma in situ. The latter option is not recommended
as the lipoma may re-herniate into the inguinal canal.21
CONCLUSION
Low Spigelian hernia
We have described in detail our approach for laparoscopic
A Spigelian hernia is a rare hernia that protrudes repair of femoral and obturator hernias. The repair is no
through a congenital or acquired defect in the Spigelian different in principle to that of direct or indirect inguinal
hernias. The most important step to remember is that
(c) wide coverage of all of the possible hernia orifices is nec-
essary 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
(a) pelvic regions than the open technique. This is especially
helpful when one encounters some of the more unusual
(d)
(f) 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.
(b) REFERENCES
(e)
1 Rutkow I. Epidemiologic, economic, and sociologic aspects of
hernia surgery in the United States in the 1990s. Surg Clin N Am
1998; 78: 941–51.
2 Sandblom G, Haapaniemi S, Nilsson E. Femoral hernias: a register
analysis of 588 repairs. Hernia 1999; 3: 131–4.
Figure 10.9 Anatomy of the low Spigelian hernia. Shaded area: 3 Haith LR, Simeone MR, Reilly KJ, et al. Obturator hernia:
Spigelian aponeurosis. (a) Region of Spigelian hernia; (b) region laparoscopic diagnosis and repair. JSLS 1998; 2: 191–3.
of low Spigelian hernia; (c) Spigelian line; (d) lateral border of 4 Koontz AR. Femoral hernia. Arch Surg 1952; 64: 298–308.
rectus abdominus muscle; (e) inferior epigastric vessels; and 5 Glassow F. Femoral hernia: review of 2,105 repairs in a 17 year
(f) transversus abdominus muscle. Modified from Bennett D. period. Am J Surg 1985; 150: 353–6.
6 Bendavid R. A femoral ‘umbrella’ for femoral hernia repair. Surg
Spigelian hernias. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus Gynecol Obstet 1987; 165: 153–6.
& Condon’s Hernia, 5th edn. Philadelphia: Lippincott Williams & 7 Lichtenstein IL, Shore JM. Simplified repair of femoral and inguinal
Wilkins, 2002: 405–13, with permission. hernia by a ‘plug’ technique. Am J Surg 1974; 128: 439–44.
8 Hernandez-Richter T, Schardey HM, Rau HG, et al. The femoral 16 Kavic MS. Chronic pelvic pain in women. In: Bendavid R,
hernia: an ideal approach for the transabdominal preperitoneal Abrahamson J, Arregui ME, et al., eds. Abdominal Wall Hernias
technique (TAPP). Surg Endosc 2000; 14: 736–40. Principle and Management. New York: Springer-Verlag, 2001:
9 Marchal F, Parent S, Tortuyaux JM, et al. Obturator hernias – 636–8.
report of seven cases. Hernia 1997; 1: 23–6. 17 Skandalakis JE. Perineal hernia. In: Skandalakis JE, Gray SW,
10 Skandalakis LJ, Skandalakis PN, Colborn GL, Skandalakis JE. Mansberger AR, et al., eds. Hernia Surgical Anatomy and
Obturator hernia: embryology, anatomy, surgery. Hernia 2000; 4: Technique. New York: McGraw-Hill, 1989: 185–206.
121–8. 18 Harkins HN. In: Nyhus LM, Condon RE, eds. Hernia, 3rd edn.
11 Arregui ME, Navarrete J, Davis CJ, et al. Laparoscopic inguinal Philadelphia: JB Lippincott, 1989: 302–3.
herniorrhaphy – techniques and controversies. Surg Clin N A 1993; 19 Bocci P. Paravascular hernias. In: Bendavid R, ed. Prostheses
73: 513–27. and Abdominal Wall Hernias. Austin, TX: RG Landes Co., 1994:
12 Miklos JR, O’Reilly MJ, Saye WB. Sciatic hernia as a cause of 415–16.
chronic pelvic pain in women. Obstet Gynecol 1998; 91: 998–1001. 20 Spurbeck WW, Voeller GR. Prevascular and retropsoas hernias:
13 Carter JE. Sciatic, obturator, and perineal hernias: a view from the incidence of rare abdominal wall hernias. Abstract presented at
gynecologist. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and American Hernia Society Hernia Conference, Tucson, AZ, May
Condon’s Hernia, 5th edn. Philadelphia: Lippincott Williams & 2002.
Wilkins, 2002: 539–49. 21 Lilly MC, Arregui ME. Lipomas of the cord and round ligament.
14 Kavic MS. Chronic pelvic pain in females and obscure hernias. Ann Surg 2002; 235: 586–90.
Hernia 2000; 4: 250–4. 22 Spangen L. Spigelian hernia. Surg Clin North Am 1984; 64: 351–66.
15 Chaudhuri A, Chye KK, March SK. Sciatic hernias: choice of 23 Bennett D. Spigelian hernia. In: Fitzgibbons RJ, Greenburg AG, eds.
optimal prosthetic repair material in preventing long-term Nyhus and Condon’s Hernia, 5th edn. Philadelphia: Lippincott
morbidity. Hernia 1999; 4: 229–31. Williams & Wilkins, 2002: 405–13.
11
Results of laparoscopic inguinal/femoral
hernia repair
KETAN M. DESAI AND NATHANIEL J. SOPER
TEP versus TAPP repair 83 Laparoscopic femoral hernia repair 86

Laparoscopic versus open tissue repair 84 References 86
Laparoscopic versus open mesh repair 85 Further reading 87
Summary 86
Over 750 000 inguinal hernia repairs are performed in the approaches for the repair of inguinal hernia include the
USA annually. Historically, many techniques for the tissue transabdominal pre-peritoneal (TAPP) and the totally
repair of groin hernias have been used, including the extraperitoneal (TEP) approaches. These two laparo-
Bassini, McVay, Cooper and Shouldice repairs. Currently, scopic procedures, based upon the open Stoppa repair,
the tension-free repair of Lichtenstein and the mesh-plug provide pre-peritoneal mesh reinforcement of the ilio-
procedure dominate the majority of surgical practices. pubic tract.
Since the introduction of laparoscopic cholecystectomy
in the late 1980s, advancements in minimally invasive sur-
gery have led surgeons to investigate laparoscopic tech-
TEP VERSUS TAPP REPAIR
niques for treating inguinal hernia while still providing a
durable repair. Accepted indications for laparoscopic her-
nia repair are recurrent and bilateral inguinal hernias in a TAPP repair requires entry into the peritoneal cavity.
patient at low anesthetic risk. However, considerable debate Following placement of trocars, the peritoneum is divided
over laparoscopic inguinal hernia repair, not seen with transversely anterior to the internal ring, wide peritoneal
other laparoscopic procedures, has diminished the enthu- flaps are raised, and the hernia sac is reduced. A large
siasm for adopting this technique for unilateral, primary prosthetic mesh is stapled into place, widely overlapping
inguinal hernias. the defect and buttressing the iliopubic tract. Similarly,
The emergence of laparoscopic groin hernia surgery is TEP repair requires advanced knowledge of the anatomy
multifactorial. Following open repair, high rates of post- of the inguinal floor. However, access to the pre-peritoneal
operative patient discomfort, pain, and increased time space is achieved without incision of the peritoneal mem-
away from work, coupled with recurrence rates that brane. Following balloon or blunt dissection of the pre-
ranged from one to ten per cent, influenced surgeons to peritoneal space, the cord structures are dissected, and
explore alternative repair methods. Early attempts at indirect or direct hernias are reduced. The inguinal floor
laparoscopic inguinal hernia repair included intraperi- is covered with a large prosthetic mesh and secured with
toneal onlay mesh (IPOM) techniques, simple inguinal staples or another fixation device. Potential early postop-
ring closure, and plug-and-patch repair. However, these erative complications include bowel injury from trocar
early laparoscopic approaches were abandoned secondary insertion (TAPP), bowel obstruction from adhesion for-
to an unacceptable rate of recurrence and the formation mation (TAPP), nerve entrapment from staple placement
of intra-abdominal adhesions, except at a few centers (see (TAPP and TEP), and mesh infection (TAPP and TEP).
Chapter 7). Today, the two predominant laparoscopic The extraperitoneal approach avoids a number of these
Table 11.1 Recurrence rates of laparoscopic repairs
Follow-up Recurrence
Study Procedure Number (months) rate (%)
Aeberhard et al. (1999)3 TEP 1605 12 1.3
Katkhouda et al. (1999)4 TEP 99 24 0
Farinas and Griffen (2000)5 TEP 96 12 0
Knook et al. (1999)6 TEP 256 40 5
Ferzli et al. (1999)7 TEP 100 8 0
Frankum et al. (1999)8 TEP 779 30 0.2
Halkic et al. (1999)9 TEP 118 22 0
Lucas and Arregui (1999)10 TEP 199 36 0
O’Riordain et al. (1999)11 TEP 71 12 0
Juul et al. (1999)1 TAPP 138 12 2.9
Knook et al. (1999)12 TAPP 34 35 0
Smith et al. (1999)13 TAPP 536 17 0.6
Johansson et al. (1999)14 TAPP 204 12 2
pitfalls that are unique to entry into the peritoneal cavity. invasive repairs, due to conversions and recurrences
However, early problems with nerve entrapment and requiring the alternative procedure.
hernia recurrence secondary to inadequate mesh size
following either procedure have resulted in significant
morbidity.
LAPAROSCOPIC VERSUS OPEN
Outcome measures following groin hernia repair
TISSUE REPAIR
include postoperative pain, complications, return to work,
patient satisfaction, and cost, as well as long-term hernia
recurrence rates. Comparisons of laparoscopic approaches Although we currently use the Lichtenstein (tension-free)
have revealed lower rates of postoperative pain following repair for open inguinal herniorrhaphy, the Shouldice
TEP repair; however, operating times and return to nor- technique appears to have similar advantages in terms of
mal activity were generally similar. Recurrence rates fol- short recovery time and low recurrence rates. Laparo-
lowing either laparoscopic repair were variable (Table 11.1). scopic repair has been compared with a number of open
Non-randomized (usually sequential) trials comparing repair methods, with varying results. A number of early,
TEP versus TAPP approaches have reported lower recur- small trials failed to demonstrate a clear benefit following
rence rates following the TEP technique. However, in a laparoscopic repair. More recent randomized trials com-
number of these trials the differences were not statistically paring laparoscopic and open suture repair have reported
significant, with subsequent randomized studies report- superior outcomes following the laparoscopic approach
ing similar recurrence rates irrespective of laparoscopic in terms of less postoperative pain and a faster return to
procedure. normal activity. Although operative times of the laparo-
Evaluations of these two laparoscopic techniques have scopic approaches have been reported to be significantly
demonstrated a slightly lower complication rate following longer than with open suture methods in a number of
TEP repair. Reports of bowel injury and small-bowel studies, wound complications and overall recurrence
obstruction secondary to intra-abdominal adhesions were rates were similar (Table 11.2). In addition, general anes-
more common following the TAPP approach than the TEP thesia was used in the vast majority of laparoscopic cases
approach. The difference in complication rates between the as opposed to local, epidural or spinal anesthesia in the
two accepted laparoscopic approaches may result from open group. Despite this, several trials have shown earlier
remaining completely extraperitoneal during TEP dissec- hospital discharge and less postoperative pain (early
tion and repair. However, initial experience with TAPP may and late) in patients undergoing laparoscopic repair. A
have provided surgeons with the additional skills and randomized comparison of extraperitoneal laparoscopic
knowledge to perform a superior TEP repair. repair with various open approaches by Liem and col-
In general, due to the small number of comparative leagues revealed longer procedure times for the laparo-
studies, firm conclusions on the relative merits of the dif- scopic repair.13 However, the laparoscopy group had
ferent techniques are difficult to obtain. However, TEP lower analgesia requirements, less postoperative pain, and
repair may have some advantages regarding complica- an earlier return to work. The recurrence rate was slightly
tions and postoperative pain. Despite these potential dif- lower in the laparoscopy group, as were wound infections
ferences, surgeons should be skilled in both minimally and chronic postoperative pain.
Results of laparoscopic inguinal/femoral hernia repair 85
Table 11.2 Comparison of open versus laparoscopic repair

Recurrence (%)
No.
Study randomized Open Laparoscopic Open Laparoscopic
Liem et al. (1997)15 994 Various TEP 6 3
Juul and Christensen (1999)1 268 Shouldice TAPP 2 3
Fleming et al. (2001)2 200 Shouldice TEP 5 2
Paganini et al. (1998)16 108 Mesh TAPP 0 4
Zieren et al. (1998)17 240 Mesh TAPP 0 0
Koninger et al. (1998)18 280 Mesh TAPP 1 1
Payne et al. (1994)19 100 Mesh TAPP 0 0
Heikkinen et al. (1997)20 38 Mesh TAPP 0 0
Beets et al. (1999)21 79 Mesh TAPP 3 14
Filipi et al. (1996)22 53 Mesh TAPP 7 0
Johansson et al. (1999)14 613 Mesh TAPP 5 2
Aitola et al. (1998)23 60 Mesh TAPP 8 13
Wellwood et al. (1998)24 403 Mesh TAPP 0 0
Champault et al. (1997)25 100 Mesh TEP 2 6
Khoury (1998)26 292 Mesh TEP 3 2
Laparoscopic repair of groin hernias is generally A number of prospective non-randomized studies

reserved for bilateral and recurrent hernias. However, the have compared laparoscopic and open mesh repair.
benefits of laparoscopic repair for primary, unilateral her- Objective pain scoring, analgesia use, and complication
nias have been demonstrated. Patients with primary, uni- rates were similar. Laparoscopic repair was shown to be
lateral hernias may recover more rapidly after TAPP repair superior to open mesh repairs in terms of faster return to
than after an open approach, as assessed by analgesia normal activity and return to work. Although recurrence
requirement and functional status. In a randomized clinical rates did not differ significantly, a short duration of
trial by Juul and coworkers of laparoscopic (TAPP) versus follow-up and small cohort numbers were potential lim-
open (Shouldice) inguinal hernia repair, complication rates iting factors to a number of these studies. Laparoscopic
were similar, whereas the laparoscopic repair resulted in repair required longer operating times and, in general,
less postoperative pain, shorter analgesia requirement, was more expensive; however, more rapid return to work
and an earlier return to work.1 At postoperative follow- may result in lower overall societal costs following the
up, there were similar rates of recurrences. Comparison laparoscopic approach.
of Shouldice and TEP repairs by Fleming and colleagues Randomized clinical trials of open versus laparo-
also demonstrated the potential benefits of the laparoscopic repair of primary, unilateral inguinal hernias have
scopic approach. TEP repair led to a more rapid return to shown comparable results with respect to overall compli-
work, with fewer complications at one-year follow-up, cations and recurrences (Table 11.2). Major intraopera-
when compared with the open group.2 tive 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
LAPAROSCOPIC VERSUS OPEN MESH REPAIR among the laparoscopic groups, possibly contributing to
the earlier return to regular activity in patients undergo-
The practice of tension-free groin hernia repair using ing laparoscopic hernia repair. However, length of hospi-
prosthetic mesh materials has become increasingly popu- tal stay was similar in patients undergoing open mesh
lar over the last decade. Laparoscopic inguinal hernia sur- and laparoscopic repair, with no difference in recurrence
gery should be comparable to the standard Lichtenstein rates between open mesh and laparoscopic repair at
repair, which has a reported recurrence rate of 0.1–1 per short- to medium-term follow-up (Table 11.2).
cent. Multiple small studies with relatively short-term Outcomes of randomized trials comparing laparo-
follow-up have reported that laparoscopic repair can be scopic and open herniorrhaphies have shown less pain
performed safely with results that equal or surpass open and faster recovery following laparoscopic approaches,
hernia repair. Although the laparoscopic approach may but at increased cost and slightly greater risk. However,
offer shorter recovery time owing to less pain, only a few prospective, randomized data comparing laparoscopic
large studies have investigated overall differences in versus open bilateral hernia repair are lacking. It would
complication and recurrence rates. be expected that bilateral open repairs would result in a
doubling of operative time and postoperative pain when Table 11.4 Perceived disadvantages of laparoscopic
compared with laparoscopic repair. The laparoscopic inguinal hernia repair
approach for repair of unilateral or bilateral hernias
Requirement for general anesthesia
utilizes the same ports, thereby limiting additional time Complications unique to laparoscopic approach
requirements for bilateral herniorrhaphy. In addition, Steep learning curve
pre-peritoneal repair (TEP/TAPP) avoids the scarring of Increased cost
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. LAPAROSCOPIC FEMORAL HERNIA REPAIR
The published literature on femoral hernia repair is

inadequate to make firm conclusions regarding the rela-
SUMMARY tive safety and efficacy of different surgical approaches.
Although a few prospective studies comparing different
Recurrence rates following various open hernia repair methods of open femoral hernia repair exist, small study
techniques have ranged from less than one per cent to more sizes hinder definitive conclusions regarding differences
than ten per cent at long-term follow-up. Laparoscopic in outcomes. Laparoscopic femoral hernia repair is per-
techniques that were introduced in the early 1990s show formed in the same fashion as that for inguinal hernior-
promise in treating unilateral, bilateral and recurrent her- rhaphy. Reports of laparoscopic femoral hernia repair
nias with respect to less postoperative pain, earlier recovery, are, in general, limited to case reports, with no random-
and improved cosmesis (Table 11.3). Recurrences that do ized trials comparing open and laparoscopic repair.
occur following laparoscopic repair are usually the result of
inadequate lateral pre-peritoneal dissection or an inade-
quate size of the prosthesis. In addition, the skill and expe- REFERENCES
rience of the operating surgeon greatly affect the rate of
recurrence, such that results during the initial learning 1 Juul P, Christensen K. Randomized clinical trial of laparoscopic
curve are worse than later in a surgeon’s operative series. In versus open inguinal hernia repair. Br J Surg 1999; 86: 316–19.
2 Fleming WR, Elliott TB, Jones RM, Hardy KJ. Randomized clinical
addition, the lack of an inguinal incision, avoidance of
trial comparing totally extraperitoneal inguinal hernia repair with
extensive dissection, creation of a tension-free repair, and the Shouldice technique. Br J Surg 2001; 88: 1183–8.
low complication rates all contribute to more rapid return 3 Aeberhard P, Klaiber C, Meyenberg A, et al. Prospective audit of
to normal activity following laparoscopic inguinal hernia laparoscopic totally extraperitoneal inguinal hernia repair: a
repair. multicenter study of the Swiss Association for Laparoscopic and
Thoracoscopic Surgery (SALTC). Surg Endosc 1999; 13: 1115–20.
Comparing laparoscopic and open inguinal hernior-
4 Katkhouda N, Campos GM, Mavor E, et al. Laparoscopic
rhaphy, differences in outcomes regarding postoperative extraperitoneal inguinal hernia repair. A safe approach based on
pain, return to work, and analgesia requirements have the understanding of rectus sheath anatomy. Surg Endosc 1999;
generally favored the laparoscopic approach. However, 13: 1243–6.
potential limitations to the laparoscopic approach include 5 Farinas LP, Griffen FD. Cost containment and totally extra-
peritoneal laparoscopic herniorrhaphy. Surg Endosc 2000;
increased cost, the requirement for general anesthesia,
14: 37–40.
and a steep learning curve. Disadvantages to laparo- 6 Knook MT, Weidema WF, Stassen LP, van Steensel CJ. Endoscopic
scopic hernia repair include the widespread use of gen- total extraperitoneal repair of primary and recurrent inguinal
eral anesthesia and the potential for visceral and vascular hernias. Surg Endosc 1999; 13: 507–11.
complications, unique to the laparoscopic approach 7 Ferzli GS, Frezza EE, Pecoraro AM, Jr, Ahern KD. Prospective
randomized study of stapled versus unstapled mesh in a
(Table 11.4).
laparoscopic preperitoneal inguinal hernia repair. J Am Coll Surg
1999; 188: 461–5.
8 Frankum CE, Ramshaw BJ, White J, et al. Laparoscopic repair of
Table 11.3 Potential advantages of laparoscopic inguinal bilateral and recurrent hernias. Am Surg 1999; 65: 839–42,
hernia repair 842–3.
9 Halkic N, Ksontini R, Corpataux JM, Bekavac-Beslin M.
Less difficulty in repairing a recurrent hernia Laparoscopic inguinal hernia repair with extraperitoneal double-
Ability to treat bilateral hernia via same incisions mesh technique. J Laparoendosc Adv Surg Tech A 1999; 9: 491–4.
Performance of simultaneous diagnostic laparoscopy (TAPP) 10 Lucas SW, Arregui ME. Minimally invasive surgery for inguinal
Less postoperative pain hernia. World J Surg 1999; 23: 350–5.
Reduced recovery time 11 O’Riordain DS, Kelly P, Horgan PG, et al. Laparoscopic
Improved cosmesis extraperitoneal inguinal hernia repair in the day-care setting. Surg
Endosc 1999; 13: 914–17.
Results of laparoscopic inguinal/femoral hernia repair 87
12 Knook MT, Weidema WF, Stassen LP, van Steensel CJ. Laparoscopic 25 Champault GG, Rizk N, Catheline J-M, et al. Inguinal hernia repair;
repair of recurrent inguinal hernias after endoscopic totally preperitoneal laparoscopic approach versus Stoppa
herniorrhaphy. Surg Endosc 1999; 13: 1145–7. operation: randomized trial of 100 cases. Surg Laparosc Endosc
13 Smith AI, Royston CM, Sedman PC. Stapled and nonstapled 1997; 7: 445–50.
laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia 26 Khoury N. A randomized prospective controlled trial of laparoscopic
repair. A prospective randomized trial. Surg Endosc 1999; 13: extraperitoneal hernia repair and mesh-plug hernioplasty: a study
804–6. of 315 cases. J Laparoendosc Adv Surg Tech A 1998; 8: 367–72.
14 Johansson B, Hallerbäck 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: 225–31. FURTHER READING
15 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: 1541–7. Barkun JS, Wexler MJ, Hinchey EJ, et al. Laparoscopic versus open
16 Paganini AM, Lezoche E, Carle F, et al. A randomized, controlled, inguinal herniorrhaphy: preliminary results of a randomized
clinical study of laparoscopic vs open tension-free hernia repair. controlled trial. Surgery 1995; 118: 703–10.
Surg Endosc 1998; 12: 979–86. Champault G, Benoit J, Lauroy J, et al. Inguinal hernia in adults.
17 Zieren J, Zieren HU, Jacobi CA, et al. Prospective randomized study Laparoscopic surgery versus the Shouldice method. Controlled
comparing laparoscopic and open tension-free inguinal hernia randomized study in 181 patients. Preliminary results. Ann Chir
repair with Shouldice’s operation. Am J Surg 1998; 175: 330–3. 1994; 48: 1003–8.
18 Koninger JS, Oster M, Butters M. Management of inguinal hernia: Cheek CM, Black NA, Devlin HB, et al. Groin hernia surgery: a
a comparison of current methods. Chirurg 1998; 69: 1340–4. systematic review. Ann R Coll Surg Engl 1998; 80 (suppl 1): S1–80.
19 Payne JH, Jr, Grininger LM, Izawa MT, et al. Laparoscopic or open Collaboration EH. Laparoscopic compared with open methods of groin
inguinal herniorrhaphy? A randomized prospective trial. Arch Surg hernia repair: systematic review of randomized controlled trials.
1994; 129: 973–9, 979–81. Br J Surg 2000; 87: 860–67.
20 Heikkinen T, Haukipuro K, Leppala J, Hulkko A. Total costs of EU Hernia Trialists Collaboration. Mesh compared with non-mesh
laparoscopic and Lichtenstein inguinal hernia repairs: a methods of open groin hernia repair: systematic review of
randomized prospective study. Surg Laparosc Endosc 1997; 7: 1–5. randomized controlled trials. Br J Surg 2000; 87: 854–9.
21 Beets GL, Dirksen CD, Go PM, et al. Open or laparoscopic Kozol R, Lange PM, Kosir M, et al. A prospective, randomized study of
preperitoneal mesh repair for recurrent inguinal hernia? A open vs laparoscopic inguinal hernia repair. An assessment of
randomized controlled trial. Surg Endosc 1999; 13: 323–7. postoperative pain. Arch Surg 1997; 132: 292–5.
22 Filipi CJ, Gaston-Johansson F, McBride PJ, et al. An assessment of Maddern GJ, Rudkin G, Bessell JR, et al. A comparison of laparoscopic
pain and return to normal activity. Laparoscopic herniorrhaphy vs and open hernia repair as a day surgical procedure. Surg Endosc
open tension-free Lichtenstein repair. Surg Endosc 1996; 10: 983–6. 1994; 8:1404–8.
23 Aitola P, Airo I, Matikainen M. Laparoscopic versus open Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus
preperitoneal inguinal hernia repair: a prospective randomised open inguinal hernia repair: randomised prospective trial. Lancet
trial. Ann Chir Gynaecol 1998; 87: 22–5. 1994; 343: 1243–5.
24 Wellwood J, Sculpher MJ, Stoker D, et al. Randomised controlled Vogt DM, Curet MJ, Pitcher DE, et al. Preliminary results of a
trial of laparoscopic versus open mesh repair for inguinal hernia: prospective randomized trial of laparoscopic onlay versus
outcome and cost. Br Med J 1998; 317: 103–10. conventional inguinal herniorrhaphy. Am J Surg 1995; 169: 84–90.
12
Complications and their management
RICARDO V. COHEN, CARLOS A. SCHIAVON, SÉRGIO ROLL AND JOSÉ C.P. FILHO
Anesthesia 89 Neuropathy 91
Events related to laparoscopic access 89 Visceral complications 92
Organ involvement 90 Mesh-related problems 93
Hydrocele 90 Recurrence 93
Seroma 90 Conclusion 94
Vascular injury 91 References 94
The modern era of the treatment of inguinal/femoral than age, to general anesthesia exists, then hernias must be
hernias has evolved over the past 155 years. From truss repaired through an anterior approach under local anes-
support to elective outpatient procedures, the surgical thesia. No controlled trial has been published that has
techniques to treat these patients have progressed, such shown definitely that a local anesthetic is truly superior
that now surgeons are able to employ the use of laparoscopy to carefully administered general anesthesia. Consequently,
to approach these hernias. Laparoscopic approaches allow this does not represent a strong reason to avoid TAPP
the inspection of the inguinal and femoral areas bilaterally, or TEP.
thereby avoiding unexpected non-diagnosed contralateral
hernias. This method of hernioplasty has been shown to
reduce postoperative pain and disability and allows the EVENTS RELATED TO LAPAROSCOPIC
treatment of bilateral defects in one sitting. But, as in ACCESS
all operative procedures, complications exist. Nothing is
more effective in the prevention of the occurrence of
Inherent to laparoscopy are the insufflation of carbon
complications as one’s awareness and fear of them.
dioxide and the possibility of systemic alterations follow-
In this chapter, complications and their management
ing pneumoperitoneum, documented very well in the
will be focused on the two most commonly performed
literature. Additionally, trocar access may carry some
laparoscopic inguinal hernia repairs, the transabdominal
intra-abdominal complications, such as major vascular
pre-peritoneal (TAPP) approach and the totally extraperi-
or visceral injuries.3 Blind insertion of the Veress needle
toneal (TEP) technique.
or trocars may cause intra-abdominal and abdominal
wall complications. In a retrospective study of 103 852
laparoscopic operations (nine per cent inguinal hernias),
ANESTHESIA which involved the insertion of 390 000 trocars, the inci-
dence of serious complications was 3.2/1000 inter-
It has been suggested that the general anesthesia needed ventions (0.032 per cent).4 Bleeding from the trocar site
for laparoscopic herniorrhaphy is a major drawback, and was the most common complication, accounting for
open procedures are preferred because they can be two-thirds of the accidents; this resulted in conversion to
performed under local anesthesia. However, numerous an open procedure in 11.3 per cent. Visceral injuries
reports have revealed the relative absence of anesthesia- occurred in 0.6/1000 interventions, and the conversion
related complications, probably associated with proper rate was 65 per cent. The incidence of vascular injuries
patient selection.4,5 If a medical contraindication, other was 0.5/1000, and resulted in six deaths (17 per cent); the
conversion rate to laparotomy was 85 per cent. The two with the conventional techniques, ranging from 0.3 to
most important risk factors were inexperienced surgeons 5 per cent.12
and the introduction of the first trocar, which was respon-
sible for 83 per cent of vascular injuries, 75 per cent of
bowel injuries, and 50 per cent of local hemorrhage. Vas deferens complications
Complications are theoretically different depending
upon the laparoscopic technique (TAPP or TEP). In TEP, The incidence of vas deferens injuries is about the same
because there is no invasion of the abdominal cavity, major (about 0.04 per cent) regardless of whether the hernia
intracavity injuries are very rare. However, there have repair is performed open or laparoscopically. Trauma to
been reports of enterotomies resulting from the tearing of the vas deferens can be one of immediate transection or
adhesions during extraperitoneal balloon dissection.5 ultimate obstruction. Transection is a very rare mishap
Another complication related to the laparoscopic following TAPP or TEP repair. If this does occur, then
approach is trocar site incisional hernia. Although quite repair must be attempted unless fertility is not a con-
uncommon, this is associated particularly with TAPP sideration. Obstruction can result from the vigorous
repair. Because the incidence varies from five to 15 per handling of the vas deferens with instruments/graspers,
cent, it is recommended that all port sites over 5 mm yielding a fibrosis of variable intensity through the mus-
should be closed in order to avoid this postoperative cular wall of the vas deferens. Sometimes, the vas defer-
complication. ens may become adherent to the posterior inguinal floor
following the operation and form kinks that may repre-
sent an outflow obstruction and hence account for
ORGAN INVOLVEMENT dysejaculation.
Almost all organ complications that follow the laparo- HYDROCELE

scopic 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 This is an uncommon complication following either
and colleagues in 1994,7 Phillips and colleagues in 1995,8 laparoscopic approach. It may be secondary to overzealous
and Crawford and Phillips in 19989 reported complica- skeletonization of the spermatic cord or tissue dissection
tion rates in the order of 11 per cent. Roll and coworkers, from the sac and at the internal ring. Some authors, in
in a large Brazilian multicenter trial of 4000 operated retrospective studies, found a low incidence of hydrocele.
patients, found that the rate of complications was seven When a TEP repair was employed, the incidence reported
per cent.10 Felix and colleagues in 1999 reported an inci- varied from 0.5 to 1.5 per cent.13,14 Felix and coworkers, in
dence of complications of 6.1 per cent.11 All authors a paper devoted to significant complications following
demonstrated that the incidence of the complications laparoscopic hernia repair, pointed out that the incidence
were significantly higher in the period of the learning of hydrocele was higher in patients with the use of a mesh
curve and could be reduced to less than one per cent with that was modified to place a ‘keyhole’ to accommodate
greater experience. 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
Testicular complications In a study of open repairs by Obney and Chan, the inci-
dence of hydrocele formation was 0.9 per cent.15
The two pertinent complications concerning the testicle
are ischemic orchitis and testicular atrophy. Postoperative
inflammation of the testicle occurs within 24–72 hours fol-
SEROMA
lowing the procedure. The associated pain is severe, usu-
ally requiring aggressive and effective analgesia. Ischemic
orchitis may progress, resulting in testicular atrophy, a Seromas represent an exudate, normally resulting from the
process that may be observed over several months. The trauma of electrocautery, balloon dissection of the pre-
mechanism of this complication originates from an intense peritoneal space in the TEP approach, scissors dissection,
venous congestion within the testicle, secondary to throm- or foreign bodies, such as sutures and mesh. They are
bosis of the veins within the spermatic cord. The initiating infrequently clinically evident and usually they can be
trauma is seen during dissection of the spermatic cord allowed to reabsorb spontaneously. Size may vary, and
from the hernia sac, whether for direct, indirect or femoral ultrasound follow-up may be important to determine
hernias, or the TAPP or TEP procedure. The incidence of whether needle aspiration and/or drainage is necessary.
testicular complications is lower with laparoscopy than Several publications have discussed whether the incidence
Complications and their management 91
of seromas is more common in the TEP or the TAPP The aggressiveness of the dissection and complete parietal-
approach. Studies by Felix and colleagues,11 Ramshaw and ization of the cord structures is the probable cause. Injuries
colleagues,16 D’Allemagne and colleagues,17 Kald and col- of the aorta were described during TAPP, either secondary
leagues,18 and Cohen and colleagues19 revealed different to the first blind trocar or during dissection in the inappro-
results regarding the higher incidence of seroma in the priate location and resultant injury to the terminal aorta.20
TEP approach. It seems plausible that the use of balloon The introduction of prosthetic materials originally
dissection in TEP repair can be more aggressive to the pre- raised some concerns with regard to their proximity to
peritoneal space than the TAPP technique. Consequently, arteries and veins. Flat sheets of prosthetic materials
it appears that seromas following TAPP are often smaller have not been associated with vascular erosions and
and easier to manage than those that follow TEP. thrombosis.21
Additionally, it is quite rare for a seroma to become encap-
sulated with such a strong fibrotic capsule that resection is
required.
NEUROPATHY
Residual neuralgia following laparoscopic hernia repair

VASCULAR INJURY represents the most vexing complication of the inguinal
region. The absence of convincing objective tests and the
Bleeding from arteries or veins can occur at all anatomic subjective nature of the complaints do not favor an easy
levels during an inguinal hernia repair. Superficially, sub- resolution of the problem.
cutaneous hematomas or severe ecchymoses can result The femoral branch of the genitofemoral nerve, the
from injuries to superficial vessels, such as the epigastric lateral cutaneous nerve of the thigh, and the intermediate
artery or vein. The dissection in the space of Bogros dur- cutaneous branch of the femoral nerve are at risk of dam-
ing TAPP, if careless, may incur bleeding that is usually age during laparoscopic inguinal hernioplasty because of:
insidious and may result in large hematomas that can
extend from the anterior abdominal wall to the scrotum. • a failure to appreciate the anatomy from the
posterior aspect;
During TEP, it is recommended after balloon insertion
and insufflation to keep the balloon full of air for five to • difficulty in visualizing the nerves pre-peritoneally;
seven minutes to allow for better hemostasis. • the variable course of the nerves in this region;
Injuries below the iliopubic tract to the major vessels, • improper staple placement;
such as the iliac and femoral artery and vein, can occur • extensive pre-peritoneal dissection.
and obviously must be controlled swiftly. All control of The incidence of neurological complications varies
bleeding must be done under direct vision. Blind clamp- with the technique (TAPP, 1.2–2.2 per cent; TEP, 0–0.5
ing and the use of deep suture ligatures must be avoided. per cent).22,23
Careful postoperative observation must be instituted, and The main clinical features of genitofemoral nerve
early detection of vascular complications is important. injury consist of intermittent or constant pain and burn-
Injury to the inferior epigastric vessels is not infre- ing sensations in the inguinal region, with radiation of
quent during the learning curve. As this injury is diag- pain to the genitalia and upper medial thigh. As the
nosed, the vessels should be clamped; posterior clip mechanism of injury is defined poorly, its diagnosis may
ligation is the desirable treatment. No adverse sequelae be imprecise and available treatment options are varied.
have been reported when the inferior epigastric vessels The best way to minimize this kind of complication is to
have been ligated. avoid any extensive dissection of the posterior pelvis and
The presence of an aberrant obturator artery origi- to avoid placement of staples or tacks below the iliopubic
nating from the deep inferior epigastric artery can be tract, thereby keeping far away from the triangle of doom
the source of bleeding when tacks or staples are anchored and the trapezoid of disaster (Figure 12.1).24 A study in 50
to the ligament of Cooper. Care must be taken, and cadaveric inguinal regions by Rosen and Halevy demon-
acknowledgment of its existence underneath the mesh is strated that the mean safe distance to avoid any possible
very important. If this bleeding is managed poorly, the contact with the genitofemoral nerve or the lateral
result can be a bloody operative field that can be an femorocutaneous nerve during fixation is 3.95 cm lateral
obstacle to the completion of the procedure. This dan- to the internal inguinal ring.25 To take all anatomic vari-
gerous injury must be avoided. This complication has ations into account, Rosen and Halevy recommended
earned the artery the unenviable designation of the placement of staples no further than 1.5 cm lateral to the
‘artery of death’. lateral border of the internal inguinal ring. This location
Injuries to the spermatic vessels are more common dur- of fixation, in addition to the non-extensive dissections
ing the learning curve for both TAPP and TEP procedures. and the avoidance of manipulation or stapling below the
of the pain. Electromyography may also be helpful.

The management is controversial and multimodal.
Initial efforts at clinical control with non-steroidal anti-
inflammatory drugs, rest, and eventually infiltration with
local anesthetics are frequently helpful. If inguinodynia
persists, and sensory/motor deficit is present on examina-
tion, 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 ten-
derness persists with positive Tinel’s sign, then removal of
the staple/tack or mesh or neurectomy may be required.
If re-exploration is undertaken, care must be exer-
cised during the removal of the staples/tacks and/or
(a) 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
Laparoscopic hernia repair is associated with urinary

complications with an incidence of 1.5–5 per cent,
(b) 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 pre-
peritoneal space or space of Retzius, such as a prior
laparoscopic hernia repair or prostatectomy.
Intestinal complications
Bowel obstruction is almost unheard of with conventional
repair, but it can be associated with the laparoscopic
(c) approach, particularly TAPP. However, its incidence in
the literature is low, ranging from 0.06 to 0.2 per cent.27
Figure 12.1 (a) TAPP – anatomical view: (1) Cooper’s ligament; The complication was frequent in the developmental
(2) vas deferens; (3) spermatic cord; (4) nerve area below the stages secondary to inadequate peritoneal closure over
iliopubic tract; (5) iliopubic tract; (6) internal ring. (b) Black the prosthesis, allowing bowel to migrate into the pre-
area, triangle of doom; red area, trapezoid of disaster. peritoneal space, which could result in intestinal obstruc-
(c) Recurrence Mesh invagination in the defect. tion. The major advantage of the TEP procedure is the
theoretical avoidance of this problem, as the peritoneal
iliopubic tract, are the most effective tools to avoid sheath is kept untouched.
neuralgia paresthetica that may follow the laparoscopic Another situation, related almost solely to TAPP
approach to groin hernias. repair, is the lack of appreciation of the need to close
The ilio-inguinal nerve and the ilio-hypogastric nerve trocar sites. If one considers any hernia as a part of a
are more superficial structures, making them easier to systemic abdominal wall disease, then it is mandatory to
injure in open repair than in the laparoscopic method. close all fascial defects, avoiding potential port site her-
Diagnosis can be made after careful anatomical localization nias. The incidence of delayed bowel obstruction related
to adhesions because of the intra-abdominal nature of required, due to their pore diameter, the inability of
TAPP has yet to be determined but would appear to be drainage through them, and impaired macrophage
extremely low. migration and activity.
Intraoperative laceration of incarcerated or sliding When systemic conditions are unstable and sepsis is
(large bowel) hernias must be avoided and currently are present, an aggressive surgical approach is the rule. One
reported rarely. Following general principles of gentle should never forget, however, that removal of an infected
surgical technique, this kind of problem should seldom mesh could be perilous, as firm adhesions to local struc-
be found. tures 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
Bone complications Rarely, delayed infections may be seen months or years
later. The mechanism in this delay is not understood.
Bone-related complications were very rare before the
Conservative management is the choice, and mesh
laparoscopic era. Today, osteitis pubis after the learning
removal is required rarely, subject to the above discussion.
curve is an avoidable complication. The usual mecha-
nism of injury is tacking/stapling the mesh while anchor-
ing it over the periosteum. Oral analgesia and eventually Mesh and infertility
local infiltration may be a good way to initiate treatment
of this complication. If unsuccessful, re-exploration with Although infertility is not usually reported after hernia
tack/staple removal is the best alternative to treat such a repair, a few reports from fertility clinics have shown an
painful complication. It is a personal observation that association of infertility and previous hernia repair,
pubic pain is more frequent when employing tacks rather without accounting for vas deferens injuries or ‘over-
than the regular hernia staples, probably due to their manipulation’. The placement of large meshes in the pre-
penetration into the bone. peritoneal space in TAPP or TEP repair may lead to
fibrosis in the proximity of the vas deferens and may pre-
dispose to an unknown effect on its function, without any
Skin complications clear vas luminal obstruction. Further studies are needed.
It should be noted that it is important to avoid extensive
In major series, ecchymoses and subcutaneous emphy-
manipulation of the cord structures and vas deferens in
sema were reported, but these are self-limiting and with-
men of reproductive age to avoid affecting fertility.
out 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.
RECURRENCE
MESH-RELATED PROBLEMS As stated by Rutkow in 1995, recurrences are not a param-

eter of success in the surgical repair of groin hernias;29
rates higher than three per cent are unacceptable, and
The introduction of prosthetic mesh in an inguinal
if any technique reports recurrences higher than that
hernioplasty is a standard procedure today. Mesh place-
number, then it should be abandoned. However, despite
ment allows tension-free repair, leading to significantly
Rutkow’s reasonable ideas on recurrence, and the increas-
lower recurrence rates, but its main complication – infec-
ing popularity of the comparison of outcomes by mea-
tion – poses a series of special management problems.
surement of postoperative pain, return to work, patient
The use of monofilament biomaterials carries a theoretic
satisfaction, and cost, the standard by which any repair is
advantage over the braided biomaterials. Pores in braided
measured is its recurrence rate. That rate in laparoscopic
yarns and expanded polytetrafluoroethylene (ePTFE) are
techniques has fallen gradually as experience and knowl-
smaller than macrophages, which implies that an infec-
edge of the anatomy and mesh sizes have improved.
tion associated with these types of mesh affects its man-
Recurrence may be due to a variety of mechanisms,
agement. The presence of infection does not necessarily
including:
mandate removal of a polypropylene or polyester mesh,
unless the mesh is sequestered or is bathing in a puru- • incomplete dissection, with missed hernias,
lent exudate. The infection is predominantly in the sur- inadequate identification of anatomical landmarks,
rounding tissue, and abscess drainage and aggressive and the prosthesis being allowed to roll up instead
clinical management with broad-spectrum antibiotics of lying flat;
are required. However, when a braided mesh or ePTFE • mesh being too small, therefore not covering all
prosthesis is employed, their removal is almost always potential defects;
Table 12.1 Recurrences in large multicenter trials REFERENCES

Mean
No. Recurrence follow-up 1 Arvidsson D, Smedberg S. Laparoscopic compared with open
Reference Repair hernias (%) (months) hernia surgery: complications, recurrences and current trends. Eur
J Surg 2000; 585: 40–47.
Tetik et al. TAPP 553 0.7 13 2 Moreno-Egea A, Aguayo JL, Canteras M. Intraoperative and
(1994)7 TEP 457 0.4 postoperative complications of totally extraperitoneal
laparoscopic inguinal hernioplasty. Surg Laparosc Endosc 2000;
Fitzgibbons TAPP 562 5 23
10: 30–33.
et al. (1995)27 TEP 87 0 3 Baadsgard SE, Egelblad K. Major vascular injury during
Phillips et al. TAPP 1944 1 22 gynecologic laparoscopy: report of a case and review of published
(1995)8 TEP 578 0 cases. Acta Obstet Gynecol Scand 1989; 68: 283–5.
4 Champault G, Cazacu F, Taffinder N. Serious trocar accidents in
laparoscopic surgery: a French survey of 103,852 operations. Surg
Laparosc Endosc 1996; 6: 367–70.
5 Topal B, Hourlay P. Totally preperitoneal endoscopic inguinal
• migration of the mesh; hernia repair. Br J Surg 1997; 84: 61–3.
• mesh slit (the slit is the site of the recurrence); 6 Bendavid R. Complications of groin hernia surgery. Surg Clin N Am
• folding or invagination of the mesh into the defect; 1998; 78: 1089–2000.
• displacement of the mesh by hematoma. 7 Tetik C, Arregui M, Castro D. Complications and recurrences
associated with laparoscopic repair of groin hernias: a multi-
The first reports with the abandoned laparoscopic institutional retrospective analysis. In: Arregui M, Nagan RF, eds.
plug or plug-and-patch reported recurrence rates of Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe
Medical Press, 1994: 494–500.
25 per cent.30 As experience and knowledge of the anatomy 8 Phillips EH, Arregui M, Caroll BJ, et al. Incidence of complications
and mesh size have grown, so recurrence rates have following laparoscopic hernioplasty. Surg Endosc 1995; 9: 16–21.
decreased. Evaluation of large multicenter trial results 9 Crawford DL, Phillips EH. Laparoscopic repair and groin hernia
reveals the low recurrence rates for TEP (Table 12.1). surgery. Surg Clin N Am 1998; 78: 1047–62.
Tetik and coworkers reported a 0.4 per cent incidence of 10 Roll S, Cohen R, Miguel P, et al. Laparoscopic transabdominal
inguinal hernia repair with preperitoneal mesh. Surg Endosc 1994;
recurrence in TEP,7 whereas no recurrences were reported 8: 485.
in 578 patients by Phillips and colleagues8 or in 87 repairs 11 Felix EL, Harbetson N, Vartanian S. Laparoscopic hernioplasty.
by Fitzgibbons and colleagues.27 It is important to stress Significant complications. Surg Endosc 1999; 13: 328–31.
that the vast majority of surgeons throughout the world 12 Cohen RV. Laparoscopic transabdominal preperitoneal hernia
began their experience and learned the TAPP procedure repair. Doctoral thesis presented to the Department of Surgery,
University of Sao Paulo, Brazil. Sao Paulo, Brazil: University of Sao
first; TEP came later, bringing more comfort with the Paulo Press, 1996: 43–57.
anatomy and handling the mesh better. Adoption of the 13 Ferzli G, Massad A, Albert P. Extraperitoneal endoscopic inguinal
TEP technique by many of these surgeons occurred later, hernia repair. J Laparoendosc Surg 1992; 2: 281–5.
thereby providing a higher level of comfort with the 14 McKernan B, Laws HL. Laparoscopic repair of inguinal hernias
anatomy, and better handling and sizing of the mesh using a totally extraperitoneal prosthetic approach. Surg Endosc
1993; 7: 26–8.
for the laparoscopic procedure. This may explain the 15 Obney N, Chan CK. Hydrocoeles of the testicle complicating
relatively lower recurrence rates with TEP than with inguinal hernias. Can Med Assoc J 1956; 75:733–6.
TAPP in these large trials. 16 Ramshaw B, Tucker JG, Conner T, et al. A comparison of the
approaches to laparoscopic herniorrhaphy. Surg Endosc 1996;
10:29–32.
17 D’Allemagne B, Markiewicz S, Iehaes C. Extraperitoneal
CONCLUSION laparoscopic inguinal hernia repair: technique and results. Surg
Endosc 1996; 10: 228–34.
18 Kald A, Anderberg B, Smedh K. Transperitoneal or totally
Over the past 15 years, laparoscopic hernioplasty has extraperitoneal approach in laparoscopic hernia repair. Surg
made the transition from an experimental to a proven Laparosc Endosc 1997; 7: 86–9.
procedure. With increasing laparoscopic skills, many 19 Cohen RV, Alvarez G, Roll S, et al. Transabdominal or totally
surgeons are now faced with the question of when to extraperitoneal hernia repair? Surg Laparosc Endosc 1998; 8: 264–8.
20 Oshinsky GS, Smith AD. Laparoscopic needles and trocars: an
recommend a laparoscopic approach to their patients.
overview of designs and complications. J Laparoendosc Surg 1992;
Complication and recurrence rates, although initially 2: 117–25.
higher than traditional repairs, have now fallen to equal 21 Kathkouda N. Avoiding complications of laparoscopic hernia
or lower levels at centers experienced in laparoscopic repair. In: Arregui M, Fitzgibbons R, Kathkouda N, eds. Principles of
techniques. Prospective randomized trials prove that when Laparoscopic Surgery: Basic and Advanced Techniques. New York:
Springer-Verlag, 1995: 435–8.
patients are selected properly and surgeons are trained,
22 Starling JM. Genitofemoral neuralgia. In: Arregui M, Nagan RF,
TAPP or TEP repairs may be performed with reasonable eds. Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe
rates of complications and recurrence. Medical Press, 1994: 213–17.
23 Eubanks S, Newman L, Goehring L, et al. Meralgia paresthetica: a 28 MacFadyen BV. Laparoscopic inguinal herniorrhaphy:
complication of laparoscopic herniorrhaphy. Surg Laparosc Endosc Complications. In: Arregui M, Nagan RF, eds. Inguinal Hernia:
1993; 3: 381–5. Advances or Controversies? Oxford: Radcliffe Medical Press, 1994:
24 Seid AS, Amos E. Entrapment neuropathy in laparoscopic 284–96.
herniorrhaphy. Surg Endosc 1994; 8: 1050–53. 29 Rutkow I. The recurrence rate in hernia surgery. How important is
25 Rosen A, Halevy A. Anatomical basis for nerve injury during it? Arch Surg 1995; 130: 575–8.
laparoscopic hernia repair. Surg Laparosc Endosc 1997; 7: 469–71. 30 Schultz L, Graber J, Pietrafitta J. Laparoscopic laser herniorrhaphy:
26 Payne JH. Complications of laparoscopic herniorrhaphy. Semin a clinical trial preliminary study. J Laparoendosc Surg 1990; 1:
Laparosc Surg 1997; 4: 166–81. 41–5.
27 Fitzgibbons RJ, Camps J, Cornet DA, Annibali R. Laparoscopic
inguinal herniorrhaphy: results of a multicenter trial. Ann Surg
1995; 221: 3–13.
PART
3
Laparoscopic incisional and
ventral hernioplasty
13 History 99 19 Parastomal hernia repair 143

14 Anatomy and physiology 103 20 Lumbar hernia and ‘denervation’ hernia repair 151
15 Laparoscopic repair in the emergent setting 111 21 Results of laparoscopic incisional and ventral
16 Herniorrhaphy with the use of transfascial sutures 115 hernia repair 155
17 Pre-peritoneal herniorrhaphy 125 22 Complications and their management 161
18 Hernioplasty with the double-crown technique 133
13
History
KRISTI L. HAROLD, BRENT D. MATTHEWS AND B. TODD HENIFORD
Laparoscopic ventral herniorrhaphy 99 Conclusion 100

Adoption of procedure 100 References 100
Ventral hernias present a challenging surgical problem. to the armamentarium of biomaterials in the 1970s and
Approximately 3–11 per cent of all laparotomy incisions has become a popular prosthetic for ventral/incisional
develop a fascial defect, resulting in 90 000 ventral hernias hernia repair.3
repairs each year.1 Due to the high rate of recurrence with The introduction of tension-free repair with bio-
simple suture closure, the techniques of hernia repair materials has drastically reduced the recurrence rate of
have evolved from primary repair to those employing abdominal wall hernias. In several studies, the addition
biomaterials. More recently, surgeons’ options have of prosthetic mesh has reduced hernia repair failure
expanded to include repairs using minimally invasive by more than 50 per cent.4 Nevertheless, the techniques
approaches. developed by Stoppa and others to employ meshes
Primary repairs involve suturing of the aponeurotic for repair involve large areas of tissue-flap dissection
layers of the abdominal wall to close defects, along with and create significant patient morbidity, including
unique variations such as the ‘vest-over-pants’ technique wound complications, infection, a need for drains, and
developed by William J. Mayo in 1895. To repair large pain.5
defects, in the 1920s Gibson introduced the concept of Advances in minimally invasive surgery prompted the
relaxing incisions, which allowed closure of the abdomi- first attempts at laparoscopic ventral hernia repair in the
nal wall in the midline with reduced tension.2 Despite the early 1990s.6 These techniques eliminated the need for
various and inventive techniques for primary repair, the wide soft-tissue dissection and large incisions, and it was
recurrence rate after primary repair remained unaccept- hoped that there would be a corresponding decrease
ably high, spurring the development of biomaterials in morbidity, such as was seen in the transition from
to repair abdominal wall defects in the first half of the conventional to laparoscopic cholecystectomy.
twentieth century.
The first biomaterials employed for hernia repair were
metallic. Silver wire mesh, tantalum mesh, and stainless-
LAPAROSCOPIC VENTRAL
steel mesh were all used in an attempt to create stronger
HERNIORRHAPHY
hernia repairs. The metallic prostheses, however, led to
problems such as erosion, fragmentation, fistulas, and
patient intolerability. Hence, a variety of synthetic poly- Initial laparoscopic ventral hernia repairs were usually
meric meshes were developed, leading to a revolution in performed by placing a large intraperitoneal prosthesis
hernia repair. Francis Usher introduced monofilament and securing it to the anterior abdominal wall with her-
polypropylene mesh in 1958, and today this is the most nia staples or spiral tacks.6–8 Recurrences secondary to
commonly used mesh. Polyester mesh, which is very the mesh pulling free from the abdominal wall or migra-
popular in Europe, was also introduced in the 1950s. tion with the peritoneum into the hernia prompted most
Expanded polytetrafluoroethylene (ePTFE) was added surgeons to adopt a fixation technique that employs
100 Laparoscopic incisional and ventral hernioplasty
transfascial non-absorbable sutures in addition to staples Table 13.1 Number of articles published
or tacks to secure the mesh.7,9 Surgeons also recognized concerning laparoscopic ventral hernia
that the lack of overlap of the defect by the prosthesis repair by year (Medline and Embase search)
contributed to recurrent hernia formation.10 This has
Publication Number of
led to the recommendation that at least a 3-cm overlap year articles published
be provided circumferentially. Many surgeons advocate a
4–6-cm circumferential overlap if the mesh can be placed 2001 18
without undue technical difficulty. We and others often 2000 19
1999 11
underlay the entire previous incision, even if it is not
1998 13
involved with the hernia, to prevent the development of
1997 9
another hernia above or below the repaired defect. 1996 12
The choice of prosthetic material for laparoscopic ven- 1995 8
tral hernia repair is varied and often debated. By far, how- 1994 13
ever, the most frequently used mesh has been expanded 1993 3
polytetrafluoroethylene (ePTFE). While some authors 1992 3
have reported the use of polypropylene or polyester mate-
rials for laparoscopic ventral herniorrhaphy without
complication,8 these biomaterials lead to adhesion for-
mation and have been associated with intestinal erosion CONCLUSION
and fistula formation in up to five per cent of patients
when placed intraperitoneally.11 Accordingly, the trend The future of laparoscopic ventral and incisional hernia
has been toward the use of PTFE in most hospitals. 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.
ADOPTION OF PROCEDURE 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
While laparoscopic inguinal herniorrhaphy enjoyed a invasive approach is a positive milestone in the history of
rather quick acceptance after its introduction, the popu- hernia surgery.
larity of laparoscopic ventral hernia repair has arrived
somewhat more slowly. This can probably be attributed
to the inherent difficulty of the adhesiolysis in the previ-
ously operated abdomen and the need for surgeons with REFERENCES
limited laparoscopic experience to apply large pieces of
mesh. A search of Medline and Embase demonstrated 1 Mudge M, Hughes LE. Incisional hernias: a 10-year prospective
only three articles concerning the procedure published study of incidence and attitudes. Br J Surg 1985; 72: 70–71.
in 1992, the year that laparoscopic ventral herniorrha- 2 Flament JB, Palot J, Burde A, et al. Treatment of major incisional
hernias. In: Bendavid R, Abrahamson J, Arregui M, et al., eds.
phy was introduced. However, interest in the technique Abdominal Wall Hernias: Principles and Management. New York:
increased, and by 1994, 13 publications were posted. Springer-Verlag, 2001: 508–16.
There has been a steady or increasing number since that 3 DeBord JR. The historical development of prosthetics in hernia
time, and now more than 100 peer-reviewed articles surgery. Surg Clin North Am 1998; 78: 973–1006.
concerning laparoscopic ventral hernia have been pub- 4 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
lished (Table 13.1). Additionally, the number of patients 2000; 343: 392–8.
included in single and multi-institutional studies has 5 White TJ, Santos MC, Thompson JS. Factors affecting wound
continued to grow. Currently, well over 1000 patient out- complications associated with prosthetic repair of ventral hernias.
comes have been reported in peer-reviewed articles, and Am Surg 1998; 64: 276–80.
one manuscript details the outcomes of more than 400 6 LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal
hernias using expanded polytetrafluoroethylene: preliminary
patients.9 findings. Surg Laparosc Endosc 1993; 3: 39–41.
Use of the technique for laparoscopic ventral hernior- 7 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
rhaphy has also been reported in cases of unusual defects, incisional and ventral herniorrhaphy: our initial 100 patients.
such as lumbar hernias, parastomal hernias, and diaphrag- Hernia 2001; 5: 41–5.
matic hernias.12–14 While the number of patients in these 8 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and
incisional hernioplasty. Surg Endosc 1997; 11: 32–5.
series is small, the outcomes have been positive, and the 9 Heniford BT, Park A, Ramshaw B, Voeller G. Laparoscopic ventral
laparoscopic approach seems uniquely suited for defects and incisional hernia repair in 407 patients. J Am Coll Surg 2000;
located in challenging anatomical locations. 190: 645–50.
History 101
10 LeBlanc KA. The critical technical aspects of laparoscopic 12 Arca MJ, Heniford BT, Pokorny R, et al. Laparoscopic repair of
repair of ventral and incisional hernias. Am Surg 2001; 67: lumbar hernias. J Am Coll Surg 1998; 187: 147–52.
809–12. 13 LeBlanc KA, Bellanger DE. Laparoscopic repair of paraostomy
11 Leber GE, Garb JL, Alexander AI, Reed WP. Long-term hernias: early results. J Am Coll Surg 2002; 194: 232–9.
complications associated with prosthetic repair of incisional 14 Matthews BD, Bui H, Harold KL, et al. Laparoscopic repair of
hernias. Arch Surg 1998; 133: 378–82. traumatic diaphragmatic hernias. Surg Endosc 2003; in press.
14
KARL A. LEBLANC
Anatomy and function 103 Maturation of the hernia repair 108

Anatomy of a hernia 105 Cosmetic result 109
Anatomical considerations in the repair of Functional result 109
abdominal wall defects 106 Conclusion 110
Effects of biomaterial placement in laparoscopic References 110
herniorrhaphy 107
The abdominal wall is a complex structure with a multi- This hernia, in turn, can result in complications such as
tude of components, including skin, muscles, aponeu- incarceration, strangulation, loss of domain, and signifi-
roses, fat and mesothelium. This musculo-aponeurotic cant cosmetic deformities. Therefore, the approximation
structure is attached to the vertebral column posteriorly, of the abdominal wall as the final act of laparotomy
the pelvic bones inferiorly, and the ribs superiorly. The should be considered to be as important as the intra-
integrity of the abdominal wall is essential for protecting abdominal procedure that necessitated the incision. This
the underlying organs, allowing for movement of the represents the optimum opportunity to avert the devel-
trunk of the body, providing assistance in respiration, opment of herniation in the future.
and preventing herniation of the intra-abdominal con- Once a hernia has developed and a surgeon is to repair
tents. Breaches in this integrity can occur with incisions, the fascial defect, many considerations influence the
drainage tubes, and postoperative complications. Further- herniorrhaphy or hernioplasty chosen, whether open or
more, the closure of the incisions is affected by the method laparoscopic. The aim of this chapter is to familiarize the
of closure, the type of suture used, and the development of laparoscopic hernia surgeon with a working knowledge of
wound sepsis. Recent studies have even identified that the anterior abdominal wall. This understanding is
the suture technique, the suture length to wound length important because the anatomical basis of the repair of
ratio, and the suture tension have an effect on the ultra- incisional and ventral hernias is necessary to assure an
structural composition of the regenerating tissue and optimal result, structurally, functionally and cosmetically.
collagen composition.1
Despite the importance of this portion of the body,
many surgeons have little knowledge of the anatomical
ANATOMY AND FUNCTION
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 The functional anatomy of the abdominal wall centers
that requires access to the abdomen and sometimes the upon the flat muscles that provide protection and reten-
retroperitoneum. The factors that influence both the tion of the abdominal viscera. These muscles also pro-
prevention and development of hernias are frequently vide assistance in respiration and allow movement of the
overlooked during the closure of wounds. The result can mid-portion of the body. These components include the
be predisposition to a fascial defect that will allow extra- rectus abdominus, external oblique, internal oblique,
abdominal migration of the contents of the abdomen. and transversus abdominus muscles.
Rectus abdominus muscle anterior iliac spine and the iliac crest. This muscle, in
concert with the internal oblique and the transversus
This muscle extends from the xiphoid process and abdominus muscles, functions to contain the abdominal
the lower rib margins to the pubis. The entire length viscera. Bilateral contraction of the external oblique
of this muscle inserts into the linea alba in the midline of lowers the ribs, thereby bringing the thorax closer to the
the abdomen. Because the linea alba is the site of the pelvic brim. In this manner, it functions as an accessory
most frequent point of entry into the abdomen for open muscle of expiration. Unilateral contraction of this mus-
surgical procedures, this is the site that most commonly cle causes the opposite hemithorax to depress and rotate
becomes the site of herniation. We have found that toward the side of muscle contraction.
approximately 80 per cent of the incisional hernias that The function of this muscle can be compromised by
we repair laparoscopically are located in the midline of the development of the hernias that are located away from
the abdomen.2 The rectus muscle, when contracted, will the midline of the abdomen. Such hernias include sub-
bring the xiphoid and ribs closer to the pubis. It also acts costal incisional, post-appendectomy, post-colostomy and
to contain the viscera in concert with the other flat mus- Spigelian hernias. Because of the lack of re-approximation
cles of the abdominal wall. The function of the rectus will of the edges of the fascial defect during laparoscopic repair,
be compromised after the development of a hernia at the expiratory function will not resume the efficiency that
site of the linea alba. The laparoscopic repair of midline was present before the herniation. The extent of this effect
hernias does not re-approximate the linea alba. A few will be dependent upon the size of the fascial defect and
centers make an effort to close this defect when possible, the tone of the other muscles of the abdomen.
but the vast majority of surgeons make no effort to do so.
Therefore, in most cases the normal function of the rec- Internal oblique muscle
tus is not restored to its native state. The placement of the
prosthetic biomaterial will reconstruct the containment These fibers course beneath those of the external oblique
function of the muscle, but it will improve its motor muscle in an opposite direction. The muscle runs from
functions only minimally, if at all. However, the contrac- the pelvic brim upward and medially to the thoracic cage
tion of the scar of the hernia itself will result in a mild to and the linea alba. The function of the internal oblique
moderate reduction in the size of the gap of the linea alba muscle is similar to that of the external oblique muscle,
in many patients. but its unilateral contraction results in rotation and low-
Some laparoscopic surgeons use the posterior rectus ering of the thorax on the ipsilateral side of the contrac-
sheath of the rectus within which to perform the operation. Consequently, laparoscopic hernioplasty has an
tive procedure and to place the prosthetic material. This effect on the internal oblique muscle that is similar to
posterior rectus sheath is entered, the hernia is reduced, that seen in the external oblique muscle.
and the repair is performed within that space. This
provides for an extraperitoneal operation similar to that
of the laparoscopic inguinal herniorrhaphy and the Transversus abdominus muscle
Rives–Stoppa repair. The space limitations of this opera-
tive field make the approach impractical for very large This innermost muscle layer of the abdominal wall
and/or incarcerated hernias that do not reside within inserts posteriorly on to the lower six ribs, the lumbo-
the rectus sheath, such as Spigelian or lumbar hernias. It dorsal fascia, the iliac crest, and the iliopsoas fascia. It
has also not been proven that this method of repair also inserts on the medial surface of the costal portion of
improves the functionality of the muscles to a greater the lower seven or eight ribs and interdigitates with the
extent than that provided by intraperitoneal placement insertions of the diaphragm. It is a very important com-
of prosthetic biomaterial. The extraperitoneal repair that ponent of respiration as it is the main antagonist of the
is described in Chapter 17 does not afford any differences diaphragm. As such, it could be considered a key muscle
as to the function of the linea alba because it is not of expiratory function. It acts in this role by displacing
re-approximated in this repair. 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
External oblique muscle abdominal wall, the transversus abdominus muscle is
also the major component of the containment function
This outermost layer of the flat muscles of the wall of the of these muscles. Because of its structure, it has a power-
abdomen arises from the lowest seven or eight ribs and ful action that results in traction on the abdominal wall.
courses obliquely downward and towards the midline. It is this action that results in the tendency of the margins
There, it interdigitates with the fibers of the contralateral of the laparotomy incision to separate. This act, of rapid
external oblique. The fleshy muscle fibers insert on the retraction, explains the dehiscence that can occur acutely
with a vertical midline laparotomy incision. It also Most incisional and ventral hernias will be single
accounts for the difficulty encountered during attempts defects within the fascia. The layers of muscle and
to provide closure of the midline following dehiscence or fascia will be displaced from the normal position into
after development of midline incisional hernias. One of all directions from the hernia. This results from the
the advantages of laparoscopic hernioplasty and the use traction effects of the flat muscles of the abdomen.
of a prosthetic biomaterial is that the forces of traction Approximately 22 per cent will be of the multiple defect
by this muscle are diminished. Therefore, the function of (‘Swiss-cheese’) variety.1 In these cases, the muscle will
the transversus abdominus that would weaken or destroy be displaced laterally from the defect, but the fascia will
a tissue re-approximating type of repair is averted. Con- be intact between the hernias. This will create one or
versely, the use of prosthetic material to bridge the gap many ‘fascial bridges’ separating the various hernias. In
that is created by the hernia does little to correct the res- either of these hernia anatomic variations, the peritoneal
piratory function that is lost after such an occurrence. surface of the hernia will then be covered with pre-
Much is known about the function of the muscles of peritoneal fat (if any exists), subcutaneous fat, and the
the abdominal wall before the occurrence of a hernia, but skin of the abdominal wall. In some patients, there may
few studies have examined the effects of the muscle func- be a lack of any tissue between the hernia sac and the
tion after incisions through them or after the develop- skin. If this is encountered, good judgment will dictate
ment and subsequent repair of the hernias. These studies that no energy source, such as electrocautery or ultra-
are needed to assess the ability of these operations to sonic dissection, should be utilized in that area during
restore the function of these muscles other than that of the dissection of adhesions. This will avoid the applica-
the retention of the viscera within the abdomen (see tion of heat in the area, which might otherwise cause
below). 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
ANATOMY OF A HERNIA procedure to be performed. Because of this, some
patients may have separate and distinct hernias in more
Approximately 90 per cent of non-inguinal hernias of than one location. This is not infrequent in patients who
the abdominal wall result from an incision through the have temporary colostomies placed after diverticular
aponeurotic layer. The loss of integrity of the transver- perforation of the colon. These are particularly well
salis fascia predates its development. Additionally, poor suited for the laparoscopic approach as both hernias can
nutritional status, infection, pulmonary disease, steroid be repaired simultaneously without the requirement of
usage, and morbid obesity can potentiate the weakening two separate incisions. A similar situation is seen in
effects of such an incision. Initially, one may not recog- patients who present with both incisional and inguinal
nize that a hernia has developed as it could take several hernias.
months for this to become apparent. Sometimes, how- The tissue disruption that can be seen following the
ever, a postoperative incisional infection will be of such flank incisions for anterior lumbar interbody fusions and
severity so as to delineate the fascial defect before dis- nephrectomies are not usually hernias. This problem is
charge of the patient from hospital. There is a five-fold not a true defect in the fascia but is the result of denerva-
increase in the occurrence of incisional hernias following tion of the musculature caused by the incision itself. The
an infection in the wound. flat layer of muscles becomes paralytic. This loss of tissue
The edges of the fascial defect may be difficult to support results in a broad area of weakness that is
demarcate preoperatively by the surgeon because of unsightly and frequently symptomatic. While there is no
obesity and/or incarceration. The muscle layers will be true fascial defect in the usual case, occasionally one will
forced aside from the herniation of the pre-peritoneal note intestinal contents in a fascial defect within the area
tissues or intra-abdominal contents. The herniated struc- of muscle paralysis (see Chapter 20).
tures can be pre-peritoneal fat, omental fat, or small or Finally, hernias that occur without a premorbid event
large intestine. Rarely, other organs can herniate. Fre- are known as primary hernias. These include epigastric
quently, these organs will be fixed to one another due to and umbilical hernias. These can represent 10–20 per
adhesions that have developed after the initial operation. cent of abdominal-wall hernias in most series (excluding
Generally, as the number of the intra-abdominal opera- inguinal hernias). These patients, however, will incur a
tions increases, so does the probability of encountering weakness in the transversalis fascia that results in hernia-
more numerous and denser adhesions. Each additional tion of pre-peritoneal fat and/or the intra-abdominal
operative procedure increases these odds, especially if the contents (Figure 14.1). Predisposing factors include low
patient has had a previous hernia repair using a polypropy- birth weight, steroid usage, pulmonary disease, urologi-
lene mesh. cal disorders, trauma and obesity. Despite the origin, the
cosmetic results for the patient. Unfortunately, this

method of repair is fraught with a recurrence rate of
25–51 per cent in most centers.4,5 In many patients, re-
approximation 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 recur-
rence to 10–25 per cent.2,6 The manner of placement of
this biomaterial can vary widely, however.7 The biomate-
rial can be placed intraperitoneally, extraperitoneally,
below the rectus muscle, above the rectus muscle, or
above the fascia. Additionally, there are several methods
Figure 14.1 Attenuated epigastric fascia (arrows) in a patient by which to handle the fascial defect itself during the
with an umbilical hernia. 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
concepts of the laparoscopic repair of these hernias are the mesh.8
not changed. Additionally, methods of fixation of biomaterial vary
There is only limited information regarding the func- greatly across the world. Indeed, it is very common for
tion of the abdominal wall once herniation develops. Of the method of fixation to vary between staff of a single
course, the development of a hernia mandates a loss of institution. Thus, a comparison of the method of pros-
the retention function of the muscles of the abdominal thetic repair of open incisional hernias can be difficult
wall. It is felt that there is also a decrease in the respira- and inaccurate.
tory function of the flat muscles as they have now been Proponents of the laparoscopic repair of incisional
compromised. With chronic incisional herniation, the and ventral hernias share the common belief that an
affected muscles are no longer inserted into the midline effective repair of the defect requires the insertion of a
and are initially hypertonic. Over time, these muscles prosthetic biomaterial. Only the very smallest of hernias
undergo ultrastructural changes that result in hypo- (⬍1–1.5 cm) are closed with sutures alone, although
tonicity. The resultant musculofascial changes increase most series have not mentioned this.9 The method of
the risk of recurrence with the sutured repair. For this fixation and the location of the prosthetic can vary, as with
reason, the use of a prosthesis is preferred. open repair. The biomaterial can be placed intraperi-
Large hernias can result in a paradoxical motion of the toneally, extraperitoneally, or behind the rectus muscle
abdominal wall with respiration. As the diaphragm is but within the rectus sheath. Most commonly, however,
moved inferiorly to inspire, this action increases the intra- it is placed in the intraperitoneal position. The method
abdominal pressure, which then forces the hernia out- of fixation is usually with tacks alone or with tacks and
ward. In this case, the respirations are shallower than transfascial sutures. Other fixation devices are also avail-
normal, which can be revealed as exertional dyspnea. This able (see Chapter 4). It appears that in only one pub-
will worsen as the hernia enlarges, but compensatory lished series has there been a concerted effort to close the
mechanisms will normalize the respiratory exchanges at fascial defect;10 it has not been the practice in other pub-
the expense of increased respiratory work.3 lished 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
ANATOMICAL CONSIDERATIONS IN THE
defect will place tension on the repair and offer no
REPAIR OF ABDOMINAL WALL DEFECTS
improvement in outcome.
The anatomical considerations of the closure of the
The goal of abdominal-wall hernioplasty is the restora- fascial defect and, in most cases, the linea alba will be the
tion of the integrity of the covering of the abdominal reconstitution of the normal anatomy and function of
contents. The oldest method by which to do this is the the anterior abdominal wall. It has not been proven that
sutured technique of herniorrhaphy. This method will any long-term benefits will be seen if this is done. Many
approximate the linea alba and attempt to restore the proponents of open repair will insist on the approx-
normal architecture of the abdominal wall. It is felt that imation of the linea alba, as it is felt that this will
this will provide the best long-term functional and restore the respiratory function of the abdominal wall.
This can be done in many but certainly not all cases of motion of the hernia and its contents in relation to the
herniation within the abdominal wall (other than normal movements of the abdominal wall. This may be
inguinal and femoral defects). Hernia defects that are enhanced over time as the healing process results in
larger than 5 cm2 are unlikely to be repaired, primarily the contraction of the original fascial defect.
because re-approximation of the fascial edges is usually The method of fixation could potentially impact the
not possible. Should one accomplish this closure, then the function of the abdominal-wall musculature, although
repair of most of these hernias will result in a consider- this has never been studied. The use of tacks, coils or
able amount of tension. The success of both open and other fixation devices alone in the fixation of biomaterial
laparoscopic hernia repair depends on the elimination of may not allow the prosthesis to act in tandem with the
tension on the tissues. This can be accomplished, in the muscles, as would the use of transfascial sutures. These
majority of patients, only with the use of a prosthetic bio- devices will penetrate only 3–4 mm, thereby attaching
material. The question of the anatomical modification of the biomaterial to the posterior layers of the transversus
the laparoscopic approach becomes moot if acknowledg- abdominus and possibly the internal oblique muscles. It
ment of the concept of tension-free hernioplasty is applied could be postulated that only the movement of the trans-
to every hernia repair. versus 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
EFFECTS OF BIOMATERIAL PLACEMENT IN
manner will function more normally.
LAPAROSCOPIC HERNIORRHAPHY
Fixation of the biomaterial with transfascial sutures
will more likely ensure that the movement of each of the
During the repair of incisional and ventral hernias, the three layers of muscle of the abdominal wall will impact
prosthesis will usually be placed in the intraperitoneal the prosthesis in some manner. The prosthesis becomes a
position. In some areas and in some patients this may not significant portion of the abdominal-wall function once
be the case, but in the majority of published series the it has been fixed in this manner. I believe that the patch
location is within the abdomen. While there is a theoreti- will respond to movement of these muscles and have a
cal risk of patch migration, such as has been seen in open greater impact in the function of the wall of the abdomen.
repair, to date none have been reported with laparoscopic However, the sutures will also transfix all of the layers
repair. In only one series has the defect within the fascia of the flat muscles together. This could diminish the
been closed.10 The usual operation will simply place the independence of each of their functions at those points
prosthesis under the defect with a minimum fascial over- of fixation. If the biomaterial is placed in the retro-
lap of 3 cm. The biomaterial is then fixed into position rectal position, then the effects of this will also be felt.
and the operation terminates without regard to the re- Usually, however, hernias are smaller and only in the mid-
approximation of the linea alba. Certainly, in hernias that line if this method is utilized. The same functional result
are located in sites not in the midline, the linea alba is not should be seen. More experimental data are needed to
involved in the repair of the hernia. These typically are evaluate the impact of these issues.
not large and are not considered to be significant in the During adhesiolysis and particularly at the time of
overall function of the wall of the abdomen. Laparoscopic fixation of the biomaterial, there is a risk of injury to the
repair does not provide for the resection of the peritoneal vessels of the abdominal wall. The significant vessels of
sac. Because this sac is not resected, seromas occur very the abdominal wall are the inferior epigastric arteries
frequently. Some authors have used electrocauterization and veins. These are usually out of harm’s way during
of the peritoneal surface of the sac to diminish the occur- more traditional repairs of hernias of the abdomen.
rence of seromas.11 Others have used argon-beam coagu- Generally, any injury to these vessels will be recognized
lation for the same purpose.12 When seromas do occur, and controlled on the operating table. The most com-
some may require additional procedures to treat them; mon method of control is the transfascial placement of
fortunately, this is infrequent. sutures, similar to the manner used to fix the patch. This
The prosthesis acts as a barrier to the protrusion of will easily and effectively control the hemorrhage. Late
the intra-abdominal contents. It does not assume any hematomas have been described in several series in the
functional role in the abdominal wall. The muscles of the literature. One could assume that these represented late
abdomen will not have any significant change in their development of hemorrhage from these vessels, due to
own function after the operation. Repair of the hernia, either partial tamponade or delayed necrosis of the vessel
especially larger ones, will probably improve the function wall secondary to electrocautery or other smaller vessels
of the flat muscles of the abdomen. There are no sup- that experience the same process.
portive data to prove this, but one would assume that The sutures may also impinge the small nerves of the
elimination of the hernia eliminates the paradoxical subcutaneous space. This is unavoidable, but it has
MATURATION OF THE HERNIA REPAIR
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 prod-
ucts can contract as much as 20–60 per cent, although
this process may take place over the ensuing one or two
years. In so doing, the original defect will correspond-
ingly 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 actu-
Figure 14.2 CT appearance of the repaired midline incisional ally be more of a detriment to this fact; no studies are
hernia with DualMesh six months postoperatively. available to verify this statement.
ePTFE biomaterials will contract 20–50 per cent but
with more flexibility than polypropylene biomaterials.
not proven to be a significant complaint following the There is rapid infiltration of cellular elements into the
operation. Most of the pain is probably related to neu- interstices of the product. This may effect more rapid
roma formation, but there are patients who seem to have healing and result in the function of the abdominal wall
prolonged pain (one to two per cent) that may be due to being more ‘matured’ at the completion of the LIVH if
suture constriction. I have had two patients who were ePTFE rather than other materials is used in the repair.
relieved of symptoms after laparoscopic incisional hernia This is especially true with the newest products that have
repair by the incision of the offending sutures. Local a ‘corduroy’ surface.13
anesthetic injection can also be used. During the healing phase following the operation,
The type of biomaterial that is used in laparoscopic many clinical changes will be seen that may be new to
incisional and ventral hernioplasty (LIVH) will also surgeons who have just started using this technique.
impact the functionality of the abdomen. The polypropy- Initially, many patients will not have any noticeable pro-
lene meshes (PPM) are usually quite stiff and result in a trusion at the site of the original hernia, particularly if
significant amount of cicatrization during the healing a pressure dressing or abdominal binder is used follow-
process. The contraction of the scar that occurs will result ing the procedure. Many, if not all, patients, however,
in a firm area of the abdomen at the site of the previous will develop a seroma at the site of the hernia sac.14 The
hernia sac and defect. This site will not be pliable in the size and significance of this varies greatly. This can be
manner of the normal anatomy. It is not an area that acts worrisome and unsightly, but it usually resolves without
in unison with the muscles of the abdomen but instead intervention.
it is an independent site in which the muscles of the Following its resolution, the patient will generally have
abdomen act around rather than with the biomaterial. an abdominal wall that is very similar in appearance to the
The thicker, two-layered Composix®mesh has an even premorbid condition before the development of the her-
greater effect of solidifying the site of implantation than nia. The cosmetic result in the vast majority of patients
does the single layer of PPM. In the few patients I have will be acceptable to both the surgeon and the patient
seen who have had this implanted, the abdominal wall because of the resumption of a normal contour as per-
was more board-like than flexible. ceived by the patient. Most patients, particularly obese
Expanded polytetrafluoroethylene (ePTFE) products individuals, will have a lax abdomen due to lack of tone in
result in an organized healing process that resembles the muscles of the abdominal wall. In these individuals,
more closely that of the normal progression. As a result, the larger patches will actually result in a flattened appear-
the abdominal wall is more likely to act with rather than ance compared with other areas of the abdomen. This is
against the patch in the function of the muscles. While probably related to the improved support of the abdomi-
this prosthesis is not stretchable, the softness of the prod- nal wall by the prosthetic. In some patients, the lateral
uct and the characteristics of the collagen infiltration aspects of the abdomen (outside the prosthetic biomater-
into the biomaterial allow it to conform more naturally ial) will seem to protrude disproportionately compared
to the abdominal wall. Follow-up computerized tomog- with the mid-portion where the repair was done. These
raphy (CT) of the abdomen after this procedure will ver- effects are more pronounced with PPM biomaterials than
ify the conformability of the prosthetic biomaterial with ePTFE products. A few patients will need reassurance
(Figure 14.2). 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 redun-
dant skin after the hernia repair may need to wear the
binder for a longer period of time. This will help to elimi-
nate the dead space that is created by the repair of the her-
nia. 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 Figure 14.3 Preoperative photograph of a patient with a
absorbed, and scar tissue will replace this fluid. The scar post-appendectomy hernia.
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 90–120 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 Figure 14.4 Postoperative photograph of the patient shown in
this period of time has transpired. Figure 14.3 after five months. Note the resumption of the
However, some surgeons believe that the cosmetic contour of the abdomen. The cosmetic result was symmetrical
result is unacceptable to themselves and their patients. bilaterally.
For this reason, open repair may be preferred so that a
paniculectomy can be performed at the same time. This and ventral hernias. This seems to be dependent on the
is particularly apparent with large hernias, such as those type of biomaterial that has been used in the repair of
that have loss of domain. One may be advised to proceed the fascial defect. The elasticity (tensile strength) of the
with the open repair from the outset. 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
FUNCTIONAL RESULT
elasticity from four to 16 per cent.15 This would indicate
that the flexibility might be affected by the implantation
There is a paucity of information regarding the functional of these meshes. These measurements, however, were
result following LIVH. The compliance of the abdominal taken in cadavers, which may have affected the results.
wall has been noted to change after the repair of incisional Nevertheless, there has been a move to decrease the
amount of PPM material that is used in the open repair of 2 LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes VK. Laparoscopic
incisional hernias when repaired with PPM. The effect of incisional and ventral hernioplasty: lessons learned from 200
patients. Hernia 2003; in press.
this can be shown in the laboratory, but the actual clinical 3 Trivellini G, Danelli P. Respiratory pathophysiology and giant
significance has not been shown conclusively. There are incisional hernias. In: Bendavid R, ed. Abdominal Wall Hernias.
even fewer data relating to ePTFE products, and no data New York: Springer-Verlag, 2001: 166–72.
are available regarding the laparoscopic approach to this 4 Hesselink VJ, Luijendijk RW, deWilt JHW, et al. An evaluation of
implantation. risk factors in incisional hernia recurrence. Surg Gynecol Obstet
1993; 176: 228–34.
It can certainly be said that there is no re-approximation 5 Luijendijk RW, Hop WCJ, Tol van den P, et al. A comparison of
of the fascia or the muscles of the abdominal wall with suture repair with mesh repair for incisional hernia. N Engl J Med
LIVH. The long-term effects of this remaining defect in 2000; 343: 392–8.
the fascia of these muscles have not been studied. The 6 Leber GE, Garb JL, Alexander AI, Reed WP. Long-term
follow-up of our patients over a period of time that exceeds complications associated with prosthetic repair of incisional
hernias. Arch Surg 1998; 133: 378–82.
ten years has not revealed a single problem related to this 7 Flament JB, Avisse C, Palot JP, Delattre JF. Biomaterials. Principles
remaining functional defect. I believe that these patients of implantation. In: Schumpelick V, Kingsnorth AN, eds. Incisional
have lost the benefit of a normal anatomical functioning Hernia. Berlin: Springer-Verlag, 1999: 217–30.
abdominal wall because of lax musculature and/or the 8 Flament JP, Palot JP, et al. Treatment of major incisional hernias.
hernia itself. The repair of the single defect does not impact In: Bendavid R, ed. Abdominal Wall Hernias. Berlin: Springer-
Verlag, 2000: 508–16.
the innate laxity of the normal muscles. Additionally, the 9 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
development of the hernia itself signifies that the patient incisional and ventral herniorrhaphy in 100 patients. Am J Surg
has weakened fascia. 2000; 180: 193–7.
10 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral
and incisional hernia repair. Surg Laparosc Endosc 1998;
CONCLUSION 8: 294–9.
11 Tsimoyiannis EC, Siakas P, Glantzounis K, et al. Seroma in
laparoscopic ventral hernioplasty. Surg Laparosc Endosc Percutan
Laparoscopic repair of incisional and ventral hernias Tech 2001; 11: 317–21.
requires the use of a prosthetic biomaterial. In all but the 12 Lehr SC, Schuricht AL. A minimally invasive approach for treating
smallest of hernias, no tension is placed on the repair. This postoperative seromas after incisional hernia repair. J Soc
Laparoendosc Surg 2001; 5: 267–71.
may explain the decrease in the length of hospitalization of 13 LeBlanc KA, Bellanger DE, Rhynes VK, et al. Tissue attachment
patients because of diminished levels of pain and ileus. strength of prosthetic meshes used in ventral and incisional hernia
This does not provide for the reconstitution of the normal repair. Surg Endosc 2002; 16: 1542–6.
anatomy of the abdominal wall. In so doing, expiratory 14 Susmallian S, Gerwurtz G, Ezri T, Charuzi. Seroma after
function may be compromised. In no cases, however, has laparoscopic repair of hernia with ePTFE patch: is it really a
complication? Hernia 2001; 5: 139–41.
this been proven to be a clinical problem. More experi- 15 Junge K, Klinge U, Prescher A, et al. Elasticity of the anterior
mental and clinical studies are needed to assess accurately abdominal wall and impact for reparation of incisional hernias
the functionality of the wall of the abdomen following using mesh implants. Hernia 2001; 5: 113–18.
laparoscopic ventral and incisional hernioplasty.
REFERENCES
1 Höer JJ, Junge K, Schachtrupp A, et al. Influence of laparotomy

closure technique on collagen synthesis in the incisional region.
Hernia 2002; 6: 93–8.
15
Laparoscopic repair in the emergent setting
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 incar-
cerated. The bowel comes to reside in the subcutaneous
tissues and can cause cosmetic problems and/or discom-
fort, but only infrequently does it acutely obstruct. When
discussing laparoscopic repair of ventral/incisional her-
nias 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 cor-
rection is most important, along with nasogastric decom-
pression and Foley catheter placement to monitor fluid Figure 15.1 Hasson cannula at left costal margin.
replacement. Appropriate antibiotic therapy should be
administered before making the first incision. If there costal margin (Figure 15.1). This is carried out through a
is evidence of a septic situation, then pulmonary artery 10-mm incision using the S-shaped Hasson retractors.
catheters, arterial lines and ventilators must be available. Each layer is incised under direct vision and the muscle
A review of our technique is published elsewhere,1 but layers are spread with a tonsil-type clamp. The retractors
important points will be described here. The abdominal hold the muscle aside while a number 11 blade is used to
wall is shaved and prepped in its entirety. The one well- incise each layer of fascia. Again, in several hundred repairs
established advantage of the laparoscopic repair of ventral/ we have never injured any viscera with this method and we
incisional hernias when compared with open techniques have never been unable to gain access. An angled laparo-
is fewer wound problems. In addition, the mesh becomes scope (30 or 45 degrees) is very beneficial since it allows
infected less frequently. We treat the mesh like a vascular viewing of almost any area, depending upon how the angle
graft and avoid any contact with the skin, etc. An Ioban® is directed. A good 5-mm laparoscope allows use of 5-mm
(3M Healthcare) protective drape is used to cover all the working ports, which keeps 10-mm holes to a minimum.
skin. Using this approach, we have never encountered a The amount of bowel distention in the case of an
patient who has developed a postoperative infection of acutely obstructed ventral/incisional hernia will dictate
the prosthesis when placed laparoscopically. the ease with which adhesiolysis and visualization can be
Safe access to the peritoneal cavity is of utmost impor- accomplished. There have been, and continue to be, deaths
tance, especially when dealing with distended loops of due to bowel injuries during lysis of adhesions that are
bowel. As we first described, our procedure of choice is the not detected at the time of surgery. In almost every case
use of a balloon-tipped Hasson-type trocar lateral at the reviewed by the author, harmonic-type scalpels and
Figure 15.2 Incarcerated small bowel. Figure 15.3 Dual-sided mesh.
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 laparo-
scopically, 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 Figure 15.4 Suture fixation of mesh.
reduced easily, then one can proceed with a standard
laparoscopic repair. If the surgeon fears the bowel might reduced, the borders of the defect are determined and the
be torn, then there are two options. The first option is to correct size of mesh is brought to the field (Figure 15.3).
take a well-insulated J-type or L-type hook and use it to We taught the first organized course in the world on
enlarge the hernia defect to aid in reduction. It is critical laparoscopic ventral/incisional hernia repair in 1996 and
that this is done away from the bowel; if the bowel is at based our technique on an open repair, the Rives–Stoppa
risk, it should not be done, since this involves use of repair, which we teach our residents and has been shown
energy close to the bowel. We have used this maneuver worldwide to have the lowest recurrence rates for ventral/
several times, with good success. incisional hernia repair.2,3 This open repair relies on
If the incarcerated bowel cannot be reduced laparo- retrorectus suture fixation of the mesh (behind the defect)
scopically, then there is a second option that involves to the fascia of the abdominal wall for long-term success.
a small incision directly over the acutely incarcerated The same holds true for the laparoscopic approach. To
bowel. One should maintain the pneumoperitoneum as believe that in-growth of various meshes is important for
the skin incision is made and monitor progress with the long-term success fails to recognize that any significant
laparoscope until pneumoperitoneum is lost. The inci- in-growth is to peritoneum, not muscular fascia, and if
sion does not have to be large, and usually the bowel can the hernia is of any size then the mesh simply migrates
be reduced under direct vision. In several cases, we have over time with the peritoneal sac into the fascial defect.
even performed a small-bowel resection through this The sutures are placed every 5–7 cm or more frequently,
small counter-incision, replaced the bowel back into the based on the size of the defect. The mesh is tacked between
abdomen, closed the skin, and finished the procedure the suture fixation points to prevent internal hernia for-
laparoscopically. In no instance has this resulted in mation. The tacks add nothing to the long-term strength
infected mesh or wound infection. of the repair (Figure 15.4).
The details of our repair technique are described The types of mesh available have significantly increased
elsewhere. Once the obstructed/incarcerated bowel is surgeons’ options in the face of emergent repair of
Laparoscopic repair in the emergent setting 113
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 problem-
atic 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 poten-
tially 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
Figure 15.5 Final repair. 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
ventral/incisional hernias laparoscopically. A detailed situation. We have used this on several occasions, with-
description of meshes is beyond the scope of this chapter, out infection of the mesh. Lastly, W. L. Gore has incor-
but a few things need to be mentioned. When we, and porated an antimicrobial coating into its DualMesh Plus
others, first developed the technique, expanded polytetra- that lasts for five to seven days. Intuitively, this makes us
fluoroethylene (ePTFE) became the prosthetic of choice feel that there is an element of protection. We have used
since it could be placed safely in an intraperitoneal posi- this mesh in many cases of minimal contamination dur-
tion without the worry of in-growth to the viscera. While ing laparoscopic ventral/incisional hernia repair, and we
Franklin has shown that polypropylene mesh (PPM) can have never had to remove it once due to mesh infection.
be placed laparoscopically against the bowel, we know that Additionally, in animals, Stone has shown that ePTFE
in-growth will occur, and long-term problems are well can be used to patch full-thickness defects in bowel with-
described when this has been done in an open fashion.3 out it becoming infected.5 He believes this is due to the
Fistulas and extrusion have been reported with PPM. type of bacteria that reside in the bowel.
Various coatings of both PPM (Sepramesh® ) and poly- In conclusion, laparoscopic ventral/incisional hernia
ester mesh (Parietex Composite® ) are being investigated can be done safely in the emergent setting but should
to prohibit visceral in-growth. Animal studies show some be limited to surgeons experienced in the technique in
effectiveness with these coatings. the elective setting. Much work needs to be done with
Strangulated bowel presents a different situation. respect to meshes and their abilities to resist infections in
First, it should be said that bowel that appears dead often the emergent setting laparoscopically.
returns to normal appearance if given time. The incar-
cerated hernia shown in Figure 15.2 had 20 cm of dark-
black-appearing small bowel incarcerated in the defect REFERENCES
once it was reduced. The patient was a physician who
presented with signs and symptoms of acute small-bowel
1 Voeller GR, Mangiante EC. Laparoscopic repair of ventral/incisional
obstruction. Once the bowel was reduced, the color hernias. In: Fitzgibbons ER, Greenburg A, eds. Nyhus and Condon’s
returned to normal after several minutes and the proce- Hernia, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2001:
dure was completed (Figure 15.5). However, if the bowel 373–9.
is truly gangrenous, then two options now exist. Another 2 Rives J, Pire JC, Palot JP, Flament JB. Surgery of the abdominal wall.
Major incisional hernias. In: Chevrel JP, ed. Surgery of the
big advantage of the laparoscopic approach is that the
Abdominal Wall. Berlin: Springer-Verlag, 1987.
hernia does not have to be fixed at the time of finding 3 Flament JB, Rives J, Palot JP, et al. Major incisional hernia. In:
truly necrotic intestine. One can simply resect the bowel Chevrel JP, ed. Hernia and Surgery of the Abdominal Wall, 2nd edn.
laparoscopically or laparoscopically assisted as above, New York: Springer-Verlag, 1997: 128–58.
wash out the abdomen, and come back later for definitive 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 repair. If the large bowel is involved in an unprepped
Hernia 2000; 4: 268–71.
colon, then a colostomy can easily be carried out laparo- 5 Stone H. Abdominal compartment syndrome. Presented at the
scopically. This is not the case through a large formal American Hernia Society Meeting, Tucson, AZ, USA, May 2002.
16
Herniorrhaphy with the use of
transfascial sutures
KARL A. LEBLANC
Indications 115 Intraoperative considerations 118

Contraindications 116 Postoperative considerations 123
Preoperative evaluation 116 Conclusion 124
Prosthetic biomaterials 117 References 124
Laparoscopic incisional and ventral hernioplasty (LIVH) few different methods that are used to perform this pro-
was first described in 1993.1 The concepts of this tech- cedure; these are described in Chapters 17 and 18.
nique are equivalent to the tension-free repair of inguinal
hernias, which has become popular in the past two
INDICATIONS
decades. The open tissue repair of incisional hernias has a
recurrence rate of 25–52 per cent. The use of a prosthetic
biomaterial to repair these fascial defects lowers the recur- Any patient that could undergo an open prosthetic repair
rence rate to 11–23 per cent. The rate of recurrence with can be considered for the laparoscopic approach. The
the laparoscopic approach has been reported to be from size of the fascial defect will play a significant role in
1 to 9 per cent.2–6 It is important to note that in most of many circumstances. The size of the defect is not a limit-
these reports, the results included the early experiences of ing factor, although I frequently restrict my use of the
the authors as well as the repairs that occurred with the laparoscopic procedure to hernias that are larger than
knowledge gained from that experience (see Chapter 21). 2–3 cm in their greatest dimension. The size of the inci-
The repair of incisional and ventral hernias by this sion required for the open repair of a small defect is sim-
approach should be considered an advanced laparo- ilar to the combined size of the incisions required for
scopic technique. It is best to have the assistance of a insertion of the laparoscopic trocars. Because we use only
surgeon experienced in performing this particular pro- 5-mm trocars to perform this operation, these hernias
cedure for at least the first ten to 15 patients if possible. will approximate the size of the combined incisions.
Of course, to optimize outcome, conversion from the Additionally, such small defects can often be repaired
laparoscopic technique to the open method should be without the use of a prosthetic material. This recommen-
done at the earliest sign of difficulty. In our experience, dation would be universally applicable only to thin
this will be necessary in 3.5 per cent of patients. patients. Obese patients will have an unacceptably high
Approximately one-third of these will be due to an injury rate of recurrence without the use of a prosthesis because
to the bowel.5 Others have reported that conversion to of the increased intra-abdominal pressure.7 Therefore, I
the open procedure was necessary in seven per cent of routinely repair these hernias in obese and morbidly
patients, with a bowel injury rate of four per cent.6 Once obese patients with the laparoscopic technique (even pri-
past the learning curve, the participation of an assistant mary umbilical hernias). Patients with recurrent hernias
surgeon who is knowledgeable in advanced laparoscopic should be repaired with this technique even if the size is
techniques is generally considered optimum for the less than 3 cm, because they have demonstrated the need
repair of all but the smallest defects. Finally, there are a for prosthetic placement. LIVH is the easiest method by
which to repair such hernias and also allows the surgeon reconsideration of a laparoscopic approach. The operat-
to inspect the entire length of the abdominal wall to ing time required to repair a defect that approximates the
identify any unsuspected fascial defects that were not entire surface of the abdominal wall could negate the ben-
apparent clinically. This can be seen in 22 per cent of efits of the laparoscopic method. These patients are prone
patients who undergo LIVH.5 Some patients will have to having significant postoperative ileus, regardless of the
areas of fascial weakness that are apparent with the repair employed. The surgeon may think that the increase
laparoscopic approach (Figure 14.1). These areas of in operative time and risk will not justify use of a laparo-
potential herniation should be repaired when identified. scopic 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 laparo-
CONTRAINDICATIONS scopically and convert to an open repair if that appears to
be the best alternative. More often than not, this proves to
As with any operative procedure, the surgeon must eval- be unnecessary. If there is a significant loss of domain, it
uate the overall status of the patient before proceeding may be impossible to actually enter the abdomen because
with a laparoscopic incisional hernia repair. In general, the entire musculature of the abdominal wall is absent. In
if the patient is a medically appropriate candidate for these cases, conversion to the open method is certainly an
the open hernioplasty, then they could be considered a option. If the patient requires preoperative pneumoperi-
candidate for the laparoscopic approach. Patients with toneum because of the size of the hernia, then it is not
severe cardiomyopathy or pulmonary disease may not recommended to attempt the repair laparoscopically.
tolerate the insufflation pressures that are necessary for Morbid obesity can occasionally become a limiting
any laparoscopic procedure. Therefore, these individuals factor. In such patients, the available trocars may be of
must be evaluated carefully preoperatively. Portal hyper- insufficient length to maintain adequate access to the
tension is nearly always a contraindication. abdominal cavity. It could become necessary to convert
If there is a suspicion of an intra-abdominal infection to the open repair because a working channel through
or an acute surgical abdomen, then the use of prosthetic the abdominal wall cannot be maintained. The open
biomaterial is generally prohibited. In this situation, the ends of the trocars will be withdrawn continually into
laparoscopic approach is contraindicated because of the the excessive fatty tissue, which eliminates the working
risk of infecting the prosthesis. One may elect to initiate channel and results in insufflation of the subcutaneous
this operation if incarcerated bowel is suspected. Release of tissues. One may actually sew the trocars to the skin to
the obstruction will allow the surgeon to inspect the viabil- ensure the position, but the newer, longer trocars that are
ity of the intestine. If there is no strangulation or perfora- now available will usually solve this dilemma.
tion, then the operation can proceed. A few centers will In our series of patients, 90 per cent of the hernias
perform a bowel resection and repair the hernia laparo- that are repaired with this method are incisional. Because
scopically and concomitantly (see Chapters 15 and 18). the most common incision of the abdomen is placed in
A relative contraindication may be the number of the midline, approximately 90 per cent of those hernias
intra-abdominal procedures that the patient may have are located in the midline of the abdomen.5 These her-
undergone prior to the anticipated LIVH. This decision nias are generally easier to approach with this method
should be made based upon the surgeon’s skill level and than hernias located outside of the midline. However,
the type of the procedures that were performed previ- as more experience is achieved, the presence of a non-
ously. Frequently, the patient may not have significant midline defect or multiple defects that are not adjacent to
adhesions despite many previous intestinal procedures. each other should not preclude the use of laparoscopy.
However, one should be very cautious if the patient has Appropriate positioning of the patient and accurate
had a previous repair of an incisional hernia that placement of the trocars will permit an approach to the
included the placement of a polypropylene biomaterial entire abdominal cavity in most cases. The use of angled
in direct contact with the contents of the abdomen. laparoscopes also facilitates these repairs.
There is nearly always a significant amount of very dense In addition to the site of the hernia, the number and
and extensive adhesions. The risk of intestinal injury is type of previous open abdominal operations will influ-
particularly high in these patients. ence the choice of patient position, the method of abdom-
inal entry, trocar placement, and the position of the
monitors. Decisions regarding these factors should be
PREOPERATIVE EVALUATION made preoperatively and then finalized when the patient is
on the operating table and under general anesthesia. There
Once the patient has been identified as an acceptable will be a greater likelihood of significant adhesions that
surgical risk, the surgeon should evaluate the condition of will require lysis during the initial phases of the operation
the patient’s abdomen and the hernia(s) that will be if the patient has had many separate intra-abdominal pro-
repaired. A very large fascial defect may sometimes cause cedures. 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 dissection required will dictate whether a patient remains
have dense scarring in all areas in which the material was in hospital overnight or for longer. Minimal preoperative
not covered by omentum; however, this should not deter preparation is required, but appropriate laboratory test-
experienced surgeons from attempting a laparoscopic ing should be obtained before the day of surgery. Patients
approach. It is important to note that the difficulty of the are routinely given an antibiotic (usually a first-genera-
procedure will be magnified greatly because of the dissection cephalosporin) preoperatively. However, if the bio-
tion of the tenacious scarring that will have occurred to material that will be implanted contains antimicrobial
the bowel and/or omentum. Because the risk of entero- agents (e.g. DualMesh Plus® ), antibiotic prophylaxis is
tomy is increased significantly in such cases, occasionally it not felt to be mandatory.
will be necessary to leave remnants of the mesh attached to
the bowel to avoid injury to the intestine (Figure 16.1).
PROSTHETIC BIOMATERIALS
Laparoscopic incisional hernioplasty should be indi-
vidualized in patients with known ascites because it is
impossible to close the trocar sites in a consistently Many products are available for the repair of incisional
watertight manner that averts ascitic leaks. Moreover, hernias. The most commonly used product for this oper-
these patients usually have a metabolic problem (e.g. ation is the 1-mm thick expanded polytetrafluoroethyl-
cardiac, renal or hepatic disease), which can cause poor ene (ePTFE) prosthesis, DualMesh®or DualMesh Plus
healing and predispose to development of multiple (see Chapter 3). My choice of biomaterial for this opera-
hernias at the trocar sites. However, it is these metabolic tion is DualMesh Plus. This contains antimicrobial
problems that make the laparoscopic approach particu- agents that impart a brown color to the biomaterial
larly appealing in these types of patients. If a medical (Figures 16.2 and 16.3). This color inhibits the glare of
comorbidity does not preclude the laparoscopic method
from these patients, then one should use 5-mm non-
cutting 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 dis-
charge on the day of surgery. Twenty-six per cent of
our patients are discharged on the day of surgery, and Figure 16.2 DualMesh Plus.
85 per cent of our patients remain in hospital for
23 hours or less.5 The type of hernia and the amount of
Figure 16.1 Laparoscopic view of small intestine with remnant Figure 16.3 Laparoscopic view of the ‘visceral’ surface color of
of polypropylene mesh. The white arrows outline the mesh. DualMesh Plus.
the white surface of the standard product and identifies

the surface that should lie in contact with the intra-
abdominal organs (‘brown is down’). If one chooses to (a)
use the standard DualMesh, it is recommended that the
parietal surface of the prosthesis is marked with a skin-
marking pencil before its insertion to avoid the inadver-
tent reversal of the orientation of the patch. The
corduroy appearance of the parietal surface also helps (b)
distinguish the two different surfaces of the biomaterial.
INTRAOPERATIVE CONSIDERATIONS
Patient preparation and positioning (c)
LIVH repair requires the use of general anesthesia to

achieve the necessary degree of relaxation and sedation. Figure 16.4 Instrument jaws for organ and prosthetic
In most cases, it is not necessary to use a gastric tube or biomaterial manipulation: (a) aggressive, (b) self-retaining,
urinary catheter unless the operative sites are in close and (c) smooth.
proximity to the stomach or bladder or if the procedure
will be prolonged. Typically, when used, both the gastric
choice of these instruments will be the shape of the jaws.
tube and urinary catheter are removed at completion of
For grasping the bowel, omentum and the prosthesis,
the procedure.
aggressive, thick jaws are preferred (Figure 16.4a). These
Most patients will be placed in the supine position.
allow for the firm grasp that is usually required during
Operations upon lateral defects of the abdominal wall,
adhesiolysis and placement of the prosthetic biomaterial.
such as those in a subcostal or flank incision, will be facil-
To pull in the biomaterial from the trocar site (see below),
itated by the use of a semi-decubitus or full decubitus
a strong-jawed, self-retaining grasper is necessary (Figure
position that is maintained with the use of a beanbag.
16.4b). This will be required to maintain a firm grasp of
The additional use of the tilt capabilities of the operating
the prosthesis so that it can be pulled into the abdomen
table (i.e. Trendelenburg or lateral rotation) will assist
through the 5-mm port site. The placement of the trans-
in the manipulation of the bowel during dissection by
fascial sutures should be done with the aid of fine-toothed
moving these into the dependent portion of the abdomen.
instruments (Figure 16.4c). These hold the sutures better
The patient’s arms should be tucked in close to the body,
than instruments with aggressive jaws because the suture
unless the size of the patient is prohibitive, to allow suffi-
will slip between the large spaces of the teeth of the latter
cient room to move around the patient. This is especially
(see Chapter 2).
important if the hernia is in the lower abdomen.
The most difficult and tedious portion of the hernio-
plasty is the dissection of adhesions within the abdomen
Instrumentation and/or the hernia itself. The method of dissection is criti-
cally important in order to prevent injury to the intestine.
There are several choices of laparoscopes (0-, 30- or 45- If the adhesions encountered are few and rather filmy, then
degree) for incisional hernia repair. Because thin patients one may use scissors with or without the additional appli-
with good muscle tone do not accommodate as much cation of electrocautery. The use of this and all energy
distention as obese patients with poor muscle tone, a sources for hemostasis should be judicious and carried out
30-degree laparoscope may provide a better view in thin only if there is absolute certainty that there is no bowel
patients. The 45-degree laparoscope is used rarely, if ever. adjacent to the area that will be affected by the lateral
Most surgeons prefer to use the 30-degree laparoscope but extension of the heat of the energy source. The upper
I generally use the 0-degree instrument. The angle or size of abdomen and falciform ligament are the most common
the laparoscope itself is not important as long as the view is locations for such a situation. In most cases, however,
the best available. Smaller laparoscopes permit the use of some dissection of omentum and bowel will be required
smaller trocars, which decreases postoperative pain and to allow the identification of the fascial edges and the
minimizes the risk of herniation at the site of the trocar. placement of the prosthetic biomaterial. One may choose
Because I prefer the exclusive use of 5-mm port sites, to use the Harmonic®scalpel (Ethicon Endosurgery, Inc.).
all of the instruments used will be of that size. However, This device has scissor-like jaws that dissect using ultra-
the size of the instrument is not important. The critical sonic 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, how-
ever, 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 elec-
trocautery) 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 1–3-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 pros-
thesis that repairs the hernia.
A variety of fixation devices is currently available (see
Chapter 4). These devices are used to secure the pros-
thetic biomaterial to the abdominal wall between the
Figure 16.5 Gore-Tex suture-passer holding a suture as it is
transfascial sutures and to prevent the migration of any
withdrawn from the abdomen.
portion of the omentum or intestine between the patch
and the abdominal wall. My preference is the Salute™
not interfere with the placement of the prosthetic bio-
device (Onux Medical, Inc.). This allows the accurate
material, in that the overlap may cover the trocar itself.
placement of the constructs while ensuring that the
Many surgeons will choose to use either an optical
periphery of the biomaterial is flat against the abdominal
trocar for abdominal entry or an open entry (Hassan
wall. Its function is equivalent to that of the helical coil in
technique) if the Veress needle method is not chosen. My
other respects, however.8 Additionally, a removal instru-
preference is the non-bladed trocar (Ethicon Endo-
ment is available if one decides that the placement of a
surgery, Inc.) but other devices are available, such as the
construct is not ideal.
Visiport®(U.S. Surgical/Tyco International, Inc.). These
Devices to place the transfascial sutures are an integral
trocars are designed to provide visualization of each layer
part of this operation. Two such devices are the Endoclose
of the abdominal wall as the trocar passes through them.
(U.S. Surgical Corp./Tyco International, Inc.) and the
The former is available in 5-, 10- and 12-mm sizes, whereas
Gore-Tex®suture-passer (W. L. Gore & Associates). This
the latter is available only in the 12-mm size. While the exact
author prefers the latter because it is reusable and has a
method in which this is accomplished differs between these
consistently sharp tip (Figure 16.5).
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
Trocar selection can also be used for the additional trocars that are necessary.
It is understood that the method of access into the
abdomen should always be the safest possible approach. Trocar site selection
In patients with a primary ventral hernia or a single inci-
sional hernia defect, a Veress needle could be considered The location of the trocars will be influenced by the loca-
for insufflation before introduction of the first trocar. In tion of the hernia defect(s). Typical sites for these are
the repair of incisional hernias, a safe area for needle shown in Figures 16.6 and 16.7. As can be seen easily, the
insertion is usually in the right or left upper quadrants effort is to achieve triangulation of the site of the hernia to
because this area is generally free of adhesions of bowel allow for its repair. This is typical of most other laparo-
and omentum, particularly for lower-abdominal hernias. scopic procedures. While I prefer to place the laparoscope
An entry point in the midline could be used if it can be in the midline and have two surgeons work from opposite
placed far enough away from the hernia so that it does sides of the operating table, others place all trocars on
the same side of the patient. The placement of the moni-

tors 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 com-

plete 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 tro-
cars 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 work-
ing space in which to allow these trocars to be placed Figure 16.6 Typical trocar site locations for a lower midline
under direct vision. After each new trocar is introduced, hernia. Blue, trocar locations; green, umbilicus; black,
the laparoscope should be placed through it to visualize hernia.
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
harm’s 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 opposi-
tion 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 possi-
ble, will prevent this viewing difficulty. Another option Figure 16.7 Typical trocar site locations for an upper midline
would be to insert an additional trocar(s) on the opposite hernia. Blue, trocar locations; green, umbilicus; black,
side of the patient from where the surgeon is standing so hernia.
that the laparoscope is always on the side where the sur-
geon (or the assistant) is standing. With experience, even Adhesiolysis and identification of fascial
this technical problem can be overcome without the use defect(s)
of additional trocars. However, additional trocars should
be used when this problem cannot be corrected easily to Before insertion of the prosthesis, the entire fascial
ensure the accurate assessment of the intra-abdominal defect(s) must be uncovered. This usually requires lysis
contents and the proper performance of the operation. of all of the adhesions within the abdomen unless these
Those surgeons who prefer to place all trocars only on are far away from the operative field, such as in the pelvis
one side of the abdomen will avoid mirror-imaging, but when the hernia is in the upper abdomen (Figure 16.8).
such site selection will not allow viewing of the adhesions It is important to dissect away from the abdominal wall
from the opposite side of the abdomen. Additionally, this any adhesions that may interfere with the subsequent
trocar location on only one side can make fixation placement of the prosthetic material. The prosthesis
awkward because the use of the fixation devices can be must contact the fascia without the interposition of any
difficult on the ipsilateral side of the patch biomaterial significant amount of adipose tissue so that tissue
(Figures 16.6 and 16.7) (see Chapter 4). 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
Cooper’s 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 12–14 mmHg to near-zero. Reducing the pressure pre-
vents 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 abdomi-
nal wall rather than on the interior surface of the fascial Figure 16.10 DualMesh Plus with marks and initial two ePTFE
defect. This measurement would be artifactually larger sutures.
than the actual measurement. After desufflation, the
defect is outlined on the skin over the abdomen with a There are many variations of the technique used to fix-
skin-marking pencil (Figure 16.9). The entire circumfer- ate the patch material once it is inserted into the abdomi-
ence of the defect should be identified to ascertain its nal cavity. Most surgeons will use transfascial sutures in
maximum dimensions. To ensure adequate coverage of addition to a metal fixation device, such as a titanium
the hernia defect, many authors have stated that a mini- staple or helical tack, a construct of stainless steel, or a
mum of a 3-cm overlap (in all directions) of the pros- nitinol anchor (see Chapters 4 and 17–22). The number
thetic biomaterial is mandatory.3–5,9 In general, I strive to of sutures that are applied to the biomaterial before inser-
cover the entire length of the original incision even tion into the abdomen will be dictated by the preference
though an actual hernia defect may be located only at of the surgeon. One method that I choose places two
one site along the incision. This will provide coverage ePTFE sutures (CV-0) at either side of the midpoint of
and prevent the future development of a hernia at the the long axis of the patch. Two marks are placed on
uncovered portions of the incision and, therefore, avoid a both sides of the midpoint of its short axis with a marking
recurrence of the hernia.5 In this situation, the patient pencil before its insertion into the abdominal cavity
develops a new hernia that is above or below the original (Figure 16.10). It is important to mark both the visceral
one that was repaired. In obese patients and/or patients and parietal surface midpoints because once fixation is
with very large defects, an overlap that exceeds this initiated, the view of the patch will be only that of the
minimum, such as 5 cm, is recommended. visceral surface. These initial two sutures and the marks
Figure 16.11 Folded and twisted DualMesh Plus patch as it is Figure 16.12 Laparoscopic view of the twisted patch as it is
pulled into the abdomen at the site of a 5-mm trocar. drawn into the abdomen.
will help to ensure the correct axial orientation and Placement of the prosthesis
the degree of overlap on all sides of the hernia defect.
Other surgeons place four or more sutures into the patch Once the insertion of the prosthetic is complete, the
before insertion. I find that this creates a tangle of suture patch must be unfolded. The surgeon and the assistant
material that is cumbersome to work with in the limited will assist each other in the manipulation of the bio-
space available. The placement of only these two initial material to unfold the patch completely until it is as flat
sutures assures that the center of the fascial defect as possible. The two initially placed sutures are now
is placed at the middle of the prosthetic biomaterial. This pulled through the entire abdominal wall with the use of
is particularly evident if the trocars are placed as in a sharp suture-passing instrument inserted through a
Figures 16.6 and 16.7. small skin incision (Figure 16.5). By pulling the initial
The DualMesh Plus patch, with its attached sutures two sutures through the abdominal wall and viewing the
placed on the inside of the folds, is folded into sequential hernia with the laparoscope, one can confirm that the
halves for introduction into the abdomen.10 These bioma- patch is centered over the defect and that there is a mini-
terials are 50 per cent air by volume, which allows them to mum of a 3-cm overlap in all directions. It may be neces-
be twisted into a tight roll that substantially reduces their sary to move the laparoscope to another port to do this
size (Figure 16.11). In those cases in which the larger effectively. If there is insufficient tautness of the prosthe-
patches are used, the skin incision at the site of patch intro- sis or if the patch is not properly centered over the hernia
duction should be made larger than that necessary for defect, then the suture(s) must be repositioned. Once the
placement of the trocar itself (typically 6–8 mm). A strong optimal position is achieved, the sutures are tied. It is
grasping instrument (Figure 16.4b) is passed through a important to make sure that these (and all of the sub-
trocar and advanced through another trocar. The trocar sequent sutures) are tied sufficiently tightly to pull the
through which the instrument is exited is then removed, knots to the fascial level without any laxity.
whereupon the instrument will grasp the biomaterial and The next step will be to confirm that the orientation
pull it into the abdominal cavity (Figure 16.12). The assis- along the short axis of the patch is correct (e.g. the lateral
tant surgeon can assist this maneuver by maintaining the aspects of the midline hernia). The biomaterial is
twist of the patch as it is introduced. This method of fold- grasped by both surgeons at the previously marked mid-
ing and introduction into the abdomen and the pliability points on either side of the biomaterial to position it over
of the abdominal wall musculature will allow even the the desired final location. Either the assistant or the sur-
largest DualMesh Plus patch (26 ⫻ 34 cm) to be inserted geon then uses a fixation device to deliver the metal con-
into the abdomen with the exclusive use of 5-mm trocars. struct to fix the midpoint of one side by placing only one
Just before the complete introduction of the patch, the or two devices at that location. The fixation instrument is
tight twist must be undone to make the patch as flat as then handed to the other surgeon and the unattached
possible, which facilitates its fixation to the abdominal opposite midpoint is secured similarly. The use of only a
wall. This is another important step because it is very few constructs at this time will permit the removal of
tedious to try to untwist and unfold the patch once it is these devices if it is determined that the prosthesis must
introduced into the abdomen. be repositioned. After four-point fixation is achieved, the
Figure 16.14 Completed repair of the hernia. The proper

Figure 16.13 Correct spacing of the constructs along the placement of the sutures and Onux constructs are seen on the
periphery of the patch. DualMesh Plus.
position of the biomaterial is verified again with the laparoscopically to confirm that this action did not result
laparoscope. After this inspection, the devices are placed in a loosening of the suture. If this has occurred, the
in a staggered fashion along the periphery of the prosthe- suture must be cut to prevent migration of any intra-
sis 1–1.5 cm apart (Figure 16.13). abdominal contents into the loop and another suture
This initial fixation not only positions the patch at its must be placed.
correct location but also ensures that bowel cannot migrate The repair is now complete. At this point, a reasonable
between the prosthesis and the abdominal wall once the precaution may be to scan the intestine to identify any
repair is completed. The most important component of possible injury that may have gone undetected. The
fixation, however, is the use of transfascial non-absorbable trocar cannulas are removed, but before their removal
sutures (e.g. ePTFE size CV-0). These sutures will be placed the suture-passer should be used to pass an absorb-
through all layers of the abdominal wall and are tied above able suture to close any port sites larger than 5 mm. The
the fascia in a manner similar to that of the initial two skin incisions can then be closed with or without a
sutures. A small (2–3-mm) skin incision is made. Through subcutaneous suture and the use of Steri-Strips®(3M
this incision the suture-passer, with a suture in its jaws, Healthcare) or Dermabond®(Ethicon, Inc.) adhesive.
is passed through all layers of the abdominal wall. The Band-Aid-type dressings or small gauze sponges should
assistant surgeon then grasps the suture with a laparoscopic be placed over the wounds. The use of an abdominal
instrument (Figure 16.4c). The suture-passer is then binder that will be left in place for at least 72 hours will
removed and re-inserted through the same skin incision. aid in the prevention of a postoperative seroma at the site
The assistant hands back the suture to the passer, where- of the hernia and eases postoperative pain. The use of
upon the suture is retrieved. During the insertion of all this binder for as long as 7–14 days is preferred, especially
sutures, it is critical to avoid the application of any instru- for very large hernias.
ment or clamp on any portion of the suture material that
will remain within the patient because this will perma-
nently weaken the suture at that site. It may later fracture
at that site, leading to a possible failure of fixation and
POSTOPERATIVE CONSIDERATIONS
recurrence of the hernia.5
These additional sutures are placed at intervals that are Patients are sent to the postanesthesia care unit, where
no more than 4–5 cm apart. Once fixation is completed, they are usually given a single dose of ketorolac intra-
the patch should now obliterate the fascial defect. A final venously. Once recovered from anesthesia, they are
examination of the prosthetic is performed to ensure transferred to the day-surgery unit. Most (85 per cent)
that all sutures are tight and that all edges of the patch patients are discharged within 24 hours. In our practice,
are secured (Figure 16.14). When any of these sutures are the average length of stay is slightly over one day. Patients
tied, a dimple of the skin may develop at the site of can consume their diet of choice on the day of surgery
the incision where the suture has been passed because the and can resume any regular medications immediately.
subcutaneous tissue may have been drawn down when Oral or parenteral sedatives are given as needed.
the suture was tied. This dimple can be removed by the Pain may be used as the guide to determine when
placement of a fine-pointed hemostat into the incision to patients can resume their normal activities. They are
lift the skin, which releases the tissue from the suture allowed to shower the next day. Patients may return to
knot. After this is done, one should view the sutures their daily activities, including work, as soon as they can
do so without marked pain. Most are able to drive within 2 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and
a week and resume job-related activities in 7–14 days. incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9.
3 Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral
We do not restrict their activities but allow their pain to and incisional hernia repair in 407 patients. J Am Coll Surg 2000;
be their own guide. 190: 645–50.
4 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
incisional and ventral herniorrhaphy in 100 patients. Am J Surg
CONCLUSION 2000; 180: 193–7.
5 LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes KV. Laparoscopic
incisional ventral hernioplasty: lessons learned from 200 patients.
LIVH continues to gain popularity. There are several Hernia 2003; in press.
6 Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications
modifications of this technique that can be adopted with laparoscopic intraperitoneal expanded
according to one’s preferences. Surgeons who perform polytetrafluoroethylene patch repair of postoperative ventral
this advanced operation must have a thorough under- hernia. Surg Endosc 2002; 16: 785–8.
standing of the specific factors that ensure that the pro- 7 Arroyo A, Garcia P, Perez F, et al. Randomized clinical trail
cedure will be associated with an acceptable outcome. comparing suture and mesh repair of umbilical hernia in adults.
Br J Surg 2001; 88: 1321–3.
Continued research and experience will result in contin- 8 LeBlanc KA, Stout RW, Kearney MT, Paulsen DB. Comparison of
ued modifications to this operation. Technical refine- adhesion formation associated with Pro-Tack (US Surgical) versus
ments will undoubtedly occur that will enhance the a new mesh fixation device, Salute (ONUX Medical). Surg Endosc
fixation methods that are currently available. 2003; in press.
The laparoscopic repair of incisional and ventral her- 9 Koehler RH, Voeller G. Recurrences in laparoscopic incisional
hernia repairs: a personal series and review of the literature.
nias may become the standard of care in the future. As J Soc Laparoendosc Surg 1999; 3: 293–304.
the population of general surgeons adopts this method- 10 LeBlanc KA. A new method to insert the DualMesh prosthesis for
ology, the recurrence rates associated with this difficult laparoscopic ventral herniorrhaphy. JSLS 2002; 6: 349–52.
malady will, hopefully, decline.
REFERENCES
1 LeBlanc KA, Booth WV. Laparoscopic repair of incisional

preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41.
17
Pre-peritoneal herniorrhaphy
SÉRGIO ROLL, WAGNER C. MARUJO AND RICARDO V. COHEN
Incisional hernias 125 Comparative studies of open versus laparoscopic repair 129
Principles of treatment 125 Advantages and disadvantages of different
Indications for laparoscopic repair 127 laparoscopic techniques 130
Laparoscopic transabdominal pre-peritoneal repair 127 Conclusion 130
Personal series results 129 References 131
INCISIONAL HERNIAS diseases such as obesity, cancer, chronic hepatic and

cardiopulmonary failures, severe anemia, and malnu-
trition.2,3 The underlying pathological process, such as
Incidence prostatism, radiotherapy, steroid therapy, and operative
technical issues are also fundamental factors. Although
Incisional hernias represent one of the more common clinical experience seems to suggest that vertical celiotomy
complications of abdominal surgical procedures. The true and certain types of suture (e.g. continuous suture and
incidence of incisional hernias has not been well defined, mass tissue closure) may increase the risk of incisional
although a number of reports suggest that 3–13 per cent hernias, randomized studies have failed to show that any
of patients undergoing laparotomy will develop a fascial of these factors significantly alters the incidence of post-
defect in their abdominal scar.1 The majority of inci- operative incisional hernia. Wound infection is associ-
sional hernias occur within the first postoperative year. ated with a five-fold increase in the risk of developing a
However, the limited follow-up of most series may hernia.1,4
underestimate late hernia occurrence.
Diagnosis PRINCIPLES OF TREATMENT

Most patients with small, uncomplicated incisional her-
The classical principles of ventral hernia repair are wound
nias are asymptomatic or have only minor or intermit-
closure without excessive tension, suture placement into
tent complaints. However, these postoperative hernias
healthy tissue, and the use of strong material to support
may be a significant source of morbidity. Patients with
the wound through the critical period of healing. In many
incisional hernias alter their lifestyles so as not to exacer-
cases of incisional hernia with small defects, fascial clo-
bate their abdominal wall hernia and often complain of
sure can be achieved by apposing the fascial edges, which
their esthetic appearance or suffer from discomfort, pain
closes the defect. When the fascial defect is large, a num-
or, occasionally, intestinal obstruction.
ber of techniques have been proposed, including relaxing
incisions, internal retention sutures, muscle or fascial
Predisposing factors flaps, fascial grafts, and mesh repair.5 However, the results
have often been disappointing. Primary repair with
Predisposing factors for the development of incisional suture only has been associated with 25–52 per cent fail-
hernias include advanced age, male gender, and systemic ure rates.6 The use of a prosthetic material to cover the
hernia defect has reduced substantially the incidence of these materials should be balanced in some situations
recurrence. In a multicenter randomized trial that enrolled (e.g. the feasibility of closing the peritoneum over the
100 patients in each arm, Luijendijk and coworkers com- mesh, and the issues of cost) when selecting all prosthetic
pared the results of suture alone with those of open mesh biomaterials.
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 Repair strategies
mesh repair of a primary hernia were 43 and 24 per cent,
respectively. The recurrence rates were 58 and 20 per cent, Although the modern era of hernia repair began more
respectively, for repair of the first recurrence. The risk fac- than a century ago, controversies continue to exist regard-
tors for recurrence were suture repair, infection, prosta- ing the optimal surgical technique to repair incisional
tism, and previous surgery for abdominal aortic aneurysm. hernias. Open techniques involve a large incision and
The size of the hernia did not affect the rate of recurrence. extensive subcutaneous and intra-abdominal dissection,
The majority of the recurrences were in the first two years and often necessitate the placement of drains. Complica-
following the repair of the hernia. The same factors involved tion rates range from 8 to 19 per cent after open ventral
in the genesis of these incisional hernias may contribute repair.14,15 Fistula rates after elective open hernia mesh
to these results. repair vary from 2 to 5 per cent.6 Moreover, the infected
prosthesis should be excised, demanding another, more
complicated repair. Transabdominal approaches carry
Prosthesis materials the risk of injury to the viscera adherent to the undersur-
face of the scar. The basic strategy of the open repair is
The use of prosthetic materials to assist in incisional based upon the Stoppa technique: the peritoneal cavity
hernioplasty usually demands a more extensive dissec- should not be entered and the mesh is secured to the fas-
tion and may increase the risk of wound complications cial edges in the pre-peritoneal space.16 However, the risk
slightly.5,8 The synthetic material should be physically of re-entering the site of a previous incision is an inad-
unmodified by tissue fluid, chemically inert, and non- vertent enterotomy. The open repair does allow the
carcinogenic. It should also induce no inflammatory or concomitant excision of a usually wide, irregular and
foreign-body reaction, allergy or hypersensitivity.9,10 unesthetic scar. If this is the case, it is not unusual to
Finally, it should resist mechanical stresses, be able to be enter the abdominal cavity.
tailored into the form required, and be easily and fully Surgical laparoscopy has become an increasingly pop-
sterilizable. The most popular prosthesis materials are ular method of treatment for many diseases because it
made of polypropylene, polyester, and expanded poly- potentially offers cost-savings as a result of shorter hos-
tetrafluoroethylene (ePTFE). These are all nonabsorbable, pital stays, less postoperative pain, and a more rapid
and there is no clear evidence from the literature that return to work.17 Laparoscopic hernioplasty has been
supports a preference for the clinical use of any one of reported to be a safe and feasible technique, with low
the three main materials.11 Polypropylene shows a rela- morbidity and low rates of early recurrence. LeBlanc and
tively small inflammatory response with a far lesser Booth first reported the laparoscopic approach to repair
degree of foreign-body reaction than does polyester incisional hernias in 1993,18 and several series have now
mesh. ePTFE elicits less chronic inflammatory cell reac- demonstrated the efficacy of minimally invasive surgery
tion but greater foreign-body reaction. Mesh infection in incisional hernia repair. Laparoscopic repair involves
rates in selected laparoscopic series for repair of ventral no long incision, no wide fascial dissection or flap
and incisional hernias vary from 0.5 to 12 per cent.12 creation, and usually no drains. It also minimizes the
Despite different characteristics regarding fibroblastic manipulation of a potentially contaminated site because
reaction and the time required for incorporation, the trocars are placed far from the original wound.19
polypropylene and polyester prosthetic materials are Additionally, the pneumoperitoneum facilitates the nec-
associated with a high incidence of dense adhesions. essary adhesiolysis in order to identify the edges of the
Their biological behavior increases the risk of adhesions defect and the hernia sac. Enterotomy rates in selected
and fistula formation when the mesh is placed in contact laparoscopic series of ventral hernia repair, including
with the peritoneum.13 There is strong evidence that incisional hernias and many with previous open mesh
adhesions are more common with polypropylene and repair, vary from 0 to 14 per cent (Table 17.1). Mesh
polyester than with ePTFE. It is acceptable to place the infection rates vary from 0.5 to 12 per cent.12 One of the
latter in contact with the bowel, as lower complication drawbacks of the laparoscopic approach is that it does
rates were reported when using ePTFE. Polypropylene not allow an esthetic reconstruction of the abdominal
and polyester require reperitonization to avoid mesh wall since the old scar that covers the hernia defect is
contact with intra-abdominal structures. The use of left untouched. The need for an overall esthetic result
Pre-peritoneal herniorrhaphy 127
Table 17.1 Results of laparoscopic ventral/incisional hernioplasty
Complications
Patients Intraoperative Postoperative Hospital Follow-up Recurrence
Reference (n) (n) (n) stay (days) (months) (n)
Constanza et al. (1998)14 31 0 2 2.0 18 1
Franklin et al. (1998)34 176 0 9 2.2 30 2
Toy et al. (1998)24 193 4 28 2.0 22 9
Sanders et al. (1999)35 12 0 3 3.5 12 1
Scott-Roth et al. (1999)20 73 2 14 2.9 17 7
Heniford et al. (2000)6 415 5 48 1.8 23 14
Roll et al. (2000)25 28 1 3 1.2 36 0
should not be underestimated because the patient fre- LAPAROSCOPIC TRANSABDOMINAL

quently demands this outcome. PRE-PERITONEAL REPAIR
Patient preparation and room set-up

INDICATIONS FOR LAPAROSCOPIC REPAIR
A thorough preoperative evaluation is performed. The
The size of the defect and the characteristics of the patient patient is informed fully of the risks of recurrence and
should dictate the best technical strategy. Patient selection the chance of conversion into an open procedure.
for laparoscopic incisional hernioplasty is usually based Educational handouts are given in order to aid the
upon a demonstrable fascial defect under a previous patient during the period of convalescence with a partic-
abdominal incision or a highly suspect abdominal wall ular emphasis on pain management. Factors that might
defect in a very obese patient, such as in Spigelian hernia. increase the recurrence rate are corrected, if at all possible,
The patient must be able to tolerate general anesthesia in the preoperative period. Special attention is given to
and abdominal insufflation.20 Patient size is not a pro- respiratory care before admitting the patient to the hos-
hibiting factor; nor is a history of previous abdominal pital. In-hospital standard guidelines to prepare patients
explorations or previous attempted repairs with or with- for abdominal surgery are followed. Mechanical bowel
out placement of prosthetic material. A massive incisional preparation is not usually necessary, and the patient is
hernia with the protrusion of a substantial portion of asked to void just before leaving the ward.
the abdominal viscera may be a contraindication for a The patient is placed on the operating table in a dorsal
laparoscopic approach. Significant loss of the abdominal recumbent position with the arms padded alongside the
domain by the intestine might preclude the placement of body. It is important that the patient is strapped securely
the functional trocars because of insufficient lateral space. to the operating table in order to permit the extremes
A densely scarred abdomen, an inability to establish safely of table positioning, which is occasionally necessary for
a pneumoperitoneum, and the presence of infected mate- visceral displacement or retraction. General anesthesia is
rial in the abdomen may also contraindicate the laparo- instituted, and an orogastric tube is inserted for gastric
scopic approach. It should be noted that the intensity and decompression. Patients are given antibiotic prophylaxis,
extent of adhesion formation is unpredictable. Because of usually with a first-generation cephalosporin.
this, multiple previous abdominal operations do not pre- For most midline hernias, the surgeon stands on
clude laparoscopy, since an entry port for the first trocar either the patient’s left or right side. The video monitor is
can be obtained. The so-called ‘Swiss cheese’ hernia is a positioned on the opposite side of the patient so the sur-
good indication for the laparoscopic approach since it geon’s view on the screen is parallel and in line with the
allows a very clear delineation of the wall defects and a laparoscopic repair of the hernia within the abdomen.
more precise repair. Hernias very close to the costal mar- The assistant stands opposite the surgeon, and a second
gin may be difficult to treat through an open approach monitor is placed in a suitable position.
since they usually lack a good rim of strong tissue to secure
the mesh. In this situation, the laparoscopic approach is Operative technique
more appropriate, because the mesh can be easily tacked
and/or sutured to the internal surface of the abdominal Good laparoscopic skills are mandatory, since each
cavity. Moreover, full-thickness stitches around this area anatomical situation may be unique. The surgeon must
are usually followed by pain. 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 identi-
fied. 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 work-
ing 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 maxi-
mizes 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 pros-
thetic material is placed posteriorly to the anterior fas- Figure 17.1 The hernia sac is opened and the healthy fascia
cia.21 Adhesiolysis is performed to free the bowel from the along the defect rim is defined clearly.
abdominal wall, and the margins of the hernia defect are
defined clearly. External manual pressure on the abdomi- case, some authors recommend interfacing the omentum
nal wall helps to delineate the edges of the hernia defect; it between the mesh and the bowel. However, we make a vig-
also changes the angles of vision and usually facilitates the orous effort to interface the sac layer between the mesh and
dissection. Once the entire abdominal wall is cleared up the abdominal contents (Figure 17.1). It is easier to dissect
and any incarcerated omentum or bowel reduced, the out the healthy fascial edges within the pre-peritoneal space
hernia defect is measured by introducing a sterile ruler of certain hernias, including incisional hernias secondary
into the peritoneal cavity. The surgeon must be very cau- to extraperitoneal surgical incisions, such as lumbar discec-
tious when dissecting the bowel wall or omentum off the tomies or Pfannenstiel incisions, and defects away from the
hernia sac, which typically encompasses attenuated fascia midline. If the pre-peritoneal technique is deemed impos-
and peritoneum. The adhesiolysis is almost always the sible, then the hernia sac is not reduced, resected or opened,
most challenging part of this procedure, especially if a and the mesh is positioned intraperitoneally according to
previous mesh repair has already been attempted. Any the onlay technique.22
energy source is capable of causing a full-thickness injury Prosthetic materials have been used with increasing
to the bowel wall. The harmonic scalpel may obviate the confidence in direct contact with the abdominal con-
risk of an inadvertent injury. The standard approach in tents. Complications have been few, but this may reflect
the advent of an enterotomy is immediate closure of the selective reporting of good results. We always attempt
site with simple suturing. If this injury is complicated by to perform a transabdominal pre-peritoneal repair that
a significant spillage of luminal fluids, then an open pri- uses a mesh prosthesis to cover and close the hernia
mary repair might be performed or a staged laparoscopic defect. Three trocars are usually employed, and it is ideal
mesh placement should be advised. to triangulate them around the hernia defect. As the
The hernia sac contents are reduced and the peritoneal abdomen is explored, care must be taken to identify and
sac is now opened, followed by the precise delineation of dissect the hernia defect. Gentle grasping and separation
the fascial defect, with at least 4 cm of healthy tissue sur- of the peritoneal sac are important steps. At this point,
rounding it. When possible, small fascial defects may be tears in the peritoneum must be recognized and man-
closed simply by suturing the edges of the defect without aged. Generally, it is not easy to dissect and actually have
tension. The suture closure is then covered by a mesh a good peritoneal flap prepared in order to have it closed
to reinforce the herniorrhaphy. This procedure may pre- over the anchored prosthesis. If a tear occurs, it should be
vent the annoying sensation of the mesh just underlying carefully dissected and more peritoneum preserved. If
the skin. this is impossible due to firm adhesions to the abdominal
Dissection within the pre-peritoneal plane, in an effort wall, then in order to cover the mesh safely an omental
to develop an intact layer of peritoneum to separate the flap may be created and used to cover the tear. The mesh,
mesh from the abdominal contents, might be extremely under some tension, should be secured to the abdominal
difficult in some patients. If unsuccessful, this might result wall using a hernia stapler or a tacking device, or sutured
in a large peritoneal defect, leaving the mesh exposed inter- into position with full-thickness transabdominal stitches
nally. This is especially true in patients with only a thin layer buried in the subcutaneous tissues. The stitches along
of subcutaneous fat and skin overlying the hernia. In this the outer border of the mesh should leave a 3-cm margin
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), epigas-
Hernia tric herniorrhaphy (four), and umbilical herniorrhaphy
Defect sac (three). In all cases except one (two incisional hernias),
Healthy the defect was covered with a single large piece of mesh. In
Mesh fascia 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 30–240
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
Figure 17.2 The mesh is positioned into the pre-peritoneal
enterotomy recognized during the procedure. The mean
space and secured to the abdominal wall. The stitches along the
length of hospital stay was 1.2 days (range 1–4 days).
outer border of the mesh must overlap the rim of the hernia
Patients required minimal post-surgical analgesia. Bowel
defect by at least 3 cm.
function returned quickly in most patients.
There were no deaths. Seven complications were
lateral to the edges of the fascial defect (Figure 17.2).
recorded (13.4 per cent of patients), most of which were
Drains are not used. The trocar sites are then closed in
minor (four seromas, two hematomas, one accidental
the usual fashion.23
small bowel enterotomy). Patients were followed closely
postoperatively for three to 60 months (mean 41
Immediate postoperative care months). Two (3.8 per cent) patients were found to have
evidence of hernia recurrence. They were among the very
Postoperatively, patients are given narcotics for appro- first cases, and they had large defects. Recurrences were
priate analgesia. A liquid diet is started on the same day, diagnosed within the first 12 months after the operation.
and patients are encouraged to ambulate as soon as pos- Lack of experience and large defects may be related to the
sible. Bowel function usually resumes early in the post- reason for recurrence. Most patients developed an area of
operative period.24 Some patients go home on the day of induration at the hernia site, but this resolved without
the operation, but 85 per cent are discharged on the first any treatment within four to six weeks. Apart from this
postoperative day. Most patients develop an area of transient induration, we have encountered no complica-
induration at the previous hernia site, but this resolves tions as a result of excising the hernia sac.
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. COMPARATIVE STUDIES OF OPEN VERSUS
The most common early complications after laparo- LAPAROSCOPIC REPAIR
scopic repair are suture-site pain (when using trans-
abdominal stitches) and seroma. The former is probably Two retrospective studies and one prospective study have
related to some muscular ischemia and nerve entrap- compared the results of open surgery techniques versus
ment. The development of seroma is secondary to the the laparoscopic approach for the repair of ventral her-
creation of a dead space and a secretory reaction to the nias. These studies consisted of a majority of incisional
prosthetic material. Only large, symptomatic collections defects (Table 17.2). In 1997, Holzman and colleagues
should be aspirated. compared 21 patients with ventral/incisional hernias
repaired laparoscopically with a group of 16 patients
who had undergone conventional open mesh repair.26
PERSONAL SERIES RESULTS The mean follow-up period was similar, and two recur-
rences occurred in each group. The investigators con-
From January 1997 to January 2002, 52 (21 female, 31 cluded that the advantages of the laparoscopic approach
male) patients underwent attempted laparoscopic inci- seem to be a reduced rate of postoperative complica-
sional hernia repair.25 We excluded from this series tions, fewer wound healing problems, and more rapid
Spigelian hernias and incisional hernias that required the recovery after surgery. In 1998, Park and coworkers
intraperitoneal onlay technique. There was a total of compared 56 laparoscopic prosthetic repairs of large inci-
53 hernia repairs (one patient with two incisional hernias). sional hernias with 49 open surgical procedures.27 The
Table 17.2 Comparison studies of laparoscopic versus open repair of ventral/incisional hernia
Complications
Intra- Post- Reopera- Hospital
Cost Repair Patients Size Time operative operative tions stay Follow-up Recurrence
Reference (US$) type (n) (cm2) (min) (n) (n) (n) (days) (months) (n)
Holzman et al. 7299 Open 16 148 98 0 5 2 4.9 18 2
(1997)26 4395 Lap 21 105 128 1 4 0 1.6 20 2
Park et al. Open 49 105 78 1 17 0 6.5 53 17
(1998)27 Lap 56 99 95 0 10 2 3.4 24 6
Carbajo et al. Open 30 141 111 0 35 1 9 27 2
(1999)28* Lap 30 139 87 0 5 1 2 27 0
*Prospective study.
mean follow-ups were 24 months for the laparoscopic or a composite mesh prosthesis in the intraperitoneal
group and 53 months for the open procedure. The hernia location.30,31 Biomaterials have become an important
recurred in six (11 per cent) patients in the laparoscopic tool because they can permanently replace the defective
group and in 17 (34 per cent) patients in the open repair transversalis fascia and permit the creation of a truly
group, but the investigators could not make a meaningful tension-free hernioplasty. However, utilization of bioma-
comparison of the recurrence rates because of the large terials is associated with four major concerns: rejection,
difference in the follow-up periods. They found that the infection, early adhesion formation and host tissue incor-
laparoscopic procedure took longer to perform, but it poration. It is well known that a peritoneal defect or the
was associated with fewer complications and shorter presence of a foreign body in the abdominal cavity creates
postoperative hospital stays. adhesions.13 This in turn may result in major complica-
In the only prospective randomized study of laparo- tions, including intestinal obstruction, migration of the
scopic repair versus open repair, Carbajo and colleagues foreign body and erosion into the bowel, fistula, and infec-
randomized 60 patients over a three-year period into two tion. In general, complications resulting from intraperi-
homogeneous groups to be operated on for major ven- toneal adhesions account for a significant number of
tral hernias using mesh.28 With an average follow-up of emergency surgical admissions and abdominal opera-
27 months, they noted that two hernias in the open repair tions.7 These concerns have prompted the development of
group and none in the laparoscopic group recurred. They a further refinement in the transabdominal laparoscopic
concluded that laparoscopic repair offers several advan- approach: the pre-peritoneal laparoscopic mesh repair.
tages over the classic surgical repair of abdominal wall Dissecting within the pre-peritoneal plane in order to cre-
defects, including a reduction in the rate of complications ate an anatomical room for the mesh may sometimes be
and recurrence. extremely difficult. However, our own experience shows
that this approach is technically feasible in many circum-
stances and, indeed, this procedure is an extension of our
ADVANTAGES AND DISADVANTAGES OF current laparoscopic techniques for repairing inguinal
DIFFERENT LAPAROSCOPIC TECHNIQUES 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 complica-
Critical assessment of the reported results is difficult and tions. Only a longer follow-up period of our patients will
potentially misleading due to the significant variations in allow us to determine whether the theoretical advantages
terminology, patient selection, and operative techniques.29 of positioning the mesh in the pre-peritoneal location will
No data are available to support unequivocally an overt overcome the possible disadvantages of a more tedious
advantage of any particular technique to repair incisional procedure that usually demands a longer operative time.33
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
CONCLUSION
available data (mainly from retrospective studies of
selected patients), recurrence rates are slightly lower and
complications less frequent in the laparoscopic group, The laparoscopic route has made possible the introduc-
regardless of the technique employed. The most popular tion of new surgical techniques for the repair of major
laparoscopic technique of incisional hernia repair pro- abdominal wall defects. The laparoscopic surgeon is able
poses a transperitoneal approach using either an ePTFE to minimize the great degree of tissue trauma involved in
classic open surgery, typically associated with large fas- 10 Amid PK. Classification of biomaterials and their related
cial dissection, tense sutures, and postoperative drains. complications in abdominal wall hernia surgery. Hernia 1997; 1: 15.
11 Morris-Stiff H. The outcomes of nonabsorbable mesh. J Am Coll
Laparoscopic repair of incisional hernias is a promising Surg 1998; 186: 352.
but still new technique that may be seen as a further refine- 12 Koehler RH, Voeller G. Recurrences in laparoscopic incisional
ment of the current surgical armamentarium to treat this hernia repairs: A personal series and review of the literature.
common problem in general surgery. As with any new JSLS 1999; 3: 293–304.
operation, we should initially be more careful about 13 Marchal F, Brunaud L, Sebbag H, et al. Treatment of incisional
hernias by placement of an intraperitoneal prosthesis: a series of
patient selection before embarking on a broader applica- 128 patients. Hernia 2000; 3: 141.
tion of this technique. Adequate training and judicious 14 Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of
indication can certainly ensure good surgical outcomes. recurrent ventral hernias. Am Surg 1998; 64: 1126–7.
Until now, patients in several series have tolerated the 15 Luijendijk RW, Lemmen MHM, Hop WCJ, et al. Incisional hernia
procedure well and had shorter postoperative hospital- recurrence following ‘vest-over-pants’ or vertical Mayo repair of
primary hernias of the midline. World J Surg 1997; 21: 62–5.
izations in comparison to open procedures. Accordingly, 16 Stoppa R. The treatment of complicated groin and incisional
given the potentially lower morbidity due to the smaller hernias. World J Surg 1989; 13: 545–54.
abdominal wall incisions, the overall hospital cost may be 17 Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional
reduced, making this a more attractive approach to inci- hernias. Surg Laparosc Endosc 1996; 6: 123–8.
sional hernias. Moreover, laparoscopy allows compre- 18 LeBlanc KA, Booth WV. Laparoscopic repair of incisional
hensive exploration of the abdominal cavity, adequate preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41.
assessment of the adhesions in the hernia process, and a 19 Hashizume M, Migo S, Tsugawa Y, et al. Laparoscopic repair of
clear delineation of the anatomy. It may be the procedure paraumbilical ventral hernia with increasing size in an obese
of choice in patients who develop a recurrence following patient. Surg Endosc 1996; 10: 933–5.
a previous open hernia repair. 20 Scott-Roth J, Park AE, Witzked, et al. Laparoscopic incisional/
ventral herniorrhaphy: a five-year experience. Hernia 1999; 4: 209.
Laparoscopic incisional hernia repair can be per- 21 Wants GE. Incisional hernioplasty with Mersilene. Surg Gynecol
formed safely with no increased morbidity or mortality, Obstet 1991; 172: 129.
but the ultimate outcome in assessing the success of any 22 Barie PS, Mack CA, Thompson WA. A technique for laparoscopic
hernia repair must be the rate of recurrence. The litera- repair of herniation of the anterior abdominal wall using a
ture suggests that the laparoscopic approach, regardless composite mesh prosthesis. Am J Surg 1995; 170: 62–3.
23 Larson GM: Laparoscopic repair of ventral hernia. In: Scott-Conner
of where the mesh is placed, has a midterm recurrence CEH, ed. The SAGES Manual. New York: Springer-Verlag, 1998: 379.
rate that is at least as good as that seen after the open 24 Toy FK, Bailey RW, Carey S, et al. Prospective multicenter study of
operation. However, long-term assessment from large, laparoscopic ventral hernioplasty. Surg Endosc 1998; 12: 955–9.
well-controlled, prospective studies is needed to confirm 25 Roll S, Benatti M, Roncada, P, et al. Laparoscopic incisional
the expected advantages of the laparoscopic approach. preperitoneal hernioplasty. Presented at the 7th World Congress of
Endoscopic Surgery, Singapore, 1–4 June 2000.
26 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral
REFERENCES and incisional hernioplasty. Surg Endosc 1997; 11: 32–5.
27 Park AE, Birch DW, Lovrics P. Laparoscopic and open incisional
hernia repair: a comparison study. Surgery 1998; 124: 816.
1 Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am 1993; 28 Carbajo MA, Martín del Olmo JC, Blanco JI, et al. Laparoscopic
73: 557–70. treatment vs open surgery in the solution of major incisional and
2 Makela JT, Kiviniemi H, Juvonen T, et al. Factors influencing wound abdominal wall hernias with mesh. Surg Endosc 1999; 13: 250–2.
dehiscence after midline laparotomy. Am J Surg 1995; 170: 387–90. 29 Chevrel JP, Rath AM. Classification of incisional hernias of the
3 Niggebrugge AH, Hansen BE, Trimbos JB, et al. Mechanical factors abdominal wall. Hernia 2000; 4: 7.
influencing the incidence of burst abdomen. Eur J Surg 1995; 161: 30 Alexandre JH, Aouad K, Bethoux JP, et al. Recent advances in
655–61. incisional hernia treatment. Hernia 2000; 4: 1.
4 Meissner K, Jirikowski B, Szecsi T. Repair of parietal hernia by 31 Balique JC, Alexandre JH, Arnaud JP, et al. Intraperitoneal
overlapping onlay reinforcement or ‘gap-bridging’ replacement treatment of incisional and umbilical hernias: intermediate results
polypropylene mesh: preliminary results. Hernia 2000; 4: 29. of a multicenter prospective clinical trial using an innovative
5 Larson GM. Ventral hernia repair by the laparoscopic approach. composite mesh. Hernia 2000; 4: 10.
Surg Clin North Am 2000; 80: 1329–40. 32 Roll S, DePaula AL, Miguel P, et al. Laparoscopic transabdominal
6 Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic ventral and inguinal hernia repair with a preperitoneal mesh. Surg Endosc
incisional repair in 407 patients. J Am Coll Surg 2000; 190: 645–50. 1994; 8: 484.
7 Luijendijk RW, Hop WC, van den Tol P, et al. A comparison of suture 33 Saiz AA, Willis IH, Paul DK, et al. Laparoscopic ventral hernia repair:
repair with mesh repair for incisional hernia. N Engl J Med 2000; a community hospital experience. Am Surg 1996; 62: 336–8.
343: 392–8. 34 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and
8 Leber GE, Garb JL, Alexander AI, et al. Long-term complications incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9.
associated with prosthetic repair of incisional hernias. Arch Surg 35 Sanders LM, Flint LM. Initial experience with laparoscopic repair of
1998; 133: 378–82. incisional hernias. Am J Surg 1999; 177: 227–31.
9 Amid PK, Shulman AG, Lichtenstein I, et al. Preliminary evaluation
of composite materials for the repair of incisional hernias.
Ann Chir 1995; 49: 539.
18
Hernioplasty with the double-crown technique
SALVADOR MORALES-CONDE AND SALVADOR MORALES-MÉNDEZ
Principles 133 Conclusion 142

Double-crown surgical technique 135 References 142
Results of our series 141
Laparoscopic surgery continues to advance in achieving Hernia

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, laparo-
scopic repair of ventral hernias has attained wide accept-
ance 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 Figure 18.1 Double-crown technique for laparoscopic ventral
series still have a limited follow-up, the technique has hernia repair. External sutures are avoided, and the mesh is fixed
shown lower rates of recurrence than the open methods, with a double crown of tacks alone.
making it a procedure that solves a long-standing
challenge to the surgeon.
Nevertheless, there are certain points of controversy postoperative pain at this level, and with the same recur-
that should be clarified, starting with the simple fact of rence rate as described by groups using transfascial
establishing more precise indications. In addition, a mul- sutures.
titude of more specific technical details should be dis-
cussed, 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
PRINCIPLES
the mesh. One of the most interesting points currently
being debated is whether it is necessary to use sutures or Indications and contraindications
tacks. We have developed a laparoscopic procedure with-
out sutures for the repair of ventral hernias, a technique Indications for the double-crown technique are the
we have come to call the ‘double-crown’ technique. same as indications for laparoscopic hernia repair with
This system avoids the use of external (transfascial) transfascial sutures. Basically, all ventral hernias can
sutures by fixing the mesh with a double crown of be repaired by laparoscopy as the standard procedure.
tacks alone (Figure 18.1). This ensures proper anchorage Emergency operations performed in cases of strangu-
of the mesh, decreasing surgery time and diminishing lated hernias must be analyzed on an individual basis to
assess whether laparoscopy should be used. However, transfascial sutures.4,7,8 In fact, they demonstrated that
various factors place limits on the indications for laparo- one of the essential factors to avoid recurrence is the use
scopic repair, such as the size of the defect and the site of these sutures.9 Analysis of the data derived from these
where the defect has occurred. Subxiphoid, suprapubic, early series – data that were later the basis for recom-
lumbar and parastomal hernias require special consider- mendations on the use of sutures – shows that other fac-
ations for laparoscopic repair, and several technical tors could have been involved in the development of
details must still be considered. At the lower end of recurrence in these patients besides the use (or not) of
the size spectrum, hernias that can be repaired with transfascial sutures:
local anesthesia, encompassing those under 3–4 cm, are
usually excluded. However, in patients requiring laparo-
• Prostheses initially recommended were small,
overlapping the defect by only 2–2.5 cm10–12 in all
scopic surgery for other concomitant conditions and in directions, and not the minimum of 3 cm currently
obese patients, laparoscopic repair would be indicated recommended. Recently, we have demonstrated in an
despite the small size of the hernia. At the upper end of experimental study that expanded polytetrafluoro-
the hernia size spectrum, our group has performed many ethylene (ePTFE) prostheses decrease in size once
successful repairs of massive abdominal wall defects. We they have been implanted (by 1.63–4 cm after five
conclude, therefore, that until the limits are established weeks), probably because of the scar tissue reaction
clearly, the degree of difficulty in managing the instru- and the encapsulation process experienced by the
ments within the abdominal cavity is the only actual mesh,13 so recurrence in these initial experiences
limit to the technique as far as large hernias are con- could have happened mainly because of the smaller
cerned. On the other hand, the characteristics of the sac size of the mesh.
of the hernia are important to determine the contraindi-
cations of this technique, since the evolution and compli-
• The method of fixation was also inadequate, since
tacks were not yet available and mesh patches were
cation of the seroma and the cosmetic results would be anchored with the old endo-staplers that did not
different depending on the type of sac. Definitive guide- ensure secure attachment of the material. This problem
lines will have to be elaborated on the basis of results was particularly important with the ePTFE mesh
from prospective studies. because of its thickness. Thus, the use of transfascial
sutures was necessary in these cases, and the real
Sutures versus no sutures with purpose of the endo-staplers was to prevent the
double-crown technique bowel from slipping between the sutures rather than
to fix the mesh.10,11,14
Why are transfascial sutures recommended? • The learning curve of these initial series could be
related more directly to the appearance of
Laparoscopic surgery for ventral hernias offers enormous recurrences than to the placement (or not) of
advantages over open surgery during the immediate post- transfascial sutures.
operative period, with clearly lower morbidity2–4 and
lower general costs of surgery.5,6 Another important issue is
that patients who were operated on by laparoscopy appear Disadvantages of using transfascial sutures
to have lower recurrence rates.2–4
Based on the reasons noted above, we do not believe that
Despite the lower recurrence rate, various authors
these sutures are needed to reduce the recurrence rates,
have made efforts to analyze the causes for recurrence in
as reported by several authors. Nevertheless, they are
order to define adequately the laparoscopic technique
associated with a number of disadvantages (Table 18.1):
and thereby achieve an even lower recurrence rate. Initial
laparoscopic ventral hernia repair series established a • Longer surgery time: surgery times associated with
direct correlation between recurrence and the absence of transfascial suture placement are longer because
Table 18.1 Comparison of factors related to the use of transfascial sutures
Mean operating Mesh infection Long-term Recurrence

Technique time (min) rate (%) pain (%) rate (%)
Double-crown (S. Morales-Conde) 79 0 0 2.86
Other technique without 62 0 0 2
transfascial sutures3
Series with transfascial sutures 120 4.87 1.97 3.98
Hernioplasty with the double-crown technique 135
sutures are recommended every 5 cm,14 4–5 cm,12 or Recurrence rate: a reason to use the double-crown
even 3–4 cm,9 in addition to at the four corners. The technique
operating time in our series is around 79 minutes.
Irrespective of the disadvantages associated with sutures
The time in the other published series that use only
listed above, if the recurrence rate in our series were higher
tacks and no sutures is between 62 and 87 minutes.2,3
than in the series using transfascial sutures, then their use
The operating times for groups using sutures were
would be warranted. In series that advocate the use of
between 82 minutes4 and 210 minutes,15 with a mean
sutures, the recurrence rate ranges anywhere from zero11
of 120 minutes,4,12,15–17 showing a significant
to 8.3 per cent,15 with a mean of 3.98 per cent.4,5,9–11,14–18
increase in surgery time due to the maneuvers
The recurrence rate of our series is 2.86 per cent, with a
needed to place these sutures.
mean follow-up of 24 months. As we noted earlier, recur-
• More incisions in the skin: transfascial suture
rence after laparoscopic repair of ventral hernias tends to
placement involves incisions of 2–3 mm at a pre-
appear more frequently during the first few months of the
established distance of 3–5 cm, as mentioned earlier.
postoperative period. Analysis of our recurrences shows
• Poorer cosmetic results: small incisions are needed to
that they were not related directly to the use of sutures: one
place the sutures. The incisions require only a Steri-
case was due to use of a short mesh at the beginning of our
Strip and typically leave a small scar; however, they
series and the other two cases were two suprapubic hernias
do contribute to a higher number of scars.
with recurrence at the inferior margin. Recurrence in these
• Greater infection rate: in our series, the mesh
two cases resulted from inadequate exposure of the pubis
infection rate was zero, in keeping with results
and Cooper’s ligament in order to anchor the mesh more
reported by other authors who do not use these
securely at this level. This is a complicated area, which
sutures.6 The infection rate reported by groups using
presents particular difficulty when placing transfascial
transfascial sutures was as high as 11.1 per cent,5
sutures. Even authors who advocate the use of sutures do
with a mean infection rate of 4.87 per cent.4,5,18 In
not recommend them at this level.
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
DOUBLE-CROWN SURGICAL TECHNIQUE
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 Preoperative management
sutures.
• Pain during the early postoperative period: the use of A clinical preoperative evaluation is performed, and the
transfascial sutures involves taking 1–2 cm of tissue, indication for laparoscopic approach is set based on pre-
trapping it, and compressing it by tying at the vious considerations. Patients are informed fully about
subcutaneous tissue level. This is associated with the risk of the surgery, the possibilities of conversion into
greater pain during the early postoperative period an open procedure, and the high frequency of the devel-
and in the longer term. In the short term, some opment of postoperative seroma (so that they do not
authors defending the use of these sutures recognize confuse this seroma with an early recurrence).
that there is more pain during the immediate We administer antibiotic prophylaxis in all cases with a
postoperative period than after laparoscopic preoperative dose of a second-generation cephalosporin.
cholecystectomy and that this pain could extend If the patient has any risk factor, such as diabetes, the pro-
hospitalization.9 There may also be discomfort at the phylaxis is continued with two additional doses in the
suture level during the first two weeks of the postoperative period. Mechanical bowel preparation is
postoperative period.17 not usually necessary; only patients who have undergone
• Long-term postoperative pain: the more significant several previous surgeries and who are thought to have
problem is long-term pain, whether continuous or densely adherent or incarcerated viscera will undergo this
associated with movement, and the pulling sensation preparation.
at the site of the sutures. In some cases, oral
narcotics, non-steroidal anti-inflammatory drugs, or
Instrumentation
even injections of local anesthetics at the suture site
have been required, perhaps due to nerve
Laparoscope
entrapment.17,18 Postoperative diagnostic
laparoscopy has been recommended to assess the A 30-degree-angled laparoscope is essential to perform
condition of the mesh and the sutures. This will the laparoscopic approach of ventral hernias, since this
allow the section of the offending sutures, if offers an excellent view of the entire anterior abdominal
necessary.19 wall and of the defect that will be repaired.
Trocars Different hemostatic systems, such as clips, must be avail-

able should their use become necessary. A needle-holder
A variety of trocar sizes are available commercially,
should be available in case of an enterotomy, so that one
including 2-, 3-, 5-, 10-, 11- and 12-mm trocars. In gen-
may repair the injury, thereby allowing the procedure to
eral, we perform the technique using one 10-mm trocar
continue laparoscopically. If we find a full-thickness injury
and two 5-mm trocars. A series of factors should be
to the small intestinal wall that penetrates into the lumen,
considered when choosing the trocars:
we usually repair it, either by laparoscopy or by an assisted
• A trocar of at least 10 mm is required for introducing mini-laparotomy, and then continue the technique by
a mesh. Contamination of the mesh due to placing the mesh intraperitoneally. However, if a colonic
microorganisms on the skin of the abdominal injury occurs, we prefer to repair the bowel and, in the case
wall can potentially occur when the mesh is of a large defect, repair the hernia defect by placing the
introduced through the opening left by the trocar patch a few days later or, in the case of a small defect,
once it is removed. Because of this, we prefer to convert to an open repair without the use of a patch.
introduce the mesh through the trocar. As a result,
we select the trocar based upon the size of the ePTFE Energy sources
patch. We most frequently use the sizes 10 ⫻ 15 cm,
Monopolar cautery is acceptable as long as it is not used in
15 ⫻ 19 cm and 18 ⫻ 24 cm (as well as others of
close proximity to any viscera. Adhesiolysis must be per-
larger size). We use a 10-mm trocar when we expect
formed with extreme care since missed bowel perforation
to use a 10 ⫻ 15-cm mesh, an 11-mm trocar for a
could be life-threatening for the patient. For this reason,
15 ⫻ 19-cm mesh, and a 12-mm trocar for an 18 ⫻
electrocautery should be used in a bleeding area after the
24-cm prosthesis. For larger mesh sizes, we use a 10-
adhesions are freed. During dissection, there is frequent
mm trocar and insert the mesh through the opening
hemorrhage, but this is usually minimal and insignificant
left in the skin by the trocar after it is removed, since
if the proper plane of dissection is maintained.
larger meshes cannot be passed through any of the
The harmonic scalpel has been advocated for lysis of
trocars. In such cases, the mesh to be inserted is
adhesions, but the blunt tip of this instrument does not
wrapped in a sterile plastic material that covers the
allow the easy localization of the proper plane to free the
mesh in order to prevent contamination from
adhesions of the bowel. For this reason, we use this source
microorganisms on the abdominal wall; this plastic is
of energy only for the lysis of omental adhesion and only
subsequently removed from the abdominal cavity.
when we are convinced that there is no bowel attached to
• We prefer to use a 10-mm, 30-degree laparoscope
the anterior abdominal wall behind the fatty tissue. This is
because the visualization and illumination provided
particularly useful in cases in which the round ligament
by the 5-mm, 30-degree laparoscope are not optimal
or the urachus must be dissected to guarantee a proper
in our institution. This, of course, requires a trocar of
fixation of the mesh, since dissection of these structures is
at least 10 mm.
a time-consuming maneuver due to frequent bleeding.
• A 5-mm trocar is used for introduction of the Pro-
Tack device (U.S. Surgical Corp./Tyco International).
Prostheses
Before this fixation system appeared on the market,
this step was performed using an endo-stapler, which Improvements are being made to attain the ideal pros-
required the use of 12-mm trocars. thetic material, i.e. one that is biologically inert, that
produces little or no foreign-body reaction, that is strong
Under these premises, we believe that a 10-, 11- or 12-
yet pliable, that maintains its shape after implantation,
mm trocar (depending on mesh size) should be used for
and that resists the formation of adhesions while support-
laparoscopic repair of ventral hernias, as these accom-
ing fibrous in-growth of connective tissue.20 Polypropylene
modate a 10-mm, 30-degree laparoscope and can be used
mesh has been the most widely used prosthetic material in
to introduce the mesh. A 5-mm trocar should be used to
hernia repair since it was introduced in 1963.21 Numerous
introduce the tacks (or other fixation device) that attach
materials are currently available, such as ePTFE, with
the mesh. Another 3- or 5-mm trocar should be used as a
excellent properties closely resembling the ideal prosthesis,
working trocar.
i.e. being biologically inert, producing fewer adhesions,22
and causing little or no inflammatory reaction, with its
Graspers, scissors, and other laparoscopic
porous microstructure providing a lattice for the incorpo-
instrumentation
ration of connective tissue.23,24
Atraumatic bowel graspers are needed to manipulate the Clinical and experimental experience indicates a vari-
bowel and to provide gentle traction to reduce the con- ety of complications that may be related to the physical
tents of the hernia sac. Sharp scissors are required for properties of polypropylene, such as the risk of bowel
proper dissection and prevention of bowel injury. obstruction and/or fistula formation.25–27 Additionally, a
recent experimental study conducted in our laboratory hernias, midline hernias located in the lower of the
revealed that polypropylene does not attach to the abdomen, or if operation is likely to be prolonged. We use
peritoneum as well as it does to the other layers of the a nasogastric tube to decompress the stomach in patients
abdominal wall previously dissected. ePTFE appeared to with subxiphoid hernias or hernias in the upper third of
attach more firmly to these layers. The new ePTFE mate- the midline of the abdomen.
rial is designed specifically to be placed intraperitoneally,
since one (visceral) surface has very small pores, which
inhibits tissue in-growth, while the opposite (parietal) Operative technique
surface that is placed on to the peritoneum has large
pores to permit significant tissue in-growth. Creation of pneumoperitoneum and placement
We usually use the DualMesh Plus with Holes of trocars
(W. L. Gore & Associates), which is impregnated with In all cases, we start by creating the pneumoperitoneum
chlorhexidine and silver. These antimicrobial agents using a Veress needle in the left hypochondrium. We do
decrease the possibility of contamination of the mesh. not use the Hasson trocar, regardless of the number of
Chlorhexidine and silver also change the color of the previous laparotomies that the patient has undergone.
ePTFE to brown; this minimizes the bright glare of the Our group has performed more than 4000 laparoscopic
ePTFE, which can otherwise hamper the management of procedures for a variety of pathologies, and there has
the mesh within the abdominal cavity because of the never been an injury to any structure because of the use
brightness of the light of the laparoscope. We also advo- of the Veress needle. Hence, we feel confident when
cate the use of the mesh with holes since it will facilitate creating the pneumoperitoneum with this technique,
the drainage of the fluid retained between the mesh and even in patients with a history of multiple operations.
the sac during the first hours of the postoperative period. Once the pneumoperitoneum is created, we generally
The use of an external compressive bandage is also rec- approach the hernia from the patient’s left side, placing
ommended, as this will aid in decreasing the size of the three trocars in line, introducing the 10–12-mm trocar
seroma that we have seen in some of our patients. first and then placing the other 5-mm trocars under direct
vision; the larger trocar is placed in the middle of the other
Fixation devices two trocars. An important thing to remember when plac-
We fix the mesh in all cases with helical tacks, which pro- ing these trocars is to stay as far away as possible from the
vide proper fixation of the mesh to the anterior abdomi- margin of the defect closest to the surgeon. This will pro-
nal wall, thereby avoiding the need of transfascial sutures. vide proper visualization of the margin, making it easier to
A new fixation device is now available, the SaluteTM achieve a wide overlap of the mesh and perform any
(Onux Medical, Inc.), which delivers a cylindrical con- maneuvers needed to secure the prosthesis (Figure 18.2).
struct of stainless steel. When it is not possible to maintain a suitable distance
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.
Operative room set-up
The description below is based upon the repair of small

to medium-sized (3–10 cm) primary or incisional her-
nias located in the midline but about 3 cm from the
xiphoid and suprapubic areas.
We usually place the patient in the supine position, Figure 18.2 Pneumoperitoneum is created using a Veress
with the surgeon and the assistant to the patient’s left and needle in the left upper quadrant of the abdominal wall. The first
the monitor in front of them to the patient’s right. A uri- trocar is introduced far enough from the defect so we do not
nary drainage catheter is used in patients with suprapubic have difficulty in fixing the proximal part of the mesh.
from this margin, we introduce another 5-mm trocar in entire defect on the skin of the patient. In obese patients,
the patient’s opposite flank in order to adequately fix the it is difficult or impossible to feel the grasper on the out-
mesh on the margin closest to the trocar through which side. In these cases, we insert an intramuscular needle
the laparoscope is placed. If necessary, a contralateral through the skin and abdominal wall. The tip of the
10-mm trocar can be inserted to help anchor the mesh. needle is visualized inside the abdominal cavity under
laparoscopic vision and, with multiple passes, is used to
Adhesiolysis detect and trace the hernia defect on the patient’s skin
(Figures 18.4 and 18.5).
Once the trocars are introduced, the adhesions are
An exact measurement of the defect is determined
evaluated. We consider adhesiolysis to be a key point of
when the abdomen is fully desufflated. The patch is then
this procedure, since incorrect performance of the adhesio-
chosen to provide an overlap of at least 3 cm. We system-
lytic process can have extremely serious consequences for
atically use a DualMesh Corduroy Plus with Holes.
the patient. Nevertheless, if there are any doubts regarding
Once the mesh is selected, several marks are traced on
the possibility of bowel perforation, the operation should
the patient’s abdomen and on the mesh surface that
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.
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 hema-
toma 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 Figure 18.4 Once adhesiolysis has been performed, the defect
(not the sac) on the skin of the patient. To facilitate the is identified since it will be where the inner crown of tacks will
accurate identification of the fascial edges, a laparoscopic be placed. In obese patients, the best way to localize the defect
grasper is used (under direct vision) to exert pressure at is by using needles from the outside under direct vision.
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 18.5 The defect identified previously is drawn on the

patient’s skin and the needles are removed. The three trocars
Figure 18.3 Defect of the hernia that needs to be covered once placed in line can be observed; one 10-mm trocar and two 5-mm
the adhesiolysis process is completed. trocars are usually used.
will be placed in contact with the viscera, in order to to perform the maneuvers needed to expand the mesh
facilitate orientation of the prosthesis within the cavity once attachment has begun. We prefer to introduce the
(Figure 18.6). A circular mark is traced at the cranial end mesh through one of the trocars to prevent potential con-
of the mesh. An identical mark is placed on the patient’s tamination, which may occur if it is inserted through the
abdomen to denote the location where the mesh will be skin, a strategy that is preferred by some authors (Figure
anchored. A triangle is then drawn at the caudad end of 18.7b). If a large prosthesis is needed (⬎18 ⫻ 24 cm), we
the mesh and the abdominal wall, followed by a line that prefer to remove the trocar and insert the mesh wrapped
passes through the triangle, starting at the lower limit of in sterile plastic through the trocar hole, and then remove
the hernia defect. This is the line where the caudad tack the plastic from inside the cavity.
will be positioned, since the outside measurements are
different from the internal measurements. Once the cra- Placement and fixation of the mesh
nial tack is placed internally, the distance will not corre-
Once the mesh is inside the cavity and unrolled properly,
spond exactly to the triangle drawn on the patient’s
it must be oriented by using the circle drawn on the
abdomen when the mesh is tightened. The second (cau-
mesh. The corresponding area of the abdominal wall
dad) tack will be placed at the level of the line that passes
where the mesh is to be fixed is located by pushing on the
through the middle of the triangle. A cross is then drawn
abdominal wall at that site. If the patient is extremely
on the left side of the patient’s abdomen and on the
obese, we insert a needle at the level of the circle on the
mesh, and two crosses are drawn on the right in order to
abdomen in order to locate the area where the first tack
extend the mesh properly in both directions.
should be placed. When this tack is placed (Figure 18.8),
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
(a)
(a)
(b)
Figure 18.7 (a) The mesh is rolled along its long axis, with the
(b)
area prepared to be placed in contact with the bowel in the
Figure 18.6 (a) Different signs are drawn on the mesh to orient inside. (b) Once it has been rolled, the mesh is grasped with a
it once it has been introduced in the cavity. (b) The same signs strong grasper to be introduced in the abdominal cavity through
are drawn on the patient’s skin on the cardinal points. the 10–12-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. (b)
Once the mesh is fixed in the four cardinal points, we Figure 18.9 (a) The second tack is placed on the opposite
extend it adequately, adding an outer crown of tacks that cardinal point (caudal) where the triangle was drawn. (b) If we
are placed right on the margin of the mesh (Figure 18.10). have difficulty in localizing the place where we want the tack,
These tacks are separated from each other by a distance of we introduce a needle from the outside.
1 cm, which is adequate to ensure that the intestinal loops
do not slip between the tacks resulting in an acute incar-
ceration. 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 Figure 18.10 Once the tacks are placed in the four cardinal
crown of tacks. Since this level contains a smaller amount points, the outer crown of tacks is placed right at the margin of
of pre-peritoneal fat, the inner crown is placed at the mar- the mesh.
gin of the hernia sac to ensure better attachment of the
mesh (Figure 18.11). Similarly, to identify the sac margin, this level in obese patients, so that we can identify the area
we draw the defect on the abdomen of the patient before where the inner crown of tacks should be placed. These
inserting the mesh inside the cavity. Pressure can then be are also executed while exerting pressure from the outside
exerted from the outside, or a needle can be introduced at 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 patient’s 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

RESULTS OF OUR SERIES
of the hernia sac to ensure better attachment.
Between November 1998 and April 2002, we operated

upon 105 ventral hernias on 102 patients using the double-
crown technique. Our series included 63 women and
42 men, with a mean age of 57.59 years (range 26–80 years).
The ventral hernias included eight primary hernias (four
umbilical hernias, four epigastric hernias) and 97 inci-
sional 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 tuber-
culous 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
Figure 18.12 The double crown of tacks is completed. and the other two required enlarging one of the trocar
holes to perform resection and anastomosis, continuing
later by laparoscopy. The following complications were
tacks used for the outer crown, the inner crown tacks are
encountered during the postoperative period: three clin-
placed about 1 cm apart.
ical seromas that required drains, two abdominal wall
Once all the tacks are placed (Figure 18.12), we pro-
hematomas, two prolonged paralytic ileus, and three
ceed to identify and remove any that are left hanging
reoperations. One of the reoperations was for missed
from the wall or that are placed improperly, since they
intestinal perforation and peritonitis requiring emer-
should be inserted through the entire thickness of the
gency laparotomy. We sutured the bowel perforation and
mesh. Poorly positioned tacks will lead to adhesions, as
removed the mesh. The second reoperation was in a
we have shown in our experimental study, and could
patient who had fever of 45 days’ duration. The seroma
cause major complications in the future, such as fistulas
fluid was drained repeatedly, but cultures were negative.
or obstruction.13
It was assumed that the patient had a foreign-body reac-
tion and the mesh was removed. The third reoperation
Postoperative management was performed due to small bowel ischemia, the etiology
of which is undetermined.
Once the procedure is completed, the abdomen is desuf- The mean hospital stay was 1.75 days, with a mean of
flated and trocar sites larger than 10 mm are closed. A 2.48 days in our first 45 cases and dropping to 1.12 days in
compressive bandage is placed at the level of the hernia sac the last 60 cases of our series. There were three recur-
to reduce the space between the mesh and the sac in an rences, accounting for 2.86 per cent of all our cases, with
a mean follow-up of 24 months. These recurrences 9 Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of
occurred in one patient in our initial series in whom a recurrent ventral hernias. Am Surg 1998; 64: 1121–7.
10 Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional
small mesh was implanted and in two cases of suprapubic hernias. Surg Laparosc Endosc 1996; 6: 123–8.
hernias in which the pubis and Cooper’s ligament were 11 LeBlanc KA, Booth W, Whitaker JM. Laparoscopic repair of ventral
not exposed adequately for suitable fixation of the mesh. hernias using an intraperitoneal onlay patch: report of current
results. Contemp Surg 1994; 45.
12 Park A, Birch DW, Lovrics P. Laparoscopic and open incisional
hernia repair: a comparison study. Surgery 1998; 124: 816–22.
CONCLUSION 13 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
Our results indicate that the use of transfascial sutures is D, Kum CK, So CK, Goh PMY, eds. Proceedings of the 7th World
not necessary and that the double-crown technique, Congress of Endoscopic Surgery (Singapore June 1–4, 2000).
which uses only tacks, offers a number of clear advan- Bologna, Italy: Monduzzi Editore, 2000: 455–60.
tages over the combined suture-and-tack method. When 14 Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of
using the technique described, we obtained a similar laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc
1998; 12: 955–9.
recurrence rate as series that use sutures, while also reduc- 15 Sanders LM, Flint LM, Ferrara JJ. Initial experience with
ing the hospital stay and short-, medium- and long-term laparoscopic repair of incisional hernias. Am J Surg 1999; 177:
postoperative pain. Hence, we consider the double-crown 227–31.
technique to be a valid alternative to ventral hernia repair 16 Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience
with sutures. with the ‘four-before’ laparoscopic ventral hernia repair. Am Surg
2000; 66: 465–9.
17 Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair: a
report of 100 consecutive cases. Surg Endosc 2000; 14: 419–23.
18 Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral
REFERENCES and incisional hernia repair in 407 patients. J Am Coll Surg 2000;
190: 645–50.
1 LeBlanc KA, Booth WV. Laparoscopic repair of incisional 19 LeBlanc KA. Current considerations in laparoscopic incisional and
abdominal hernias using expanded polytetrafluoroethylene: ventral herniorrhaphy. JSLS 2000; 4: 131–9.
preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. 20 Condon RE, DeBord JR. Expanded polytetrafluoroethylene
2 Carbajo MA, Martín del Olmo JC, Blanco JI, et al. Laparoscopic prosthetic patches in repair of large ventral hernia. In: Nyhus LM,
treatment vs open surgery in the solution of major incisional and Condon RE, eds. Hernia, 4th edn. Philadelphia: Lippincott Williams
abdominal wall hernias with mesh. Surg Endosc 1999; 13: 250–2. and Wilkins, 1995: 328–36.
3 Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment 21 Usher FC. Hernia repair with knitted polypropylene mesh. Surg
of ventral abdominal wall hernias: preliminary results in 100 Gynecol Obstet 1963; 117: 239.
patients. JSLS 2000; 4: 141–5. 22 Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and
4 Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of Gore-Tex to repair abdominal wall defects in the rat. Can J Surg
laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65: 1989; 32: 244.
827–32. 23 Bauer JJ, Salky BA, Gelernt IM, Kreel I. Repair of large abdominal
5 DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal wall defects with expanded polytetrafluoroethylene (PTFE). Ann
polytetrafluoroethylene (PTFE) prosthesis patch repair of ventral Surg 1987; 206: 765.
hernia. Surg Endosc 2000; 14: 326–9. 24 Law NW, Ellis H. Adhesion formation and peritoneal healing on
6 Morales-Conde S, López F, Tutosaus JD, et al. Cost-effectiveness prosthetic materials. Clin Mater 1988; 3: 95.
of ‘Double Crown’ technique for laparoscopic ventral hernia vs 25 Kaufman Z, Engelberg M, Zager M. Fecal fístula: a late
open repair. Presented at the 9th International Congress of he complication of Marlex mesh repair. Dis Colon Rectum 1981; 24:
European Association for Endoscopic Surgeons, Maastricht, 543.
13–16 June 2001. 26 Voyles CR, Richardson JD, Bland KI. Emergency abdominal wall
7 Koehler RH, Voeller G. Recurrences in laparoscopic incisional reconstruction with polypropylene mesh: short-term benefits
hernia repairs: a personal series and review of the literature. JSLS versus long-term complications. Ann Surg 1981; 194: 219.
1999; 3: 293–304. 27 Ponce González JF, Barriga Beltrán R, Martín Zurita I, et al.
8 Chari R, Chari V, Eisenstat M. A case controlled study of laparoscopic Prosthetic materials in incisional hernia. Experimental study. Cir
ventral hernia repair. Surg Endosc 1998; 12 (suppl): S09. Esp 1998; 63: 189–94.
19
Parastomal hernia repair
KARL A. LEBLANC
Types of hernia 143 Postoperative management 147

Principles of management 144 Results 148
Indications and contraindications to surgery 144 Conclusion 149
Preoperative preparation 145 References 149
Operative techniques 145
Hernias that develop at the site of the various intestinal TYPES OF HERNIA
stomas are quite common and often lead to many prob-
lems. Parastomal hernias may present as problems of
stoma care, difficulty with the fit of the appliances or irri- The anatomy of the herniation is variable. Four principal
gation, leakage of the fluids produced, a significant cos- types can be identified:
metic deformity, or as complications of the hernia, such • Subcutaneous: there is herniation alongside the
as intestinal obstruction or strangulation. The presence stoma, with a subcutaneous hernia sac containing
of a large protrusion may make repair a necessity irre- omentum or small or large intestine. This is the
spective of its other side effects because of a significant most common form of paracolostomy hernia
cosmetic deformity. Herniation is less frequent with and, not infrequently, the colon is found in the
ileostomy than colostomy, but the overall incidence of sac situated just proximal to the stoma. This
parastomal herniation is difficult to quantify. positioning of the intestine alters the path of the
Burns, in 1970, found 16 paracolic hernias among colon such that the ostomy can be very difficult
307 colostomates, an incidence of five per cent.1 Other to irrigate.
authors have quoted figures that range from five to 48 per • Interstitial: there is a hernia sac lying within the
cent.2–6 It is apparent that few (approximately 20 per muscle/aponeurotic layers of the abdominal wall,
cent) of these hernias are repaired surgically. This may be which may contain omentum or small or large
due to the lack of significant symptoms in the majority of intestine. In these cases, the stoma is asymmetrical,
these patients and/or the age or infirmity of these indi- and is edematous and cyanotic if its vascular supply
viduals, which may prohibit surgical intervention.7,8 The is compromised. The interstitial and subcutaneous
incidence of para-ileostomy hernia is between five and hernias are considered to be variants of a sliding
ten per cent, while that of para-urostomy stomas in hernia. Because the ring of tissue that surrounds the
urological practice is between two and ten per cent.9,10 contents of the hernia can be quite narrow, these
However, one radiological study of 28 ileostomies using hernias are particularly at risk of incarceration and
clinical and computerized tomography (CT) evaluation strangulation.
found that the rate of herniation was 35 per cent; this was • Prolapse: all stomas can prolapse, but transverse
the same whether the ileum exited through or lateral to colostomies prolapse three times more frequently
the rectus muscle.11 than any other stoma. A prolapsed stoma contains a
hernial sac within itself; other viscera, especially the There are four surgical options for treating a para-
small intestine, can enter this sac and even become stomal hernia:
strangulated. Large hernial sacs that can be
1 Local repair of the stoma, in which case it is
associated with prolapse are often seen in neonates
mobilized locally, the peritoneal sac is identified and
with a transverse colostomy for anorectal agenesis.
the sac’s contents are reduced. The peritoneum and
• Intrastomal: this type of hernia is seen only with end
the musculo-aponeurotic defect are then closed. This
ileostomies. A loop of intestine may herniate
is associated with an unacceptable recurrence rate.
alongside the stoma and lie between the emergent
2 Prosthetic repair by either an extraperitoneal or
and the everted layer of the stoma. Intestinal
extraparietal route. There have been reports of erosion
obstruction has been described in such hernias.
and perforation of the colon by the mesh used in this
repair.13
3 Stoma relocation either with formal laparotomy or
PRINCIPLES OF MANAGEMENT with limited transperitoneal transfer of the stoma.
This can be a very effective procedure.14 However,
many patients are quite comfortable with the
The exact classification of the hernia is not critical to the
location of the stoma and would rather maintain the
laparoscopic surgeon. The approach to these different
current site if feasible.
hernia types will not vary significantly, except in the situ-
4 Laparoscopy offers several advantages that
ation in which the intestine may be strangulated. In this
encompass many of the attributes noted above. The
case, the use of the laparoscopic technique may be
laparoscopic approach offers the surgeon the ability
contraindicated. In the elective operation, the condition
to visualize the entire abdominal wall so that any
of the patient and any predisposing factors, such as
incisional hernias may also be repaired at the same
cachexia, malignancy, obesity, and steroid usage, should
time. Additionally, the anatomical detail of the
influence the decision to proceed with surgical interven-
hernia is nearly always identified easily with the view
tion, as it would for any operation.
that is provided with this technique. This repair
However, an accurate diagnosis and assessment of the
requires that the prosthetic biomaterial be placed
anatomy of the hernia are essential. Therefore, the patient
in the intraperitoneal position. The use of
must be examined (1) supine and relaxed, (2) supine
polypropylene has been described, but I believe
with the muscles tensed, and (3) in the erect position.
that the preferred biomaterial is expanded
Investigation of the detailed anatomy with CT scanning
polytetrafluoroethylene (ePTFE).15–18 The experience
is useful to delineate large parastomal defects in the
with this technique, however, is not vast; nor is there
abdominal wall. CT scanning can also detect small
any significant long-term follow-up of the few
impalpable defects around ileostomies that present with
patients that have undergone this hernioplasty.
dysfunction.12 This information will assist the surgeon in
Currently, the initial reports are promising but the
the planning and execution of the operation. I have seen
optimal method of repair has not been finalized.
a herniation through the ileal conduit mesentery during
the repair of a para-urostomy hernia. This was suspected When attempted, it is very unusual that one cannot
by the findings on the preoperative CT scan and was repair these hernias laparoscopically. However, it may
confirmed at surgery. That procedure was modified sometimes be advisable to identify a potential site for
intraoperatively due to this fact (see below). relocation of the stoma if this proves necessary during the
Patients who have had cancer surgery must be screened operation due to an inability to complete the procedure
for recurrence before surgery is advised. Similarly, it is either laparoscopically or open.
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
INDICATIONS AND CONTRAINDICATIONS
ulcerative colitis and Crohn’s disease. An additional con-
TO SURGERY
sideration that has become more commonplace is the life
expectancy of the patient. An increasing number of Surgery is imperative in all cases of intestinal obstruction
patients of advanced age are seen with multiple medical or strangulation related to any parastomal hernia. Urgent
problems that add to the risk of general anesthesia. If emergency surgery is also absolutely indicated in all cases
these illnesses will significantly shorten the life of the of paracolostomy hernia where perforation has occurred
patient (i.e. by two to three years or more), or if they pro- during irrigation. Operative intervention is also the
hibit anesthesia, then one may not wish to proceed if treatment of choice when a parastomal hernia causes
there is no immediate need for surgical intervention. 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 patient’s range of vision, or if its site
on a hernia bulge makes it unmanageable in elderly
patients, especially those with arthritis. The disfigure-
ment caused by a bulging parastomal hernia may war-
rant surgery for cosmetic reasons. In special circumstances,
the repair may need to be accompanied by an abdomino-
plasty 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 Crohn’s disease, extreme obe-
sity, 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 Figure 19.1 Patient position on a roll to elevate the ipsilateral
excoriation in the areas where the transfascial sutures are side of the patient. Note the circle that is marked on the skin to
likely to be placed, then the open procedure may be pre- identify the outermost site of the appliance.
ferred, unless these lesions can be eliminated by preoper-
ative care.
stand on the contralateral side and position the trocars to
triangulate the defect (see Chapter 16). The assistant sur-
PREOPERATIVE PREPARATION geon 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.
These patients are usually elderly and should be cleared
A 2 ⫻ 2-cm gauze is placed over the paracolostomy or
for surgery in the manner that is common to all opera-
para-ileostomy stoma to prevent leakage during the
tions. If the patient has a colostomy secondary to a
procedure. If the ostomy is an ileal conduit, a urinary
malignant resection, it may be advisable to carry out pre-
catheter is inserted to provide continuous drainage.
operative colonoscopy to assure that there is no recurrent
The balloon is inflated with approximately 3 cc’s rather
disease. However, this will be dependent upon the num-
than 5 cc’s of saline due to the size of the bowel lumen.
ber of disease-free years. As noted earlier, a preoperative
The entire abdomen is then covered by a sterile, iodine-
CT scan is frequently helpful to identify the anatomy and
impregnated plastic drape. Before the placement of this
the contents of the hernia. This is especially true for the
drape, the outer aspect of the position of the stomal
para-ileal conduit hernia.
appliance is marked on the skin with a marking pencil.
I prefer to use gentle cleansing enemas on the day
This identifies the outermost boundaries of the potential
before the operation for patients that have a para-
sites of transfascial suture placement (Figure 19.1).
colostomy hernia. This does not assist in the operative
The non-bladed trocar (with the laparoscope within
procedure, but it may diminish the risk of infection if
it) is used for the initial entry into the abdomen.
there is a colonic injury during laparoscopy. Preoperative
Occasionally, a Veress needle or the open approach may
antibiotics are not necessary if an antimicrobial is
be preferred, but in our experience this is seldom neces-
impregnated into the biomaterial that will be used to
sary. As with other intra-abdominal hernia repairs,
repair the hernia (e.g. DualMesh Plus).
dissection of the adhesions is the most tedious and time-
consuming portion of the procedure. This should be
done either sharply without electrocautery or with the
OPERATIVE TECHNIQUES
cautious use of the Harmonic scalpel (see Chapter 16).
The instruments that are used for this are shown in
The patient is placed in the supine position on the oper- Figure 16.4. Although the use of a large catheter placed
ating table. It is best to place a roll underneath the ipsi- within the ostomy to palpate the stoma intraoperatively
lateral side of the hernia. This elevates the patient and is appealing, it frequently provides little benefit.
enables easier access to the area where the sutures will be As with the usual incisional hernias, the entire fascial
placed (Figure 19.1). Typically, a gastric tube is placed for defect and the adjacent abdominal wall must be cleared of
decompression, and a urinary catheter is used. The video all adhesions (Figure 19.2). It is at this point that the mea-
monitors are usually located at the foot of the table and surement of the defect can be performed. This is somewhat
on the ipsilateral side of the hernia. The surgeon will 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 proce-

dure. 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 DualMesh®Plus 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 tech-
nique 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 Figure 19.4 Position of the initial prosthesis with the slit
products. In one version, we used two DualMesh Plus placed opposite the hernia defect. In the photograph, the slit is
products; in another version, we used one MycroMesh on the left and the hernia defect is covered with the prosthesis
Plus product and one DualMesh Plus product. In both, a on the right.
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 latter product may provide better fixation for the second
3–3.5 cm, which is adequate for the colon exit, but with patch that will be placed in this method because no
the ileostomy 2.5–3 cm is preferred. This first patch is in-growth of collagen will occur through this first patch
inserted and secured to the anterior wall in a manner that into the second one.
is similar to that of the incisional hernia repair. The slit is A second biomaterial is then used, usually 18 ⫻ 24-cm
placed adjacent to the colon and directly opposite the DualMesh Plus, so as to completely cover the initial
fascial defect so that good fixation can be made at that 15 ⫻ 19-cm patch. In this way, there will also be in-
point, and the defect is covered completely with the ini- growth of tissue to the periphery of the second patch.
tial patch (Figure 19.4). Sutures are used adjacent to the Additionally, this larger product will provide greater sup-
bowel to re-approximate this slit. These sutures are port than the smaller one to the anterior abdominal wall.
pulled transfascially with a suture-passing instrument Many of these patients will have a significant deformity
(see Chapter 16). Additional fixation of the patch is of the anterior abdominal wall because of the size of the
then applied using the Onux Salute®constructs (Onux hernia itself. It is believed that the use of this second and
Medical, Inc.). This initial step has been done using larger prosthesis will result in a better cosmetic result and
either the DualMesh Plus or the MycroMesh®Plus bio- fit of the appliance. This second patch is cut similarly to
material, as noted above (see Chapter 3). The holes in the the first one, inserted into the abdomen, and fixed with
Figure 19.7 Typical suture placement in the prosthesis for the

onlay type of parastomal hernia repair.
Figure 19.5 The potential space that can exist between the
intestine and the opening in the prosthesis is shown by the arrows. Another method by which to repair these hernias
One may elect to suture the colon at this site. The ePTFE sutures to is based upon the onlay technique described by
the second patch are also seen on the left side of the colon. 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 intes-
tine 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 proce-
dure include complete dissection of the adhesions that
are present and identification of the fascial edges. A mar-
gin of at least 5 cm is also preferred with this repair. I pre-
fer 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 loca-
tion of these on the biomaterial will be dependent upon
Figure 19.6 Final appearance of the completed repair. One the size of the intestine and the location and size of the
suture that has sutured the colon to the opening is seen in the hernia itself. One must be careful that these two sutures
middle of the photograph. 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
the initial sutures similar to the initial patch. However, of 5 cm apart, and Salute constructs are placed 1 cm
the slit that is made in this patch is placed opposite the apart, along the periphery of the patch, as with all of
location of the slit in the initial patch. This placement these parastomal hernia repairs (see Chapters 16 and 20).
is chosen to prevent herniation through the slit in the This results in the placement of several sutures. Others,
initial patch because the second patch protects that slit however, do not place as many sutures.6,21
(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 con-
structs and multiple transfascial sutures that are placed
to include both the first and second patches, as described Patients are usually maintained in the surgical unit, which
in Chapter 16. Occasionally, one may choose to suture allows for a one-night postoperative stay. The gastric and
the colon to the edge of the hole in the patch if it appears urinary tubes are discontinued in the recovery room.
that there is a risk of passage of bowel into that space Patients are allowed a liquid diet immediately, although
(Figure 19.6). The final appearance reveals good coverage most have a short-term ileus. The diet is advanced as tol-
of the defect (Figure 19.6). erated. Abdominal binders, which are used routinely for
Table 19.1 Laparoscopic parastomal hernia repair publications
Patients Location of Length of hospital Length of follow-up

Reference (n) Prosthesis prosthesis stay (days) (months)
Porcheron et al. (1998)15 1 ePTFE Pre-peritoneal 4 12
Bickel et al. (1999)16 1 Polypropylene Intraperitoneal 6 12
Voitk (2000)17 4 Polypropylene Intraperitoneal 2 (3 patients), 9 (1 patient) N/A
Kozlowski et al. (2001)21 4 ePTFE Intraperitoneal 3.8 2–33
LeBlanc et al. (2002)18 3 ePTFE Intraperitoneal 1 (all patients) 3–11
Berger (2002)6 15 ePTFE Intraperitoneal N/A 3–12
the incisional hernias, are placed selectively for this repair. postulate that the method of fixation may be inadequate
The decision to use these is based upon the patient’s because of the relatively few transfascial sutures that were
request, as they do aid in the management of postopera- used in this repair. I believe that it is critical that these
tive pain and in the prevention of seromas. The level of sutures are used at not more than 5 cm apart along the
activity of the patient is based upon the pain tolerance of entire periphery of the patch unless there is a structure,
the individual, and no restrictions are given. 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 recom-
RESULTS mendation. Some surgeons have trephined the bone to
place sutures to ensure fixation.
The laparoscopic repair of parastomal hernias has been My surgical group has now performed one of the
utilized as a method to repair these defects only recently. operations described above on a total of nine patients
At the time of writing, I am aware of only six reports in (Table 19.2). The average length of stay is somewhat
the literature of this methodology.6,14–17 Each of these longer than our experience for incisional hernias, which
articles detailed a slightly different technique, involving is 1.25 days. This is not surprising, however, given the fact
few patients (Table 19.1). that all of these patients had multiple operations pre-
Pocheron and coworkers closed the hernial orifice and viously and several had recurrent parastomal hernias.
used the patch only as a reinforcing layer with no slit used The enterotomy occurred in the patient with the para-
to allow egress of the colon.15 Bickel and colleagues cre- urostomy hernia. He had undergone two previous
ated two strips of mesh, securing one to the abdominal repairs, the latter of which included the repair of an inci-
wall and the other to the intraperitoneal colon.16 Voitk sional hernia with PPM intraperitoneally. I repaired this
used a technique that mimicked that of Sugarbaker’s injury laparoscopically but did not repair the hernia at
intraperitoneal repair.17 All of these authors used tacks that time. His length of stay was increased because he
alone to provide fixation to the abdominal wall. Although remained in hospital until the hernia repair was carried
Bickel used polypropylene mesh (PPM) for the repair of out four days later. Interestingly, a counter-incision for
that patient, he commented that the use of intraperi- open access was required during the second procedure
toneal PPM may lead to adhesion formation and that the because of the inability to accurately assess and reduce
use of a ‘dual mesh nonadherent surface on one side’ may the incarceration of the hernia. In addition to the incar-
be preferable. Kozlowski and coworkers used an onlay cerated small bowel in the hernia, the patient also had a
technique with four sutures; the exact technique is not herniation through the mesentery of the urostomy
described specifically in their paper, however.21 (Figure 19.8). This was reduced, and the repair was
Berger uses an onlay technique that involves fixation completed laparoscopically.
with transfascial sutures and tacks.6 Unless the patch is The recurrence that was seen in the para-ileostomy
greater than 20 cm, he does not use any more than four hernia occurred after nearly one year. Small bowel had
sutures. He also prefers an overlap of 5 cm for this proce- herniated through the slit of both of the patches used in
dure. As noted in Table 19.1, Berger has reported upon 15 the repair. This was reduced laparoscopically, and the
patients. In the immediate postoperative period, one small bowel was sutured to the abdominal sidewall to
patient developed a hematoma and one patient required prevent migration into the slit again. The latter was also
reoperation because of incarceration of the small bowel tightened. This failed after one year, and the patient has
between the patch and the abdominal wall. This latter now undergone an open repair, which relocated the
complication was due to a ‘dislocated tack’. Three of stoma to the left side of his abdomen.
the patients (20 per cent) developed a recurrent hernia The other patients have done very well over the
between two and four months. One could certainly follow-up period, with the exception of the one fatality.
Table 19.2 Parastomal hernioplasty experience
Average length Average follow-up

Type of repair Hernia type (n) of stay (days) Complications (months)
Two DM⫹ Paracolostomy (2) 2.33 Seroma (1) 21
Para-ileostomy (1) 1 Recurrence of para-ileostomy hernia 20
Onlay of DM⫹ Paracolostomy (3) 1.67 Ileus (1) 8
Para-urostomy (1) 7 Enterotomy (1) 2
MM and DM⫹ Paracolostomy (2) 2 Death (1) 2
Total Paracolostomy (7) 1.86 Ileus (1) 11 (range 2–25)
Para-ileostomy (1) 1 Seroma (1)
Para-urostomy (1) 7 Enterotomy (1)
Recurrence (1)
Death (1)
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 1–1.5 cm
apart, preferably in a staggered fashion, and transfascial
sutures placed circumferentially along the entire periph-
ery 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 sur-
geons 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.
CONCLUSION
The forceps are placed through the hernia defect.
The repair of incisional hernias laparoscopically has pro-
This patient aspirated in the immediate postoperative vided us with the technology to repair parastomal her-
period, suffered a cardiorespiratory arrest, and did not sur- nias. The ideal method has not been identified, but the
vive the latter event. Seromas and ileus are well-recognized initial experience shows promise.
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 REFERENCES
of repair for these hernias that should be used routinely
has yet to be identified. However, with the experience of
1 Burns FJ. Complication of colostomy. Dis Colon Rectum 1970; 13:
the recurrence of the ileostomy hernia, I would suggest
448–50.
that the preferred repair of the parastomal hernia that 2 Phillips P, Pringle W, Evans C, Keighley M. Analysis of hospital
involves the small intestine should be the onlay tech- based stomatherapy service. Ann R Coll Surg Engl 1985;
nique. The peristalsis of the small bowel may predispose 67: 37–40.
the other segments of that organ to invaginate into the 3 Sjodahl R, Anderberg B, Bolin T. Parastomal hernia in relation
slits of the two-patch repair. to the site of the abdominal wall stoma. Br J Surg 1988; 75:
339–41.
Currently, however, the recurrence rate of eight 4 Londono-Schimmer EE, Leong APK, Phillips RKS. Life table analysis
per cent is quite admirable. This is an improvement in of complications following colostomy. Dis Colon Rectum 1994;
the open repair of these defects and is better than the 37: 916–20.
5 Ortiz H, Sara MJ, Armendariz M, et al. Does the frequency of 14 Rubin M, Schoetz DJ, Matthews JB. Para-stomal hernia: is the
para-colostomy hernias depend on the position of the colostomy stoma relocation superior to fascial repair. Arch Surg 1994;
in the abdominal wall? Int J Colorectal Dis 1994; 9: 65–7. 129: 413–19.
6 Berger D. Laparoscopic parastomal hernia repair: indications, 15 Porcheron J, Payan B, Balique JG. Mesh repair of paracolostomal
technique, and results. In: Morales-Conde S, ed. Laparoscopic hernia by laparoscopy. Surg Endosc 1998; 12: 1281.
Ventral Hernia Repair. Paris, Springer-Verlag, 2002: 383–7. 16 Bickel A, Shinkarevsky E, Eitan A. Laparoscopic repair of
7 Burgess P, Matthew VV, Devlin HB. A review of terminal paracolostomy hernia. J Laparoendosc Adv Surg Tech 1999; 9:
colostomy complications following abdominoperineal resection for 353–5.
carcinoma. Br J Surg Engl 1984; 71: 1004. 17 Voitk A. Simple technique for laparoscopic paracolostomy hernia
8 Martin L, Foster G. Parastomal hernia. Ann R Coll Surg 1996; repair. Dis Colon Rectum 2000; 43: 1451–3.
78: 81–4. 18 LeBlanc KA, Bellanger DE. Laparoscopic repair of para-ostomy
9 Marshall FF, Leadbetter WF, Dretler SP. Ileal conduit parastomal hernias: early results. J Am Coll Surg 2002; 194: 232–9.
hernias. J Urol 1975; 113: 4–42. 19 De Ruiter P, Bijnen AB. Successful local repair of paracolostomy
10 McDougal WS. Use of intestinal segments and urinary hernia with a newly developed prosthetic device. Int J Colorectal
diversion. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Dis 1992; 7: 132–4.
Campbell’s Urology. Philadelphia: W. B. Saunders Co., 1998: 20 Sugarbaker PH. Peritoneal approach to prosthetic mesh repair of
3121–61. paraostomy hernias. Ann Surg 1985; 201: 344–6.
11 Williams JG, Etherington R, Hayward MWJ, Hughes LE. 21 Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of
Para-ileostomy hernia: a clinical and radiological study. Br J Surg incisional and parastomal hernias after major genitourinary or
1990; 77: 1355–7. abdominal surgery. J Endourol 2001; 15: 175–9.
12 Toms AP, Dixon AK, Murphy MP, Jamieson NV. Illustrated review 22 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
of new imaging techniques in the diagnosis of abdominal wall incisional and ventral herniorrhaphy in 100 patients. Am J Surg
hernias. Br J Surg 1999; 86: 1243–50. 2000; 180: 193–7.
13 Aldridge AJ, Simson JN. Erosion and perforation of colon by
synthetic mesh in a recurrent paracolostomy hernia. Hernia 2001;
5: 110–12.
20
Lumbar hernia and ‘denervation’ hernia repair
KARL A. LEBLANC
Anatomy 151 Results 153

Indications and contraindications for surgery 152 Conclusion 153
Operative technique 152 References 154
Primary and acquired lumbar hernias are quite uncom- inferiorly. The base of the inferior lumbar triangle is the
mon. There have been about 300 cases of primary her- iliac crest, its anterior border is the posterior margin of
nias reported in the literature.1 Acquired lumbar hernias the external oblique muscle, its posterior border is the
are the result of flank incisions for renal or other retro- anterior edge of the latissimus dorsi muscle, and its apex
peritoneal operations, notably anterior lumbar interbody is superior (Figure 20.1).
fusion. These acquired hernias can also be the result of Lumbar hernias may contain a variety of intra-
division of the anterior branches of nerves that originate abdominal organs. Hernias of the colon are the most fre-
from T6 to T12. In these latter circumstances, there is no quent, but small intestine, stomach and spleen are also
fascial defect with these denervation injuries, so they are likely candidates for herniation. A particular curiosity is
not true hernias. These ‘pseudo-hernias’ are difficult to the sliding hernia of the colon, which causes intermittent
treat surgically. Rarely, they can also be seen with diabetic obstructive symptoms.
radiculopathy. Differential diagnoses include tumors of the muscles,
Approximately 55 per cent of these hernias are pri- lipoma, hematoma associated with blunt trauma, abscess,
mary, 25 per cent are acquired, and the remainder are and renal tumors. Small fatty protrusions of retroperi-
congenital in origin.2 The latter can sometimes be bilat- toneal fat through the lumbodorsal fascia have been
eral. Primary lumbar hernias are found most frequently implicated as a cause of lower back pain. Computerized
on the left side; two-thirds of these are seen in men.3,4 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
ANATOMY the protrusion of the flank will frequently complain of
back pain related to the defect. It is difficult to explain the
The lumbar area is bounded above by the twelfth rib, source of this, as many of these patients will have had a
below by the iliac crest, behind by the erector spinae long, pre-existing complaint of back pain requiring disk
muscles (sacrospinalis), and in front by the posterior surgery. The most common presentation is the acknowl-
border of the external oblique (a line passing from the tip edgment of the significant cosmetic deformity that is
of the twelfth rib to the iliac crest). Within this area, two caused by the musculature paralysis. This will cause a
triangles are described: the superior lumbar triangle (of broad laxity of the affected abdominal wall (Figure 20.2).
Grynfelt) and the inferior lumbar triangle (of Petit). The This appearance will become most pronounced if the
superior lumbar triangle is an inverted triangle: its base process is long-standing, if the patient experiences signi-
is the twelfth rib, its posterior border is the erector spinae ficant weight gain, or if the patient is morbidly obese. CT
muscles, its anterior border is the posterior margin of scanning is not so helpful for delineating this problem,
the external oblique, and its apex is at the iliac crest 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.
Iliac crest
Umbilicus
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.
of these hernias is associated with a high failure rate

Figure 20.2 Appearance of the abdominal wall following a because of the tension that occurs with the repair. The use
right nephrectomy that resulted in a ‘denervation hernia’. 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
INDICATIONS AND CONTRAINDICATIONS requires a very extensive incision to repair these defects.
FOR SURGERY Pseudo-hernias are sometimes repaired with abdominal
wall plication followed by placement of a prosthetic
biomaterial over the plicated muscle, but this also requires
These defects will increase in size over time. The cos-
a large incision if the mesh is to cover the entire area of
metic appearance will deteriorate because of this, but
paralysis.
there is a risk of incarceration and strangulation with
The laparoscopic approach has been applied to this
primary hernias. All primary hernias should be repaired,
type of herniation. Its concept is similar to the repair of
but it is not clear whether surgery can offer a permanent
incisional hernias (see Chapter 16). A tube to decom-
solution to the pseudo-hernia. Careful follow-up is
press the stomach is used routinely, but a urinary
needed to evaluate the effectiveness of the laparoscopic
catheter is placed only selectively. One significant differ-
approach to this entity.
ence 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
OPERATIVE TECHNIQUE
are critical for this operation. As with incisional hernia
repair, the initial efforts focus upon the dissection of the
The open approach to a primary, acquired or denervation adhesions and the identification of the fascial edges.
hernia is generally a formidable operation. Suture closure 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 DualMesh®Plus is recommended because
this procedure is intraperitoneal. The prosthesis should
be at least 4–5 cm larger than the defect itself. This is
slightly larger than that considered necessary for tradi-
tional 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
5–6 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 diffi- Figure 20.4 Postoperative (six months) appearance of a repair
cult to treat. Therefore, this is not recommended unless of a ‘denervation hernia’ subsequent to an anterior lumbar
absolutely necessary. The use of transfascial sutures and interbody fusion.
metal fixation devices is identical to the incisional hernia,
except as noted above.
Repair of a pseudo-hernia necessitates the use of a cosmetic result. With these patients, the intent is that the
very large prosthesis. This must cover the entire para- shrinkage of the tissues caused by scar contraction will
lyzed muscle from the lumbar area to a point across the result in an acceptable cosmetic result.
midline of the patient. Because of the positioning of the One patient had prolonged postoperative pain
patient, fixation may be very difficult near the midline. thought to be related to the use of suture around a rib.
It is sometimes necessary to place two trocars laterally One patient developed a symptomatic seroma. Both of
through the biomaterial to allow the visualization and these problems resolved without intervention. Follow-up
fixation at that site. These holes are then closed with ranged from nine months to three years. The cosmetic
sutures placed with a suture-passing device. result with this method has been acceptable to all the
patients and has been excellent in some (Figure 20.4).
RESULTS
CONCLUSION
There have been only ten laparoscopic lumbar hernio-
plasties reported in the literature.6–8 All were case reports, The incidence of lumbar hernias is low. The problem of
except for one report that included seven patients.9 This denervation hernias may become more prevalent in the
latter report included five hernias that were acquired; two future due to the increasing use of the anterior approach
were congenital and two were recurrent. Two patients had for disk disease by spine surgeons. Repair of these defor-
two or three separate hernia defects. The hernias ranged mities can be difficult and fraught with failure if it is not
in size from 1.5 ⫻ 1.5 cm to 8 ⫻ 11 cm, averaging 77.8 cm2. approached in a reasoned manner. The use of prosthetic
As noted above, a large overlap of the expanded poly- reinforcement is thought to be best, and the laparoscopic
tetrafluoroethylene (ePTFE) patches was used; the average approach may be of benefit, although more studies and
patch size was 336.4 cm2. One of these patients developed follow-up are needed.
an abscess over the repair, which required removal of
the prosthesis. The remaining six patients were free of
recurrence after 1–15 months of follow-up.
REFERENCES
This author has repaired six denervation hernias. All
were performed using the technique described above. One 1 Gentileschi P, Kini S, Gagner M. Laparoscopic repair of unusual
of these patients had an implantation of DualMesh Plus hernias: lumbar, spigelian and other special hernias. In: Morales-
Conde S, ed. Laparoscopic Ventral Hernia Repair. Paris: Springer-
with Holes. This product is 1.5 mm thick, compared with Verlag, 2002: 363–74.
the 1-mm thickness of DualMesh without Holes. It was 2 Swartz WT. Lumbar hernias. J Ky Med Assoc 1954; 2: 673–8.
hoped that the thicker material would result in a better 3 Thorek M. Lumbar hernia. J Int Coll Surg 1950; 14: 367–93.
4 Watson LE. Hernia, 3rd edn. St Louis, MO: Mosby, 1948: 443–5. 7 Bickel A, Haj, Eitan A. Laparoscopic management of lumbar hernia.
5 Knol JA, Eckhauser FE. Inguinal anatomy and abdominal wall Surg Endosc 1997; 11: 1129–30.
hernias. In: Greenfield LJ, ed. Surgery: Scientific Principles and 8 Woodward AM, Flint LM, Ferrera JJ. Laparoscopic retroperitoneal
Practice. Philadelphia: JB Lippincott, 1993: 1081–107. repair of recurrent postoperative lumbar hernia. J Laparoendosc Adv
6 Burick AJ, Parascandola SA. Laparoscopic repair of a traumatic Surg Tech A 1999; 2: 181–6.
lumbar hernia: a case report. J Laparoendosc Surg 1996; 6: 9 Arca MJ, Heniford BT, Pokorny R, et al. Laparoscopic repair of
259–62. lumbar hernias. J Am Coll Surg 1998; 2: 147–52.
21
Results of laparoscopic incisional and
ventral hernia repair
RODRIGO GONZALEZ AND BRUCE J. RAMSHAW
Results of series 155 Conclusion 159

Results of comparative studies 157 References 160
Although the principles of abdominal wall repair are fixation of a large mesh without subcutaneous tissue dis-
well established and the complication rate has decreased section in patients with large hernia defects.10–12
significantly over the past decade, the complication and Laparoscopic ventral hernia repair is based on the
recurrence rates for open incisional hernia repair are far method described by Stoppa for open incisional hernia
from ideal. A prospective, randomized, multicenter study repair,4 reported to have the lowest recurrence rate.
recently reported a 46 per cent recurrence rate after pri- It involves posterior reinforcement of the abdominal
mary open repair of ventral hernias when a prosthetic wall with a large piece of prosthetic material based on
material was not employed.1 Others have reported recur- Laplace’s law. The large surface area of the mesh allows
rence rates of 25 per cent and 52 per cent for fascial defects substantial ingrowth of tissue for permanent mesh fixa-
smaller and larger than 4 cm, respectively.2–4 Recurrences tion, and the intra-abdominal pressure tends to hold the
are also associated with the number of repairs performed, mesh in apposition to the posterior abdominal wall over
with 18–43 per cent after initial repair and over 50 per cent a wide surface area.13,14
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,
RESULTS OF SERIES
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 Patient demographics
recurrence rate compared with primary repairs,1,5 but
they have been associated with other types of complica- Since the first report of laparoscopic ventral hernia
tions, including wound infection, seromas, mesh extru- repair,15 numerous series have been published supporting
sion, fistula formation, and adhesions.5–7 Infections can the use of this technique. Table 21.1 summarizes the
occur in up to 15 to 45 per cent of open mesh repairs and results of 2002 laparoscopic ventral hernia repairs pub-
may also correlate with recurrence rates.1,8 This high lished in the literature. We have tabulated these data
infection rate is thought to be secondary to the large inci- and will discuss the averages from this information.
sion with which the mesh is in contact and the wide dis- Demographic data show a slightly higher predominance
section necessary for adequate mesh placement. The of females (56 per cent), with a mean age of 55 years.
laparoscopic technique involves access to the abdominal Fifty-six per cent of the patients were obese, with a mean
cavity away from the defect, avoiding placement of the body mass index (BMI) of 34 kg/m2. Consistent with pre-
mesh through a large incision, thereby reducing the prob- vious literature, the prevalence of incisional hernias (89
ability of contamination and infection.9 It also allows per cent) is higher than for primary hernias (11 per cent).
Table 21.1 Results of laparoscopic ventral hernia repair
Prior Hernia Operating Conversion Hospital Seroma Infection Mesh Recurrence

Patients repairs size room time rate stay rate rate removed Follow-up rate
Reference (n) (%) (cm2) (min) (%) (days) (%) (%) (%) (months) (%)
LeBlanc et al. (1994)16 28 7 – – 0 – 4 4 4 10 0
Saiz et al. (1996)17 10 20 – 68 0 2 10 10 0 – 0
Park et al. (1996)18 28 – 104 108 0 4.1 0 4 – 8 4
Tsimoyiannis et al. (1998)19 11 – – 49 0 3 9 9 0 15 0
Franklin et al. (1998)20 176 39 – – 3 – 0a 2 1 30 1
Toy et al. (1998)21 144 26 98 120 – 2.3 16 3 4 7 4
Constanza et al. (1998)22 16 100 130 – 6 2 – – – 18 6
Sanders et al. (1999)23 12 58 – 210 8 3.5 36 8 0 13 8
Kyzer et al. (1999)24 53 55 – 89 4 3.3 – 2 2 12 2
Roth et al. (1999)25 75 – 101 105 3 2.9 4 4 – – 9
Koehler and Voeller (1999)26 32 41 – 101 – 1.9 – 6 6 20 9
Balique et al. (2000)27 29 – – – – – 14 3 – – –
Farrakha (2000)28 18 33 – 85 0 3.2 33 0 0 22 6
Carbajo et al. (2000)29 100 – 93 62 1 1.2 10 0 0 30 2
Reitter et al. (2000)30 49 37 – 152 4 4.3 0 2 2 27 6
Heniford et al. (2000)31 100 49 87 88 0 1.6 3b 2 2 23 3
Heniford et al. (2000)32 415 33 100 97 2 1.8 5a 2 1 23 3
Szymanski et al. (2000)33 44 20 20 – 9 – 2 5 – – 5
Chowbey et al. (2000)34 202 – – 50 0.5 1.8 18 2 – 35 1
Kozlowski et al. (2001)35 17 – – 240 0 – – – – – 12
LeBlanc et al. (2001)36 100 18 155 – 4 1.2 7 2 1 51 9
Birgisson et al. (2001)37 64 42 34 130 0 1.7 5 4 0 10 2
Moreno-Egea et al. (2001)38 20 75 7 – 0 – 15 0 0 12 0
Bageacu et al. (2002)39 159 23 – 89 14 3.5 16 3 – 49 16
Ben Haim et al. (2002)40 100 25 6 119 7 5 11 1 1 19 2
Total 2002 32 89 114 3 1.9 7.5 2.2 1.5 26 3.3
a
Seromas persisting ⬍ 6 weeks.
b
Seromas persisting ⬎ 4 weeks.
Results of laparoscopic incisional and ventral hernia repair 157
This includes 11 per cent umbilical and 0.6 per cent is estimated that about 80 per cent of hernias are repaired
Spigelian hernias. Sixteen per cent of the hernias were utilizing ePTFE mesh, 15 per cent with polypropylene
multiple and 32 per cent were recurrent. mesh, and five per cent with polyester mesh.
Intraoperative complications Operative and postoperative results

Laparoscopic repair was shown to be safe, even in large The mean operative time was 114 minutes, with an esti-
ventral defects, with an intraoperative complication rate of mated blood loss of 80 cc. The return of bowel function
one per cent. The most frequent major intraoperative was 1.7 days after surgery. The average hospital stay was
complication was bowel injury, occurring in 0.8 per cent of 1.9 days, and the average return to normal activities was
cases. Conversions to open repair were reported in three two weeks after the operation. Postoperative wound com-
per cent of cases and were more frequent during the early plications were minimal after laparoscopic ventral hernia
phase of the learning curve.9 The most common reasons repair. They included infection (2.2 per cent), seroma
for conversion were bowel injuries, failure to reduce incar- persisting for more than six weeks (7.5 per cent), and
cerated hernias, and extensive adhesions. Enterotomies are hematoma formation (six per cent). In 1.5 per cent of
most likely to occur during adhesiolysis and reduction of patients, mesh removal was required due to mesh infec-
hernia sac contents. The occurrence of an enterotomy is tion or reoperation for missed or delayed bowel injury.
considered a reason for conversion by some surgeons; it Other complications included ileus (2.4 per cent), urinary
may also be a contraindication for mesh placement due to retention (1 per cent), bowel obstruction (0.5 per cent),
potential contamination. The incidence of unrecognized and trocar site bleeding (0.3 per cent). Chronic pain can
or delayed bowel injury is reported to be between zero and develop at sites where full-thickness abdominal wall
five per cent. These can be the result of missed injury sutures are used for mesh fixation; this has been reported
or thermal or partial-thickness injury that progresses to in 0.2–2 per cent of patients. Most instances of pain
full-thickness injury over time, and can result in serious resolve without intervention. Some authors have reported
complications such as sepsis and even death.10,11,30 the use of injection of local analgesics for the relief of pain.
Occasionally, repeat injections are necessary to achieve
Choice of prosthetic pain relief. Reoperation for suture removal is required
rarely. These sutures are considered an essential step by
Laparoscopic surgery allows placement of a large overlay most surgeons to help reduce hernia recurrences by
of mesh without soft-tissue dissection. The mean size of preventing mesh migration.
all hernia defects was 89 cm2 and the mean mesh size was
201 cm2. Most surgeons used expanded polytetrafluoro-
ethylene (ePTFE) DualMesh®as the prosthetic material Recurrence
of choice. The 3-␮m-size pores on the side of the mesh in
contact with the abdominal contents result in a low inci- The mean recurrence rate from the series in Table 21.1
dence of adhesion formation between the biomaterial was 3.3 per cent, at a mean follow-up of 26 months. Few
and the viscera. More importantly, even if bowel is adher- additional recurrences are expected in these series, since
ent to the mesh, the ePTFE DualMesh inhibits ingrowth, up to 90 per cent of recurrences occur within the first two
preventing fistula formation and bowel obstruction. A years after ventral hernia repair.1,31 In fact, future recur-
variety of composite mesh products are available and are rence rates for laparoscopic ventral hernia repair may
being evaluated (see Chapter 4). One side of the compos- actually be lower, because most of these reports included
ite mesh is made of polypropylene or polyester to pro- surgeons’ experience during their learning curve. A com-
mote ingrowth into the abdominal wall (although the mon cause for recurrence noted in some series is a lack of
mesh is actually placed in direct contact with the peri- suture fixation.26,32,36
toneum in most cases). The other side of the mesh is
made of either permanent ePTFE or an absorbable anti-
RESULTS OF COMPARATIVE STUDIES
adhesion barrier. This side is placed toward the abdomi-
nal cavity with the intention of preventing ingrowth
to the polypropylene (ePTFE permanent material) or Comparative studies between laparoscopic and open ven-
preventing adhesions (absorbable material). The great tral hernia repairs have consistently reported advantages
majority of authors who have published series of laparo- for the laparoscopic approach, especially in the evaluation
scopic ventral hernia repair refrained from using of wound complications and recurrence rates. Results of
polypropylene or polyester mesh that would allow poten- eight of these series are summarized in Table 21.2. In most
tial direct contact with intra-abdominal organs, especially comparative series, the technique is selected based on
large and/or small intestine. Based on published series, it each surgeon’s experience, and most are retrospective
Table 21.2 Results of comparative studies between laparoscopic and open ventral hernia repair
Previous Hernia Operating Length Postoperative

Patients repairs size room time of stay complication Infection Seroma Follow-up Recurrence
Reference Technique (n) (n) (cm2) (min) (days) rate (%) rate (%) rate (%) (months) rate (%)
Holzman et al. (1997)41 Open 16 4 148 98 5 31 6 0 19 13
Laparoscopic 20 8 105 128 1.6 23 5 5 10 10
Park et al. (1998)42 Open 49 9 105 78 6.5 37 2 2 54 35
Laparoscopic 56 16 99 95 3.4 18 0 4 24 11
Carbajo et al. (1999)43* Open 30 22 141 112 9.1 50 18 67 27 7
Laparoscopic 30 23 140 87 2.2 20 0 13 27 0
Ramshaw et al. (1999)10 Open 174 51 34 82 2.8 26 3 – 21 21
Laparoscopic 79 36 73 58 1.7 15 0 – 21 3
DeMaria et al. (2000)44 Open 18 3 – – 4.4 72 33 50 24 0
Laparoscopic 21 11 – – 0.8 57 10 19 24 6
Chari et al. (2000)45 Open 14 – – 78 5.5 14 0 – – –
Laparoscopic 14 – – 124 5 14 7 – – –
Robbins et al. (2001)13 Open 23 – – – – – 30 – – –
Laparoscopic 31 – – – – – 16 – – –
Wright et al. (2002)12 Open with mesh 90 28 79 102 2.5 28 13 12 32 6
Open without mesh 119 6 12 70 1.5 22 10 4 24 9
Laparoscopic 86 15 112 131 1.5 24 9 9 24 1
*Prospective randomized study.

Results of laparoscopic incisional and ventral hernia repair 159
studies. Surprisingly, in many reports, the patients in the Finally, the favorable cosmetic results for primary ventral
laparoscopic group had a tendency to have larger hernia hernia repair with the laparoscopic technique may be an
defects10,13,44 and a higher incidence of previous hernia important consideration for some patients.
repairs10,41,42,44 than in the open group. This suggests that Wright and colleagues compared the laparoscopic
the results are even more favorable for the laparoscopic approach with two techniques of open repair, with and
repair, since recurrences occur more frequently in large without use of mesh.12 The group that underwent open
defects and after previous repairs.3,42 repair with mesh had a higher incidence of previous
Some series have reported increased operative times repairs. The laparoscopic group had larger hernia defects
with the laparoscopic technique.13,42 This is important and larger mesh sizes. The laparoscopic technique resulted
when considering anesthesia times and operating room in a longer mean operative time and lower wound compli-
expenses. However, once beyond the learning curve, the cation rates. The laparoscopic approach also resulted in
laparoscopic repair can frequently be completed in a lower recurrence rates, but the difference was significant
shorter time than a comparable open repair, even in the only when compared to open repair without mesh.
presence of large hernia defects.10,34 Laparoscopic repair In the only prospective randomized study so far,
is also associated with reduced estimated blood loss.10 Carbajo and coworkers reported a shorter operative time
Most comparative series have reported lower overall and hospital stay, as well as lower recurrence and compli-
postoperative complication rates with the laparoscopic cation rates (including infections and seromas) with the
technique than with the open technique (20 v. 31 per cent, laparoscopic approach.43 The patients in each group had
respectively) (Table 21.2). The laparoscopic approach a similar incidence of previous repairs and hernia size.
results in lower wound complication rates,10,11,13,42 includ- Two recurrences occurred in the open group with a 27-
ing fewer seromas,42,43 fewer infections,10,11,13,44 and fewer month follow-up. Two mesh explantations were required
dehiscences.13 Since wound complications that may be in the open group for postoperative infections. There
present after laparoscopic hernia repairs occur in small were no recurrences or late complications in the laparo-
trocar incisions, they tend to be less severe, to be treated scopic group.
more easily, and to require mesh removal less frequently A primary goal for ventral hernia repair is to mini-
than in open repairs.10,43 Seromas are frequently obser- mize recurrence rates. Factors associated with recurrences
ved following a ventral hernia repair whether performed include larger hernias,3,42 previous hernia repairs, lateral
through an open or laparoscopic approach. Ultrasound defects, and postoperative complications (mainly infec-
examinations revealed seroma formation in 100 per cent tions). The laparoscopic technique has resulted in lower
of patients, with a peak occurrence seven days after the recurrence rates, even in the presence of larger defects,10,13
operation, and almost complete resolution after 90 days.46 and higher rates of previous repairs.10,42 Indeed, as
Seromas may be a source of concern to patients not demonstrated in Table 21.2, the recurrence rate was 15
informed of the likelihood of their occurrence. Most sur- per cent for the open repair, with a 33-month follow-up,
geons agree that they should not be considered a com- and 4.5 per cent for the laparoscopic technique, with a
plication unless they persist, increase steadily in size, or 22-month follow-up.
cause symptoms. Aspiration of seroma contents should be
approached with caution, since even under sterile condi-
tions there is a potential for contamination. Infection
CONCLUSION
requiring mesh removal has been reported following aspi-
ration of a seroma.44 After repair of large hernias, the use
of binders can be considered in an attempt to reduce Laparoscopic repair of ventral and incisional hernias is an
seroma formation. attractive approach for a difficult problem. The achieve-
Another advantage consistently reported with the ment of a low recurrence rate while minimizing wound
laparoscopic technique is the shorter length of hospitaliza- complications is a combination of goals that has eluded
tion.10,42–44 This may be due partially to decreased pain,44 open approaches for ventral hernia repair. While the
fewer complications,10,11,13,42,43 earlier oral intake,45 infre- laparoscopic approach makes sense and is being adopted by
quent use of drains,10 and reduced postoperative ileus.10,42 many surgeons, it remains an advanced laparoscopic proce-
In general, these patients ambulate earlier than patients dure with inherent potential complications, especially dur-
undergoing open repair. Laparoscopic ventral hernia repair ing the learning curve. Results of the studies presented in
can be performed on an outpatient basis in some cases.41,44 this chapter point out the importance of good patient selec-
The shorter operative time and length of stay after laparo- tion and recognition of the potential for intraoperative and
scopic repair may offset the increased operative costs for delayed visceral injury. Improvements in training and edu-
surgical equipment compared with open techniques.41 One cation of minimally invasive surgical procedures will help
study shows lower costs for the laparoscopic approach, even to maximize the safe adoption of advanced laparoscopic
when accounting for the costs of treating complications.44 techniques, such as laparoscopic ventral hernia repair.
REFERENCES 25 Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic

incisional/ventral herniorrhaphy: a five-year experience. Hernia
1999; 4: 209–14.
1 Luijendijk RW, Hop WCJ, van der Tol MP, et al. A comparison of 26 Koehler RH, Voeller G. Recurrences in laparoscopic incisional
suture repair with mesh repair for incisional hernia. N Engl J Med hernia repairs: a personal series and review of the literature.
2000; 343: 392–8. JSLS 1999; 3: 293–304.
2 Larson GM. Ventral hernia repair by the laparoscopic approach. 27 Balique JG, Alexandre JH, Arnaud JP, et al. Intraperitoneal
Surg Clin North Am 2000; 80: 1329–40. treatment of incisional and umbilical hernias: Intermediate results
3 Hesselink VJ, Luijendijk RW, de Wilt JHW, et al. An evaluation of of a multicenter prospective clinical trial using an innovative
risk factors in incisional hernia recurrence. Surg Gynecol Obstet composite mesh. Hernia 2000; 4 (suppl): S10–16.
1993; 176: 228–34. 28 Farrakha M. Laparoscopic treatment of ventral hernias. Surg
4 Stoppa RE. The treatment of complicated groin and incisional Endosc 2000; 14: 1156–8.
hernias. World J Surg 1989; 13: 545–54. 29 Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment
5 Korenkov M, Sauerland S, Arndt M, et al. Randomized clinical trial of ventral abdominal wall hernias: preliminary results in 100
of suture repair, polypropylene mesh or autodermal hernioplasty patients. JSLS 2000; 4: 141–5.
for incisional hernia. Br J Surg 2002; 89: 50–56. 30 Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience
6 Cassar K, Munro A. Surgical treatment of incisional hernia. with the ‘four-before’ laparoscopic ventral hernia repair. Am Surg
Br J Surg 2002; 89: 534–45. 2000; 66: 465–9.
7 Leber GE, Barb JL, Albert AI, Reed WD. Long-term complications 31 Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair.
associated with prosthetic repair of incisional hernias. Arch Surg A report of 100 consecutive cases. Surg Endosc 2000; 14: 419–23.
1998; 133: 378–82. 32 Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral
8 George CD, Ellis H. The results of incisional hernia repair in a and incisional hernia repair in 407 patients. J Am Coll Surg 2000;
12-year review. Ann R Coll Surg 1986; 68: 185–7. 190: 645–50.
9 White TJ, Santos MC, Thompson JS. Factors affecting wound 33 Szymanski J, Voitk A, Joffe J, et al. Technique and early results of
complications in repair of ventral hernias. Am Surg 1998; 64: outpatient laparoscopic mesh onlay repair of ventral hernias. Surg
276–80. Endosc 2000; 14: 582–4.
10 Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of 34 Chowbey PK, Sharma A, Khullar R, et al. Laparoscopic ventral
laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65: hernia repair. J Laparoendosc Adv Surg Tech A 2000; 10: 79–84.
827–32. 35 Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of
11 Morris-Stiff GJ, Hughes LE. The outcomes of nonabsorbable mesh incisional and parastomal hernias after major genitourinary or
placed within the abdominal cavity. Literature review and clinical abdominal surgery. J Endourol 2001; 15: 175–9.
experience. J Am Coll Surg 1998; 186: 352–67. 36 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
12 Wright BE, Niskanen BD, Peterson DJ, et al. Laparoscopic ventral incisional and ventral herniorrhaphy. Our initial 100 patients.
hernia repair: are there comparative advantages over traditional Hernia 2001; 5: 41–5.
methods of repair? Am Surg, 2002; 68: 291–6. 37 Birgisson G, Park AE, Mastrangelo MJ, et al. Obesity and
13 Robbins SB, Pofahl WE, Gonzalez RP. Laparoscopic ventral hernia laparoscopic repair of ventral hernias. Surg Endosc 2001; 15:
repair reduces wound complications. Am Surg 2001; 67: 896–900. 1419–22.
14 Temudom T, Siadati M, Sarr MG. Repair of complex giant or 38 Moreno-Egea A, Lirón R, Girela E, Aguayo JL. Laparoscopic
recurrent ventral hernias by using tension-free intraperitoneal repair of ventral and incisonal hernias using a new composite
prosthetic mesh (Stoppa technique): lessons learned from our mesh (Parietex). Surg Laparosc Endosc Percutan Tech 2001;
initial experience (fifty patients). Surgery 1996; 120: 738–44. 11:103–6.
15 LeBlanc KA, Booth WV. Laparoscopic repair of incisional 39 Bageacu S, Blanc P, Breton C, et al. Laparoscopic repair of
abdominal hernias using expanded polytetrafluoroethylene: incisional hernia. A retrospective study of 159 patients. Surg
preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. Endosc 2002; 16: 345–8.
16 LeBlanc KA, Booth WV, Whitaker JM. Laparoscopic repair of 40 Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications
ventral hernias using an intraperitoneal onlay patch: report of with laparoscopic intraperitoneal expanded
current results. Contemp Surg 1994; 45: 211–14. polytetrafluoroethylene patch repair of postoperative ventral
17 Saiz AA, Willis IH, Paul DK, Sivina M. Laparoscopic ventral hernia hernia. Surg Endosc 2002; 16: 785–8.
repair: a community hospital experience. Am Surg 1996; 62: 336–8. 41 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral
18 Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional and incisional hernioplasty. Surg Endosc 1997; 11: 32–5.
hernias. Surg Laparosc Endosc 1996; 6: 123–8. 42 Park A, Birck DW, Lovrics P, et al. Laparoscopic and open incisional
19 Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopic hernia repair: a comparison study. Surgery 1998; 124: 816–22.
intraperitoneal onlay mesh repair of incisional hernia. Surg 43 Carbajo MA, Martín del Olmo JC, Blanco JI, et al. Laparoscopic
Laparosc Endosc 1998; 8: 360–2. treatment vs open surgery in the solution of major incisional and
20 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and abdominal wall hernias with mesh. Surg Endosc 1999; 13:
incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. 250–52.
21 Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of 44 DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal
laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral
1998; 12: 955–9. hernia. Prospective comparison to open prefascial polypropylene
22 Constanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of mesh repair. Surg Endosc 2000; 14: 326–9.
recurrent ventral hernias. Am Surg 1998; 64: 1121–7. 45 Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of
23 Sanders L, Flint LM, Ferrara JJ. Initial experience with laparoscopic laparoscopic incisional hernia repair. Surg Endosc 2000; 14:
repair of incisional hernias. Am J Surg 1999; 177: 228–31. 117–19.
24 Kyzer S, Alis M, Aloni Y, Charuzi I. Laparoscopic repair of 46 Susmallian S, Gewurtz G, Ezri T, Charuzi I. Seroma after
postoperation ventral hernia. Early postoperation results. Surg laparoscopic repair of hernia with PTFE patch: is it really a
Endosc 1999; 13: 928–31. complication? Hernia 2001; 5: 139–41.
22
SAMUEL K. MILLER, STEPHEN D. CAREY, FRANCISCO J. RODRIGUEZ AND ROY T. SMOOT, JR
Bowel injury 161 Prolonged ileus/persistent nausea and vomiting 166

Laparoscopic assisted hernia repair 163 Recurrence of hernia 166
Mesh infection 164 Conclusion 168
Seroma 165 References 168
Postoperative/suture pain 166
A ventral hernia is any protrusion through the anterior Review of laparoscopic hernia repairs demonstrates an
abdominal wall with the exception of the inguinal area. overall complication rate ranging from five to thirty per
Ventral defects include those found in the umbilical, epi- cent,3–16,18,19 with a mean of 15.2 per cent. The major
gastric, Spigelian, incisional, and parastomal locations. advantage of laparoscopic ventral hernia repair is a
Five to fifteen per cent of laparotomies will result in ventral decreased rate of major wound complications19 and
incisional hernias, with the incidence of incisional hernia lower recurrence rates.3–18,20
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
BOWEL INJURY
hernia repairs annually.
Over the past decade, techniques for the laparoscopic
approach to ventral hernia repair have been developed. The most feared complication associated with the laparo-
Potential advantages include avoidance of large incisions scopic approach to ventral hernia is enterotomy. Bowel
with associated flaps and drains, tension-free repairs injury has resulted in serious morbidity and mortality.
stabilized by intra-abdominal pressures (Laplace’s law), Several authors report bowel injuries,3,4,9,11–13,18 with an
reduced length of stay with reduced convalescence and overall average incidence of 1.1 per cent. Table 22.2 pres-
more rapid return to full activity, and lower complication ents the series reporting bowel injuries. Holzman and col-
and recurrence rates. leagues describe a single enterotomy during laparoscopy
A review of the literature on laparoscopic ventral and that required conversion to an open procedure to avoid
incisional hernia repair as well as our clinical experience placement of prosthetic material.3 Toy and coworkers
over ten years was undertaken. A Medline search demon- mention two enterotomies in their prospective multicen-
strated 18 articles suitable for analysis. These articles ter study but do not give any further details.4 Ramshaw
contained data on complications and recurrences. This and colleagues had two serious bowel injuries: one was
chapter will give an overview of the complications asso- recognized and repaired at the time of injury but subse-
ciated with laparoscopic ventral and incisional hernia quently it dehisced and required reoperation; the second
repairs, and will suggest strategies to address these com- went unrecognized and required reoperation with mesh
plications. Table 22.1 lists the articles chosen for review. removal.9 Ramshaw and colleagues also had one minor
In comparison to open hernia repairs, overall compli- serosal bowel injury with no sequelae.9
cation rates for laparoscopic hernia repairs are much Koehler and Voeller mention two unrecognized bowel
lower. Complication rates reported for recent series of injuries, with one patient ultimately dying of hepatic fail-
open repairs may be high as 27–34 per cent.16,19,21,22 ure on the twenty-ninth postoperative day.11 This death
Table 22.1 Reported series analyzed, with recurrence rates and total complication rates
Mean follow-up Recurrence Complications

Reference Cases (n) (months) (%) (%)
Holzman et al. (1997)3 20 10.2 1.0 25
Toy et al. (1998)4 144 7.4 4.2 25
Franklin et al. (1998)5 176 33.6 1.1 5
Costanza et al. (1998)6 15 18 0 13
Tsimoyiannis et al. (1998)7 10 15 0 30
Park et al. (1998)8 56 24 11.0 18
Ramshaw et al. (1999)9 79 21 2.5 19
Kyzer et al. (1999)10 53 12 0 11
Koehler et al. (1999)11 34 20 8.8 21
Roth et al. (1999)12 75 17 9.3 19
Chari et al. (2000)13 14 – 7.0 14
LeBlanc et al. (2000)14 96 51 9.3 15
Carbajo et al. (2000)15 100 30 2.0 16
DeMaria et al. (2000)16 21 – 4.8 10
Reitter et al. (2000)17 42 27 7.1 –
Heniford et al. (2000)18 407 23 3.4 13
Robbins et al. (2001)19 31 – – 16
Kozlowski et al. (2001)20 17 – 11.8 24
Personal series (2002) 182 31 2.7 17
Total 1572 65/1541 233/1530
Mean 22.7 4.2 15.2
Table 22.2 Series reporting bowel injuries
Cases Enterotomies Complications

Reference (n) (n) (%)
Holzman et al. (1997)3 20 1 5.0
Toy et al. (1998)4 144 2 1.4
Ramshaw et al. (1999)9 79 3 3.8
Koehler and Voeller (1999)11 34 2 5.9
Roth et al. (1999)12 75 2 2.7
Chari et al. (2000)13 14 2 14.3
Heniford et al. (2000)18 407 6 1.5
Reporting no injuries 799 0 0
Total 1572 17 1.1
occurred in a patient requiring lysis of densely adherent mesh due to infection. The second enterotomy resulted
small-intestinal loops to the polypropylene mesh. The in a prolonged postoperative course, with respiratory
other patient presented on the fifth postoperative day with failure and sepsis; the patient survived.
an enterocutaneous fistula, and required removal of the Finally, Heniford and colleagues, with the largest
patch and segmental resection of the small bowel. Kyzer retrospective study involving 407 patients, describe
and coworkers had two recognized small-bowel injuries, six patients with small bowel enterotomies.18 Minimal
which were both converted to open laparotomy: one spillage was noted in four cases. These four patients had
required a bowel resection and the other required simple their enterotomies repaired laparoscopically and the her-
suture closure.10 Roth and colleagues had two cases of nia repairs completed. The fifth patient was converted to
intraoperative enterotomies recognized at the time of an open repair. None of the five patients had infectious
operation: in one case, the operation was converted to complications or recurrence of the hernia. The sixth
an open procedure; the second enterotomy was closed patient had an unrecognized enterotomy and subse-
laparoscopically, but no prosthetic patch was placed.12 quently underwent a laparotomy with resection of a
Chari and coworkers, in a small case–control study, short segment of small bowel and removal of the mesh.
describe two patients with enterotomies in the laparo- Bowel injury can occur during initial entry into the
scopic group.13 One patient required removal of the peritoneal cavity, although no such injury has been
reported in the literature describing laparoscopic ventral ‘beware of mesh’, although a previous mesh repair is not a
incisional hernia repairs. Most surgeons, including contraindication to the laparoscopic approach.
Voeller and Heniford,18,23 prefer the Hasson technique in Management of enterotomies requires sound clinical
a site well away from the hernia defect and in a quadrant judgment. In most cases, we recommend conversion to
free of previous surgery. We agree with this technique and open laparotomy to repair bowel injuries. Koehler and
use the Hasson technique for nearly all cases. LeBlanc, Voeller advise the same, especially for surgeons that are
however, favors the use of the Optiview trocar (Ethicon still early in their laparoscopic ventral hernia repair expe-
Endosurgery, Inc.).23 rience.11 The decision to place any prosthetic material in
Nearly all reported bowel injuries have occurred dur- the setting of bowel perforation depends on the degree of
ing lysis of adhesion. Ramshaw and coworkers9 and Park contamination and whether the injury involves the
and coworkers23 considered this to be the most dangerous colon. If a colonic injury is suspected, then prosthetic
part of laparoscopic ventral hernia repair, and Koehler hernia repair must be aborted.11,26 The injury must be
and Voeller described it as the most challenging part of addressed, and the incisional hernia can be repaired at a
laparoscopic incisional ventral hernia repair.11 Robbins later time. In the setting of a small bowel injury, we rec-
and colleagues, however, believe that the most difficult ommend conversion to a laparotomy and repair of the
part of the procedure is adhesiolysis and reduction of the bowel injury in most cases. A decision to place prosthetic
hernia contents.19 The mechanisms of injury include material in a contaminated field must be taken with great
direct injury during sharp dissection and thermal injury caution. We would err on the side of conservatism and
from various energy sources.24,25 We recommend that all avoid the use of any prosthetic material because of the
adhesiolysis is done with cold scissors under direct vision, risk of infection. Many others agree with this.10,11,13 The
with absolute minimal use of energy. Ramshaw and col- only exception to this would be in a setting where there is
leagues,9 Park and colleagues,23 Robbins and colleagues,19 a skilled laparoscopic surgeon who can routinely repair
and others support this position. Cautery and harmonic bowel perforation in a proficient manner and there is
dissection can produce immediate perforations as well as minimal contamination. Heniford and colleagues
delayed perforation. Delayed perforations are more com- describe six bowel injuries.18 In four patients, the entero-
mon with harmonic dissection because the edges are tomy was repaired laparoscopically, one was converted to
sealed immediately and the mucosa is not seen readily. open repair, and the hernia repair was completed in each.
Kyzer and coworkers note several special situations in In spite of their good outcomes with no mesh infections,
which the risk of bowel injury is particularly high.10 they caution strongly against placement of mesh in the
These include patients with previous episodes of peri- setting of bowel perforation and contamination. If there
tonitis, patients in whom a previous repair utilized is any doubt about the situation, then we recommend
intraperitoneal Marlex mesh, and cases of giant hernias conversion to laparotomy. Once the enterotomy is
that contain multiple irreducible bowel loops. Koehler repaired and a decision is made not to proceed with the
and Voeller also warn of the dangers during adhesiolysis mesh repair, then the patient can be closed, placed on
in the setting of previous synthetic mesh repair.11 intravenous antibiotics, and returned to the operating
Adhesions to the prosthetic material can be fairly dense, room in three to seven days for completion of the laparo-
and lysis of adhesions may be almost impossible. An scopic hernia repair.23 Koehler and Voeller describe a
excellent strategy in this situation is conversion to open similar second-stage patch placement if an enterotomy is
enterolysis, closure of the abdominal wall, and comple- made and repaired.11
tion of the hernia repair laparoscopically. Many others Lastly, sage advice given by Koehler and Voeller is that
are advocates of this technique.9,10,13,23 Heniford and one should always consider the possibility of the conver-
coworkers describe conversion to open surgery in eight of sion of an occult partial-thickness injury into a full-
415 patients:18 two patients were opened because of an thickness bowel injury when a patient is clinically
inability to reduce incarcerated intestine, one was deteriorating after an uneventful laparoscopic ventral
opened for loss of abdominal domain, one for resection hernia repair.11 We second this opinion and do not hesi-
of strangulated bowel, and one for enterotomy. tate to relaparoscope a patient who is not doing well
As noted above, a special circumstance in which clinically and who is deteriorating.
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
LAPAROSCOPIC ASSISTED HERNIA REPAIR
vascular, with clear planes of dissection that are difficult to
define. Our one enterotomy occurred in the face of a pre-
vious repair with Prolene mesh. This prompted us to be The techniques of laparoscopic assisted ventral hernia
especially wary of the risk of enterotomy when working repair should be part of the armamentarium of all sur-
adjacent to a previous mesh repair. A good rule to follow is geons who perform hernia repairs using the laparoscopic
approach. Indications for this approach include inability draped. Many surgeons recommend the use of an adhe-
to gain access to the peritoneal cavity, inability to com- sive barrier drape, as is commonly done in vascular
plete safe lysis of adhesions laparoscopically, any question surgery. The mesh itself should be treated in the same
of visceral injury, and incarcerated hernias for which fashion as any vascular graft, in that contact with the skin
reduction using laparoscopic techniques is impossible. should be avoided. Even the largest expanded polytetra-
When these indications are encountered, the abdomen is fluoroethylene (ePTFE) patches can easily be drawn into
opened through a limited incision. The bowel is inspected the abdomen through a standard Hasson trocar. Use of
if visceral injuries are suspected, and any injuries are antibiotic-impregnated prosthetics may offer some meas-
repaired in the appropriate fashion. The remainder of the ure of protection against infection. The lower infection
adhesiolysis is then completed with the abdomen open. rates in laparoscopic repairs may be due to the avoidance
The defect is then measured, and an appropriately sized of long incisions, wide dissection or flap creation, open-
patch is prepared, including placement of pre-tied ing of the hernia sac, and placement of drains.4,8,18,28
sutures. The patch is then introduced into the abdomen, With rare exception, all infected biomaterials placed
unrolled, and oriented. The abdomen is closed in an air- laparoscopically to repair incisional hernias must be
tight fashion. The pneumoperitoneum is re-established removed to control infection and sepsis. Toy and col-
and the procedure completed in the standard laparo- leagues describe five wound infections, four of which
scopic fashion. Other authors have employed this started at a trocar site.4 Three responded to intravenous
technique.9,10,13,23 antibiotic therapy without mesh removal, and two cases
The laparoscopic assisted technique provides the sur- required removal of the mesh. Franklin and coworkers
geon with an alternative to complete abandonment of the document only a single mesh infection with staphylococ-
laparoscopic approach should the problems described cus in series of 176 patients.5 The mesh infection occurred
above be encountered. It also provides the surgeon with a 14 months postoperatively and the mesh was removed.
safe alternative if visceral injury is suspected. Until a sur- Kyzer and coworkers had a single mesh infection that
geon gains experience with laparoscopic ventral hernia required removal and subsequently led to a recurrent her-
repair, this may initially be the procedure of choice. nia.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
MESH INFECTION requiring mesh removal because of an abscess.16 The
author felt that seroma aspiration led to contamination
Mesh infections (Table 22.3) are a very serious complica- and subsequent abscess formation. Heniford and col-
tion reported in multiple series, with an average reported leagues had four mesh infections in 407 patients, and all
incidence of 1.4 per cent.4–6,8,10–12,16,18,19 Infection rates required removal of the mesh.18 Two had prior mesh
for open incisional hernia repairs are 16 per cent.27 infections with open hernia repair. One developed skin
Avoidance of infection includes strict attention to sterile necrosis over the mesh, which eventually became exposed.
technique. The patient should be carefully prepped and The last patient developed a mesh infection several weeks
Table 22.3 Series reporting mesh infections
Cases Mesh infection Complications

Toy et al. (1998)4 144 2 1.4
Franklin et al. (1998)5 176 1 0.6
Costanza et al. (1998)6 15 1 6.7
Park et al. (1998)8 56 2 3.6
Kyzer et al. (1999)10 53 1 1.9
Koehler et al. (1999)11 34 2 5.9
Roth et al. (1999)12 75 2 2.7
DeMaria et al. (2000)16 21 1 4.8
Heniford et al. (2000)18 407 4 1.0
Robbins et al. (2001)19 31 1 3.2
Personal series (2002) 182 5 2.7
Reporting no mesh infections 378 0 0
Total 1572 22 1.4
postoperatively. Robbins and coworkers reported 31 reported average incidence of 4.4 per cent, with a range
laparoscopic hernia repairs with a single abdominal wall of 0–16 per cent (Table 22.4). Toy and colleagues describe
abscess in the hernia site.19 Ultimately, the mesh had to be the largest number of seromas in their prospective, mul-
removed. In our series, we had one infection that required ticenter study.4 Seromas occurred in 23 (16%) patients.
patch removal; the hernia recurred and was later repaired Fifteen of these seromas resolved within 30 days, two
laparoscopically. resolved after 30 days, and six required aspiration. These
Once the infected mesh is removed, options for closure six patients required aspiration because of the size of the
of the abdominal defect include primary closure of the seroma, per patient request, or because there was suspi-
fascia or closure of the fascial defect with biological grafts. cion of infection. None of the seromas became infected
The wound is generally left open to close secondarily. After after aspiration. Tsimoyiannis and coworkers describe a
the open wound has closed completely, and at least three single seroma that was aspirated, but they give no details
to four months have passed since the infection developed of the indication for drainage.7 Park and colleagues
and the mesh was explanted, the patient can return to the aspirated two seromas because of symptoms or their
operating room for laparoscopic hernioplasty. 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
SEROMA subcutaneous abscess that required open drainage, but
the underlying mesh did not have to be removed.
The standard laparoscopic techniques for ventral hernia Koehler and Voeller had two obvious seromas, but nei-
repair involve reduction of the hernia contents followed ther required drainage and both resolved over a period of
by coverage of the defect with an appropriately sized three to six weeks.11 LeBlanc and colleagues had seven
piece of mesh. The hernia sac is left in situ. Fluid accu- seromas, none of which required aspiration.14 They have
mulation in the hernia sac is very common in our expe- instituted bulky dressings for 72 hours to help minimize
rience and confirmed by many others.3–5,7–9,11,12,14,15,18,23 seroma fluid accumulation. Heniford and coworkers des-
LeBlanc and colleagues considered postoperative sero- cribed eight seromas that were defined as fluid collec-
mas to be the most common ‘minor complication’.14 tions over the mesh that lasted for six to ten weeks.18
Heniford and coworkers state that many patients develop They stated that no long-term complications occurred,
‘small, self-limited collections’ of fluid over the mesh.18 regardless of whether the seromas were aspirated.
The definition of ‘significant’ collection varies among Most fluid collections can simply be observed, because
reported series. Some authors define a significant fluid they will resolve spontaneously over four to ten weeks.
collection as one that requires aspiration because of Therefore, we recommend observation for the vast major-
steady growth or clinical symptoms. Others define a ity of postoperative seromas.14,23 Not all authors agree,
significant fluid collection as one that lasts for more than however. Carbajo and colleagues described ten seromas, all
six weeks.8,18 Review of the literature demonstrates a of which were managed with aspiration.15 No comments
Table 22.4 Series reporting seromas
Cases Seromas Complications

Holzman et al. (1997)3 20 1 5.0
Toy et al. (1998)4 144 23 16.0
Franklin et al. (1998)5 176 2 1.1
Tsimoyiannis et al. (1998)7 10 1 10.0
Park et al. (1998)8 56 2 3.6
Ramshaw et al. (1999)9 79 2 2.5
Koehler and Voeller (1999)11 34 2 5.9
Roth et al. (1999)12 75 3 4.0
LeBlanc et al. (2000)14 96 7 7.3
Carbajo et al. (2000)15 100 10 10.0
Heniford et al. (2000)18 407 8 2.0
Personal series (2002) 182 8 4.4
Reporting no seromas 193 0 0
Total 1572 69 4.4
were made as to when and why these seromas required defined prolonged suture site pain as pain lasting for
aspiration. DeMaria and coworkers also aspirated all more than eight weeks.18 They describe eight cases in
seromas; they stated that most resolved with one or two their report, most of which resolved with time (in six
aspirations, with three attempts at most.16 DeMaria and patients) or injection (in two patients) of bupivacaine.
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 PROLONGED ILEUS/PERSISTENT NAUSEA
removed, and they concluded that the infection occurred AND VOMITING
because of inadequate sterile technique during seroma
aspiration. Park and colleagues feel that routine aspiration
Several authors report prolonged ileus or persistent nau-
of seromas has resulted in mesh infection, and they advise
sea and vomiting following these procedures. The cumu-
against this practice.23
lative reported incidence is two per cent.3,4,8,9,12,14,18,20
Although not well described in the literature, our
Other authors have also reported prolonged ileus and
experience shows that many postoperative seromas will
persistent nausea and vomiting, but they did not comment
display subtle signs of inflammation, such as localized
further.
warmth, erythema, and minimal tenderness to palpation,
We generally do not use nasogastric tubes in the post-
but do not represent true infections. Subtle signs of
operative period. If patients develop nausea, this is treated
inflammation do not require any specific treatment other
with anti-emetics, such as ondansetron hydrochloride
than observation. There is also no associated leukocytosis
4 mg every four hours, as necessary. If patients develop
or fever. These findings generally resolve spontaneously as
protracted emesis along with their ileus, a nasogastric
the fluid is reabsorbed. The level of comfort in observing
tube will be placed, but this will be removed as soon as
these subtle signs will depend upon one’s clinical experi-
possible. Early ambulation and activity are encouraged to
ence. Close clinical follow-up is critical in this setting.
prevent ileus.
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
RECURRENCE OF HERNIA
aspiration because it may contaminate the seroma and
cause an abscess.4 Aspiration may be required for sero- Overall recurrence rates for open ventral incisional her-
mas that are painful and enlarging. Park and coworkers nia repairs have been high and range from 30 to 60 per
and other experts feel that aspiration of seromas tends to cent.4,29–37 A review of the literature demonstrates that
increase the rate of mesh infections.23 Removing fluid laparoscopic hernia repair has lowered this dramatically
may be both therapeutic and diagnostic in this setting. to approximately four per cent (with a mean follow-up
Clear, straw-colored fluid is normal; however, turbid and period of 22.5 months) (Table 22.1).
purulent fluid is highly suggestive of infection, requiring Several factors are reported to increase the risk of
removal of the prosthetic material. recurrence after ventral hernia repairs. These include
infection at the original operation38 and size of the orig-
inal hernia.31 Other authors have noted wound infec-
tions, obesity, advanced age, pulmonary complications,
POSTOPERATIVE/SUTURE PAIN hepatic insufficiency, and male gender as risk factors for
recurrence.6 Park and colleagues report higher recur-
We have found that laparoscopic ventral and incisional rences with larger hernias, hernias in a central or midline
hernia repairs tend to be exceedingly painful compared location compared with lateral hernias, and wound com-
with other minimally invasive surgeries. Ramshaw and plications after hernia repair.8 Roth and coworkers, on
colleagues report similar findings.9 They believe that the the other hand, found no association between the size
pain is related to the number of full-thickness sutures and the number of previous repairs, age, postoperative
and posterior fascial tacks used. Length of hospital stay complications, or location of recurrence.12 Koehler and
will be proportional to the degree of pain. We generally Voeller warn us to consider occult liver disease in any
keep patients in the hospital for three to four days for hernia recurrence that cannot be explained by infection
postoperative pain management. This is several days or collagen-vascular disease, and they give supporting
longer than the average length of stay reported in the lit- references.11,39,40 LeBlanc and colleagues state that their
erature. Our preferred method of analgesia is patient- recurrences are generally associated with large and mul-
controlled analgesia (PCA) with morphine. tiple defects, the use of only one method of fixation for
The reported incidence of suture and/or protracted the prosthetic patch, and an inadequate patch size.14
pain is around 1.3 per cent. Heniford and colleagues Hesselink and coworkers noted a 41 per cent cumulative
recurrence rate at five years, with second, third and We believe that sutures and spiral tacks are needed in all
fourth incisional hernia repairs having recurrence rates repairs.
of 56, 48 and 47 per cent, respectively.31 To place transabdominal nonabsorbable sutures, we
Several factors are crucial for the maintenance of low employ a suture-passer to place them 4–5 cm apart.
recurrence rates. The defect must be defined completely, Heniford and coworkers also place full-thickness abdom-
the adhesions must be separated, and the repair must not inal-wall sutures every 4–5 cm.18 The sutures should be
have any tension. The prosthetic patch should be below placed no more than 5 cm apart. Koehler and Voeller state
the plane of the fascial defect, and the size of the patch that tacks should be placed every 1.5 cm on the periphery,
must be larger than the hernia defect.41,42 with sutures every 6 cm.11 They also suggest using three to
The use of prosthetic materials is by far the most four tacks around the edges of the hernia defect to mini-
important step in the evolution of recurrent hernia mize the dead space. LeBlanc and colleagues believe that
repairs.37,39,43,44 In the early reports of laparoscopic ventral both sutures and tacks are important for securing the
and incisional hernia repairs, many authors reported that mesh.14
their early recurrences were due to the use of only one type Overlapping the hernia defect with the prosthetic patch
of fixation method, such as staples or tacks alone, without of an adequate size is also critically important. Several
properly fixing the mesh with sutures. Conversely, pure studies have demonstrated that side-to-side suturing of
suture repair of hernias without using mesh is also the patch to the edge of the hernia defect leads to recur-
not advisable. This advice is confirmed by Franklin and rence rates of 11–42 per cent.55–57 Tsimoyiannis and col-
colleagues, who report that one recurrence (out of two) leauges7 and Park and colleagues8 state that the overlap
was due to the lack of use of a prosthetic patch.5 must be at least 2.5 cm. Ramshaw and coworkers,9 LeBlanc
Tension-free placement of a prosthetic patch on the and coworkers,14 and Robbins and coworkers19 prefer a
posterior surface of the abdominal wall is important, and 3–4-cm overlap beyond the edge of the defect. Kyzer and
this alone has led to lower recurrence rates.26,29,31,35,41,45–47 colleagues10 and Koehler and Voeller11 suggest that the
The intra-abdominal pressure tends to hold the mesh in overlap should be 5 cm or greater. Koehler and Voeller
place by Laplace’s law. describe a recurrence due to patch disruption with a 9-cm
We believe, like others, that tissue in-growth into the overlap but with no suture fixation.11 Gillion and col-
mesh material is important for long-term fixation.4,48–50 leagues have shown clearly that overlapping the mesh with
However, in the immediate postoperative period, sutures the hernia defect lowers the recurrence rate significantly.58
and spiral tacks play a critical role in fixation. Franklin We feel that complete coverage of the entire incision is
and colleagues5 and Reitter and colleauges17 all place important whenever possible, even though the actual
strong emphasis on full-thickness transabdominal wall recurrent hernia defect may encompass only a small por-
sutures to prevent recurrent hernias. However, they felt tion of the entire incision. Koehler and Voeller also state
that tacks and staples were necessary only to hold the that coverage of the entire incision is crucial to minimize
mesh in place initially and to fill in the gaps between the recurrence risk.11 For example, if a patient has a midline
sutures. Ramshaw and coworkers describe one recurrence incision with a recurrence at one end, we would cover
in a laparoscopic repair where only a hernia stapler was the entire midline incision with the prosthetic material
used for fixation (i.e. without sutures or tacks).9 They to minimize recurrence. In our personal series, several of
subsequently modified their technique using sutures and the recurrent hernias were noted above or below the pre-
tacks in all but the smallest (⬍2 cm) hernia defects. viously placed prosthesis. We have not seen a recurrence
Heniford and colleagues state that 43 per cent (6/14) of in which the prosthetic material failed intrinsically.
their recurrences developed in patients in whom sutures Most laparoscopic recurrences tend to occur within
were not used at all or not placed in difficult areas, such as the first two years, and this has also been our experience.
the costal margins.18 We feel, as do Heniford and cowork- Toy and colleagues had six patients (other than those
ers,6 Ramshaw and coworkers,9 and LeBlanc and cowork- recurrences from removal of infected mesh) with recur-
ers,14 that suture fixation is extremely important to the rences of their ventral hernias.4 All six recurrences
success of the laparoscopic hernia repair. Without suture presented by nine months postoperatively, with none
fixation, the prosthetic patch can pull away from the thereafter. Franklin and coworkers report two recur-
abdominal wall, eventually leading to recurrence. This has rences, one at four months and the other at 13 months
been documented clearly.3,11,14,18,26,51–54 However, we and following the operation.5 The first recurrence occurred
Park and colleagues8 feel that spiral tacks are just as after a non-prosthetic umbilical hernia repair. The sec-
important. The mesh should be secured to the abdominal ond recurrence followed the removal of an infected pros-
wall with spiral tacks placed 1 cm apart. Not all authors thetic biomaterial. LeBlanc and colleagues report nine
agree: Carbajo and colleagues felt that sutures led to hernia recurrences at a mean of 24 months, with a range
more complications (hematomas, increased postopera- of four to 47 months.14 Recurrence in one patient was
tive pain) and abandoned them for helical tacks only.15 recorded at 47 months. If this patient is excluded, then
the mean time of recurrence was 22 months. LeBlanc and 4 Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of
coworkers also report four of nine recurrences occurring laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc
1998; 12: 955–9.
after 30 months.14 5 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and
We have had five recurrences in 182 laparoscopic her- incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9.
nia repairs. They all occurred within the first 24 months 6 Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of
after repair. Other series report nearly all of the recur- recurrent ventral hernia. Am Surg 1998; 12: 1121–7.
rences by two years.8,11,12,16 7 Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopic
intraperitoneal onlay mesh repair of incisional hernia. Surg
Laparosc Endosc 1998; 8: 360–2.
8 Park A, Birch DW, Lovrics P. Laparoscopic and open incisional
hernia repair: a comparison study. Surgery 1998; 124: 816–22.
CONCLUSION 9 Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic
and open ventral herniorrhaphy. Am Surg 1999; 65; 827–32.
10 Kyzer S, Alis M, Aloni Y, Charuzi I. Laparoscopic repair of
With the adaptation of laparoscopic techniques to general
postoperation ventral hernia. Early postoperation results. Surg
surgical procedures over the past 15 years, several ques- Endosc 1999; 13: 928–31.
tions have arisen relative to ventral hernia disease. Could 11 Koehler RH, Voeller G. Recurrence in laparoscopic incisional hernia
ventral and ventral incisional hernias be repaired laparo- repairs: a personal series and review of the literature. JSLS 1999;
scopically? Would the laparoscopic approach result in a 3: 293–304.
12 Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic
reduction in surgical complications as well as a reduction
incisional/ventral herniorrhaphy: a five year experience. Hernia
in recurrence rates? Finally, would the techniques result in 1999; 4: 209–14.
increased patient satisfaction with reduced convalescence 13 Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of
and early return to full activity and work? laparoscopic incisional hernia repair. Surg Endosc 2000; 14:
Over ten years’ experience with laparoscopic ventral 117–19.
14 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
hernia repair has helped us to answer these questions.
The laparoscopic techniques could easily be adapted to 2000; 180: 193–7.
ventral hernia repair. The procedure is technically feasi- 15 Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic
ble and can be mastered by surgeons skilled in advanced treatment of ventral abdominal wall hernias: Preliminary results of
laparoscopic surgery. In addition, the procedure has 100 patients. JSLS 2000; 4: 141–5.
16 DeMaria EJ, Moss JM, Surgerman HJ. Laparoscopic intraperitoneal
resulted in reduced morbidity, with a reduction in oper-
polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral
ative and postoperative complications. Recurrence data hernia. Surg Endosc 2000; 14: 326–9.
are very encouraging and appear to reveal a marked 17 Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience
reduction in recurrence rates versus open repair. Patient with the ‘Four-Before’ laparoscopic ventral hernia repair. Am Surg
satisfaction is very high, with patients who have under- 2000; 5: 465–9.
18 Heniford TB, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral
gone multiple repairs of recurrent hernias finally finding
and incisional hernia repair in 407 patients. JACS 2000; 190:
a solution to their problem. The data on length of stay, 645–50.
return to full activity, and return to work attest to the 19 Robbins SB, Pofahl W, Gonzales RP. Laparoscopic ventral
benefits of the laparoscopic approach. hernia repair reduces wound complications. Am Surg 2001; 9:
Laparoscopic ventral hernia repair has shown itself to 896–900.
20 Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of
be an excellent solution to what has been a serious prob-
incisional and parastomal hernias after major genitourinary or
lem in surgery, namely ventral and incisional hernia dis- abdominal surgery. J Endourol 2001; 15: 175–9.
ease. The future of the procedure rests upon the sound 21 Leber GE, Garb JL, Alexander AI, Reed WP. Long-term
judgment of the surgeons performing the procedure. complications associated with prosthetic repair of incisional
Surgeons must adhere to basic surgical principles and hernias. Arch Surg 1998; 133: 378–82.
22 White TJ, Santos MC, Thompson JS. Factors affecting wound
always make the safety of the patient their priority. The
complications in repair of ventral hernias. Am Surg 1998; 64:
initial results of the procedure are encouraging, and 276–80.
long-term follow up is essential to verify the long-term 23 Park A, Heniford BT, LeBlanc KA, Voeller GR. Laparoscopic repair of
benefit of the procedure. incisional hernias. Part 2: surgical technique. Contemp Surg 2001;
57: 225–38.
24 Brill AI, Feste MD, Hamilton TL. Patient safety during laparoscopic
monopolar electrosurgery – principles and guidelines. J Soc
REFERENCES Laparoendosc Surg 1998; 2: 221–5.
25 Vancille TG. Active electrode monitoring; how to prevent
unintentional thermal injury associated with monopolar
1 Mudge M, Hughes LE. Incisional hernia: a 10 year prospective electrosurgery at laparoscopy. Surg Endosc 1998; 12: 1009–12.
study of incidence and attitudes. Br J Surg 1985; 72: 70–1. 26 Temudom T, Siadati M, Sarr MG. Repair of complex giant or
2 Munson JL. Problems in General Surgery 1985; 2: 589–614. recurrent ventral hernias by using tension-free intraperitoneal
3 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral prosthetic mesh (Stoppa technique): lessons learned from our
and incisional hernioplasty. Surg Endosc 1997; 11: 32–5. initial experience (fifty patients). Surgery 1996; 120: 738–44.
27 Houck JP, Rypins EB, Sarfeh IJ, et al. Repair of incisional hernia. 44 Condon RE. Incisional hernia. In: Nyhus LM, Condon RE, eds.
Surg Gynecol Obstet 1989; 169: 397–9. Hernia, 4th edn. Philadelphia: JB Lippincott, 1995: 319–39.
28 Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic 45 Mclanahan D, King LT, Weems C, et al. Retrorectus prosthetic mesh
treatment vs open surgery in the solution of major incisional repair of midline abdominal hernia. Am J Surg 1997; 173: 445–9.
and abdominal wall hernias with mesh. Surg Endosc 1999; 46 Amid PK, Shulman AG, Lichtenstein L. A simple stapling technique
13: 250–2. for prosthetic repair of massive incisional hernias. Am Surg 1995;
29 Langer S, Christiansen J. Long-term results after incisional hernia 60: 934–7.
repair. Acta Chir Scand 1985; 151: 217–19. 47 Ramshaw BJ, Schwab J, Mason EM, et al. Comparison of
30 Van der Linden FT, van Vroonhoven TJ. Long-term results after laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65:
correction of incisional hernia. Neth J Surg 1988; 40: 127–9. 827–31; 831–2.
31 Hesselink VJ, Luijendijk RW, de Wilt JWH, et al. An evaluation of 48 Cristoforoni PM, Kim YB, Preys Z, et al. Adhesion formation after
risk factors in incisional hernia recurrence. Gynecol Obstet 1993; incisional hernia repair: a randomized porcine trial. Am Surg 1996;
176: 228–34. 62: 935–8.
32 Santora TA, Roslyn JJ. Incisional hernia. Surg Clin N Am 1993; 49 Law NW, Ellis H. Adhesion formation and peritoneal healing on
73: 557–70. prosthetic materials. Clin Mater 1988; 3: 95–101.
33 Paul A, Korenkov M, Peters S, et al. Unacceptable results of the 50 Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and
Mayo procedure for repair of abdominal incisional hernia. Gore-Tex to repair abdominal wall defects in the rat. Can J Surg
Eur J Surg 1998; 164: 361–7. 1989; 32: 244–7.
34 Luijendijk RW, Lemmen MH, Hop WC, Wereldsma JC. Incisional 51 Molloy RG, Moran KT, Walaron RP, et al. Massive incisional hernia:
hernia recurrence following ‘vest over pants’ or vertical Mayo abdominal wall replacement with Marlex mesh. Br J Surg 1991;
repair of primary hernia of the midline. World J Surg 1997; 78: 242–4.
21: 62–6. 52 McCarthy JD, Twiest MW. Intraperitoneal polypropylene
35 Koller R, Miholic J, Jakl RJ. Repair of incisional hernias with mesh support incisional herniorrhaphy. Am J Surg 1981;
expanded polytetrafluoroethylene. Eur J Surg 1997: 163: 261–6. 142: 707–11.
36 Gecim II E, Kocak S, Ersoz S, et al. Recurrence after incisional 53 Bellon JM, Contreras LA, Sabeter C, Bujan J. Pathologic and clinical
hernia repair: results and risk factors. Surg Today 1996; 26: 607–9. aspects of repair of large incisional hernias after implant of PTFE
37 George CD, Ellis H. The results of incisional hernia repair: a twelve prosthesis. World J Surg 1997; 21: 402–7.
year review. Ann R Coll Surg Engl 1986; 68: 185–7. 54 Monaghan RA, Meban S. ePTFE patch in the hernia repair: a
38 Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a review of clinical experience. Can J Surg 1991; 34: 50–55.
prospective study of 1129 major laparotomies. Br Med J 1982; 55 Ambrosiani N, Harb J, Gavelli A, Huguet C. Echec de la cure des
284: 931–3. eventrations et des hernies par plaque de PTFE (111 cas). Ann Chir
39 Bauer JJ, Salky BA, Gelernt IM, Kreel I. Repair of large abdominal 1994; 48: 917–20.
wall defects with ePTFE. Ann Surg 1987; 206: 765–9. 56 Saiz AB, Willis IH, Paul DK, Sivina M. Laparoscopic ventral
40 Lamont PM, Ellis H. Incisional hernia in re-operated abdominal hernia repair: a community hospital experience. Am Surg 1996;
incisions: an overlooked risk factor. Br J Surg 1988; 75: 374–6. 5: 336–8.
41 Stoppa RE. The treatment of complicated groin and incisional 57 Ven der Lei B, Bleichrodt RP, Simmermacher RKJ, van Schilgaarde
hernias. World J Surg 1989; 13: 545–54. R. Expanded polytetrafluoroethylene patch for the repair of large
42 Condon RE. Prosthetic repair of abdominal hernias. In: Nyhus LM, abdominal wall defects. Br J Surg 1989; 76: 803–5.
Condon RE, eds. Hernia, 4th edn. Philadelphia: JB Lippincott, 1995: 58 Gillion JF, Begin GF, Marecos C, Fourtanir G. Expanded
188–210. polytetrafluoroethylene patches used in the intraperitoneal or
43 Wantz G. Incisional hernioplasty with Mersilene. Surg Gynecol extraperitoneal position for repair of incisional hernias of the
Obstet 1991; 172: 129. anterolateral abdominal wall. Am J Surg 1997; 174: 16–17.
PART
4
Laparoscopic treatment of
diaphragmatic herniation
23 History 173 29 Etiology of recurrent gastroesophageal

24 Anatomy and physiology 179 reflux disease 217
25 Preoperative evaluation 187 30 Reoperation for recurrent gastroesophageal
26 Gastroesophageal reflux disease 193 reflux disease 227
27 Para-esophageal hernias 201 31 Results of laparoscopic treatment of hiatal hernias 235
28 Traumatic and unusual herniation 209 32 Complications and their management 239
23
History
RAYMOND C. READ
Initial experience 173 Laparoscopic approach 175

Short esophagus 173 Conclusion 176
Phillip Allison’s contribution 174 References 176
Rudolph Nissen’s contribution 175
Even though Barrett did not introduce the term ‘reflux though diaphragmatic hernias were considered rare,
oesophagitis’ until 1950,1 this entity is now considered Hedblom reviewed almost 400 cases (19 at the Mayo
to be the most common chronic disease afflicting the Clinic) operated upon worldwide by 1925. The following
Western world. Forty per cent of the population complain year, Akerlund published his radiological studies;8 these
of occasional heartburn, and a third of these require long- were performed with barium, the patient being placed in
term medical treatment. A significant minority progress the Trendelenburg position, as recommended by Soresi.9
to Barrett’s metaplasia. Other complications include Most surgeons operated only on large protrusions
esophagitis, ulceration, stricture, herniation and neopla- (mainly para-esophageal) because of their known risk of
sia, many of which require surgery. The purpose of this incarceration, volvulus and strangulation. Based on experi-
chapter is to trace the evolution of such therapy. ence 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
INITIAL EXPERIENCE (and associated) with the more commonly recognized
peptic ulcer disease or cholecystitis.10 Therefore, in con-
Herniation of abdominal contents through the diaphragm trast to most surgeons of his time, he preferred the
has been recognized for centuries. According to Reid, the abdominal approach. Thoracotomy allowed phrenic nerve
lesion was first documented by Sennertus in 1541 at post- crush, which was still being recommended in the 1950s
mortem examination.2 Boyle described the clinical find- to facilitate return of the stomach to the abdomen.11
ings in 1812.3 Successful repair was accomplished by Gastropexy was used to limit recurrence and prevent
Potemski in 1889.4 Congenital diaphragmatic herniation postoperative volvulus.12
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 SHORT ESOPHAGUS
and post-traumatic protrusion at autopsy, but it was
not until 1908 that the former, discovered fortuitously
Harrington10 and other surgeons in the period between
at laparotomy, was dealt with in a living person. Even
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
Part of this review was presented at the third Annual Scientific Meeting
of the American Hernia Society, Toronto, 15 June 2000, and has been
esophagus. Forceful taxis resulted in disruption. These
published previously as ‘Contribution of Allison and Nissen to laparo- individuals were therefore not operated upon, being
scopic hiatal herniorrhaphy’ in Hernia 2002; 5: 200–203. managed instead by bougienage. Harrington, as pointed
174 Laparoscopic treatment of diaphragmatic herniation
out by Hayward,13 also deserves credit for being the first Barrett in 1950 distinguished between peptic ulcera-
to distinguish between ‘really’ short esophagus and one tion of the esophagus lined with squamous epithelium
that is ‘apparently’ so.14 He also separated para-esophageal and gastric ulceration distally in what he called thoracic
hiatus herniation from the sliding type, the latter, the more stomach, even though it had no serosal covering to go
common, having a higher incidence of stricture. along with its adenomatous mucosa.1 (Barrett’s rejoinder
A seminal but ultimately malign contribution to our to such quibblers was ‘Neither does the cardia!’) Three
understanding of these cases was made by Findlay and years later, Allison and Johnstone, in a paper entitled ‘The
Kelly in 1931.15 Their paper was entitled ‘Congenital esophagus lined with gastric mucous membrane’, argued
shortening of the esophagus and the thoracic stomach that Barrett’s thoracic stomach was actually esophagus
resulting therefrom’. In this, they described nine infants with an abnormal mucosa.18 They conferred his name on
and children who presented with dysphagia from high both the epithelium and ulcers arising therein. They also
strictures of the esophagus. Distally, the remaining foregut noted the presence of sliding hiatus herniation with or
in the chest was shown by endoscopic biopsy to be lined by without a para-esophageal component in their patients,
‘gastric’ mucosa. This structure was therefore considered all of whom demonstrated ‘peptic esophagitis’ (Allison’s
to be the stomach. Since their youngest patient was only term) or Barrett’s ‘reflux esophagitis’. In over 100 patients
five days old, its intrathoracic position was presumed to with peptic stricture of the esophagus, less than ten per cent
have been present before birth; thus it was not a hernia were in the ‘gastric’ lining. Most occurred at the junction
but a congenital misplacement. To support this concept, of squamous and adenomatous epithelium. Their con-
Findlay and Kelly cited seven necropsies, mostly of elderly clusion was that the ‘gastric’ epithelium in the esophagus,
men whose intrathoracic stomach had been thought pre- rather than being congenital in origin, might develop by
viously to be herniation. Kelly later reported further healing of reflux esophagitis with metaplasia. Lortat-
examples of congenital intrathoracic stomach, but he Jacob19 and Hayward13 concluded that all such cases were
did accept that in some patients herniation could occur acquired. Interestingly, the former, a Frenchman, intro-
postnatally.16 The associated strictures were considered to duced the term ‘endo-brachy-oesophage’, analogous to the
arise from esophagitis, spasm, and ascending fibrosis. English ‘short esophagus’. Lortat-Jacob agreed with Allison
During barium studies on normal children, these authors that reflux esophagitis could shorten the squamous-lined
incidentally observed longitudinal muscular spasm pro- esophagus when its inferior portion became lined with
ducing hiatal herniation during deglutition. This was the gastric-type mucosa.
first evidence for the modern concept that hernia may fol- One of Allison and Johnstone’s patients developed a
low rather than cause gastroesophageal reflux disease cancer in the adenomatous lining of the esophagus.18 At
(GERD). 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 pre-
PHILLIP ALLISON’S CONTRIBUTION viously reported on four such examples of malignancy
associated with short esophagus and hiatus herniation.20
This thoracic surgeon (1908–74) was born and educated In discussion, Sweet commented that 13 per cent of his
and, for most of his career, practiced in Yorkshire, resections for cancer of the cardia at the Massachusetts
England. In the late 1930s, while at the University of Leeds, General Hospital had been in patients with the short
he pioneered intrapericardial pneumonectomy. In 1954, esophagus–hiatus hernia syndrome. Cases of the latter
he was appointed Nuffield Professor of Surgery at Oxford presenting with perforation or massive hemorrhage had
University. Unfortunately, because of petty parochialism ulcers arising in the adenomatous epithelium of the
practiced by the Harley Street surgeons of London, his esophagus (Barrett’s), not in the squamous lining above.
achievements were appreciated more overseas than in To prevent reflux esophagitis, Allison focused on
his native land. In 1943, he and his colleagues described hiatus herniorrhaphy.21 Since there was, at the time, no
ten middle-aged or elderly men and women with short anatomical or physiological evidence for a sphincter at
esophagus and peptic ulceration. They had complained the esophagogastric junction, he set out to re-establish
for months or years of substernal pain, dysphagia and, both the angle of His and the diaphragmatic ‘pinchcock’
in half, occasional bleeding. Symptoms responded to dila- formed by the right crus of the diaphragm and the
tion and antacids, and endoscopy demonstrated fibrotic phreno-esophageal ligaments. The situation being consid-
narrowing. Some patients also had gastric or duodenal ered analogous to that of the puborectalis sling around the
ulceration. Allison and colleagues’ conclusion was that ‘the anorectal junction, Allison felt that a posterior rather than
deformity referred to as congenitally short esophagus may the popular anterior repair was indicated. His hernior-
be acquired and result from herniation of the stomach rhaphy was conducted through the chest, the diaphragm
with ulceration and scarring’.17 being incised to expose the abdomen.
History 175
Unfortunately, Allison’s repair, which was adopted and stitched the fundoplication to the esophageal wall
widely, proved unsatisfactory because a significant num- to obviate slippage. He mobilized the lesser curvature of
ber of patients suffered symptomatic relapse. Collis cited the stomach, being careful to preserve the vagi and their
these results in recommending a return to anterior clo- branches. The left gastric vasculature rather than the short
sure of the defect in the dome of the diaphragm.22 This gastric vessels was divided. A nasogastric tube was left
surgeon, who also worked in the UK (Birmingham), had postoperatively to prevent vomiting.
described in 1957 an operation for patients with hiatus Initially, Nissen performed a partial wrap since he did
hernia and short esophagus that has stood the test of not mobilize the fundus by dividing its blood supply.
time.23 This involved constructing a neo-esophagus from Later, he recommended 360-degree rotation, since he
the ‘Magenstrasse’ of the stomach. Hiebert and Belsey pro- ligated the short gastric vessels rather than branches of
vided an explanation for the failure of Allison’s procedure the left gastric on the lesser curvature. Today, both partial
when they documented incompetence of the gastric cardia and complete fundoplications are performed, depending
in the absence of hiatal herniation.24 The problem was on the emptying characteristics of the esophagus and
primary incompetence of the intrinsic gastroesophageal stomach. Whereas Nissen was not concerned about an
sphincter of Code and colleagues.25 intrathoracic location of the fundoplication, either intra-
operatively with short esophagus or, later, secondary to
herniation, surgeons have adopted Belsey’s recommenda-
RUDOLPH NISSEN’S CONTRIBUTION tion 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
This distinguished thoracic surgeon (1896–1981), the scarring, secondary to GERD, is eliminated by the use of
son of a surgeon, was an assistant between 1921 and 1933 Collis’ procedure.23 To avoid gas bloat and dysphagia, the
to Professor Sauerbruch of Munich and Berlin. Being length of the wrap, which is floppy, has been halved.
Jewish, Nissen was forced to emigrate to Turkey, from his Nissen retired from surgical practice in 1967 and died in
Fatherland despite being wounded in the lung during 1981. Despite modifications, his operation continues to
World War I. In 1931, he performed the world’s first suc- be the basis for the surgical relief of complications arising
cessful pneumonectomy on a 12-year-old girl with a torn from reflux esophagitis with or without hiatus herniation.
left mainstem bronchus. While in Istanbul, he undertook
a transthoracic gastroesophagectomy for benign ulcera-
tion of the cardia.26 He later learned that this was the sec-
LAPAROSCOPIC APPROACH
ond such resection to be accomplished successfully, the
first being performed by the Japanese in 1933. It is inter-
esting that Sauerbruch pioneered the procedure experi- This mini-invasive surgical technique evolved from
mentally in the dog in 1906. Since almost all previous endoscopy,29 which began on the island of Kos with the
attempts had failed in humans because of anastomotic school of Hippocrates (460–375 BC), who described the
leakage, Nissen buried the anastomosis of the transected rectal speculum. A three-bladed vaginal speculum was
esophagus in the fundus of the stomach. He brought up recovered from the ruins of Pompeii. The earliest light
two folds in the manner of a Witzel gastrostomy. sources were mirrors, introduced by the Arabs before
Amazingly, while he was Chief of Surgery at Basel, 1000 AD. In 1587, Aranzi described the use of the camera
Switzerland, 17 years after this operation he obtained obscura, popularized by Leonardo da Vinci in 1519. A
follow-up information from a relative of the patient. spherical glass flask filled with water was used to focus a
The patient was well and had no symptoms of reflux beam of sunlight into the nasal cavity. In the seventeenth
esophagitis. Two years later, Nissen decided to perform century, Borell employed a lantern.
fundoplication alone for esophageal reflux disease. He Bozzini in 1806 initiated modern endoscopy by devel-
undertook this procedure in a man and a woman who oping a complex tubular system to convey light from
each had the signs and symptoms of reflux esophagitis a candle allowing observation of the bladder or cervix
without evidence of hiatal herniation. Nissen reported through a second channel. Segal in 1826 used a similar
success in 1956.27 In agreement with modern thought,28 arrangement to fabricate a cystoscope without lenses.
he believed that hiatus herniation was the result rather Desormeaux in 1865 and Nitze in 1879 developed tele-
than the cause of reflux esophagitis. Therefore, in cases of scopic instruments. Originally, their light source was
symptomatic hiatus herniation, he paid no attention to an overheated, water-cooled platinum wire (described
the hernial sac, considered closure of the defect unneces- by Bruck in 1867), but after the electric light bulb was
sary, and with short esophagus performed transthoracic invented in 1880 by Edison, this was incorporated into
fundoplication. He always conducted the procedure over a gastroscope by Mickulicz in 1881 and into a cystoscope
a large-bore bougie to prevent postoperative dysphagia, by Newman in 1883. Later, the bulb was mounted distally,
an operating channel was added, and the lens was sepa- Whereas a 360-degree fundoplication is the most com-
rated therefrom. mon procedure, partial wraps are favored by some sur-
Laparoscopy began in 1901 when Ott reported on geons, especially if emptying of the esophagus or stomach
culdoscopy and later (1909) on ‘ventroscopy’ using a is inadequate. The mini-invasive nature of laparoscopy
speculum. Kelling in 1902 suggested that a better view has made surgery more acceptable, and it has become
of the compressed viscera could be obtained by inducing competitive with long-term medical treatment. Improved
pneumoperitoneum, this having been performed earlier outpatient pH monitoring and other diagnostic measures
in the treatment of tuberculosis. His first observations, have expanded the population known to be suffering
Koelioskopie, were made on animals but in 1910 Jacobeus from GERD.
reported 17 ‘lapothorakoskopies’ on patients with ascites The success of laparoscopic fundoplication, complete
employing a Nitze cystoscope. Further developments or partial, in both children and adults has extended this
included the use of the Trendelenburg position and a technique to prosthetic repair of hiatal defects, the Collis
trocar endoscope by Nordentoeft in 1912. The automatic operation for short esophagus, and the management of
spring insufflating needle was invented by Goetz in 1918. incarcerated para-esophageal herniation. Other dia-
Carbon dioxide, which is absorbed more rapidly than phragmatic hernias protruding through the foramina of
air, was substituted for air by Zollikofer in 1924. Kalk in Bochdalek and Morgagni have been dealt with similarly,
1929 devised a new lens system that permitted oblique along with blunt or penetrating injuries seen early or
(135-degree) viewing, along with a dual-trocar technique. late. Heller cardiomyotomies have also been performed
In the 1930s, laparoscopy was performed largely by for achalasia. Smaller ports, narrower instruments, and
general surgeons and internists (e.g. Ruddock) for the joystick controls have facilitated these procedures.30
diagnosis and biopsy of visceral disease. The stomach, Robotics are now on emerging technology.
bladder and rectosigmoid were sometimes transillumi-
nated for better evaluation. The first operation using
laparoscopy, adhesiolysis, was carried out by Fervers in CONCLUSION
1933. Boesch in 1936 used the procedure for sterilization,
coagulating the fallopian tubes. Palmer expanded its use Our understanding of the common ailment, reflux
in gynecology. Advances in instrumentation enhanced its esophagitis, has been shown to be based largely on the pio-
popularity: cold light illumination (Foursestiere in 1943), neering efforts of European thoracic surgeons. By unrav-
fiber-optics (Hopkins in 1952), and new instruments eling congenital misplacement, hiatus herniation, short
(Frangenheim in 1954, Semm in 1963). Semm also intro- esophagus, stricture, ulceration, adenomatous hyper-
duced the automatic insufflator. Later, bipolar coagulation plasia, and its malignant transformation, they made
(Frangenheim in 1972) and laser technology (Bruhat in modern surgical therapy possible.
1979) were added. Nevertheless, the major breakthrough European surgeons again played a leading role in the
was the invention of the computer-chip video camera in evolution of laparoscopy from endoscopy. The success-
1986. This enabled assistants and students to view the ful application of this technique to appendectomy and
progress of the operation. cholecystectomy stimulated its use, a decade ago, in the
In 1981, Semm performed laparoscopic appendec- management of GERD. This approach has now sup-
tomy; cholecystectomy followed (Muhe in 1986, Mouret planted open fundoplication. It has been adopted for
in 1987). Despite initial censure, laparoscopic herniorrha- prosthetic repair of various diaphragmatic hernias,
phy, hysterectomy, bowel resection, gastrectomy, nephrec- Heller myotomy, Collis gastroplasty and, combined with
tomy, cystectomy, splenectomy, adrenalectomy, vagotomy thoracoscopy, esophagectomy. Technical advances and
and esophagectomy followed rapidly. Thoracoscopy was new instrumentation continue to improve patient out-
rejuvenated. come while reducing costs and hospitalization.
Laparoscopic fundoplication was introduced inde-
pendently by Geagea and Dallemagne in 1991. Since then,
it has been adopted worldwide and has supplanted the REFERENCES
open Nissen procedure. Hospital stay is reduced along
with postoperative morbidity. Treatment costs are thereby 1 Barrett NR. Chronic peptic ulcer of the oesophagus and ‘oesophagitis’.
reduced. An increase in operating time can be eliminated Br J Surg 1950; 38: 175–82.
by experience. Follow-up studies, many of which are pro- 2 Reid J. Case of diaphragmatic hernia produced by a penetrating
longed and randomized, show that results are as good as wound. Edinburgh Med J 1840; 53: 104–12.
3 Boyle A. Case of wounded diaphragm. Edinburgh Med J 1812;
those obtained by classical open procedures, except per-
8: 42–4.
haps with esophageal shortening or giant para-esophageal 4 Potemski M. Nouvo processo operativo per la reduzione cruenta
herniation. Here, restoration of the abdominal esophagus della cruie diaframmatiche da trauma e per la sutura della ferite
or recurrence pose problems. del diaframma. Bull Reale Acad Med Roma 1889; 15: 191.
History 177
5 Holt C. Child that lived two months with congenital diaphragmatic 18 Allison PR, Johnstone AS. The esophagus lined with gastric
hernia. Philos Trans 1701; 22: 922. mucous membrane. Thorax 1953; 8: 87–101.
6 Heidenhain L. Geschichte eines Fallas von chronischer 19 Lortat-Jacob JL. Les malpositions cardia-tuberositaires.
Incarceration des Magens in einer angeborenen Zwerch fellhernie Arch Mal App Dig 1953; 42: 750–74.
welcher durch Laparotomie geheilt wurde, mit anschliessen – 20 Olsen AM, Harrington SW. Esophageal hiatal hernias of the
den Bemerkungen ueber die Moglichkeit. Das Kardiocarcinom der short esophagus type: etiologic and therapeutic considerations.
Speiserohre zu reseciren. Deutsch Ztschr Chir 1905; 76: 394–403. J Thorac Surg 1948; 17: 189–209.
7 Hedblom CA. Diaphragmatic hernia: a study of three hundred and 21 Allison PR. Reflux esophagitis, sliding hiatal hernia and the
seventy eight cases in which operation was performed. anatomy of repair. Surg Gynecol Obstet 1951; 92: 419–31.
JAMA 1925; 85: 947–53. 22 Collis JL. Review of surgical results of hiatus hernia. Thorax 1961;
8 Akerlund A. Hernia diaphragmatic Hiatusoesophagei vom 16: 114–23.
anatomischen und rontgenologischen Gesicfhtspunkt. Acta Radiol 23 Collis JL. An operation for hiatus hernia with short esophagus.
1926; 6: 3–22. J Thoracic Surg 1957; 34: 768–78.
9 Soresi AL. Diaphragmatic hernia, its unsuspected frequency: its 24 Hiebert CA, Belsey RHR. Incompetency of the gastric cardia
diagnosis, technique for radical cure. Ann Surg 1919; 69: 254–70. without radiologic evidence of hiatal hernia, the diagnosis and
10 Harrington SW. Diagnosis and treatment of various types of management of 71 cases. J Thorac Cardiovasc Surg 1961; 42:
diaphragmatic hernia. Am J Surg 1940; 50: 377–446. 352–71.
11 Adams HD, Lobb AW. Esophagoaortal hiatus hernia. N Engl J Med 25 Fyke FE, Code CF, Schlegel JF. The gastroesophageal
1954; 250: 143–8. sphincter in healthy human beings. Gastroenterologia 1956;
12 Boeremia I, Germs R. Anterior geniculate gastropexy for hiatal 86: 135–47.
hernia of the diaphragm. Zentralbl Chir 1955; 80: 1585–93. 26 Nissen R. Die Transpleurale Resektion der Kardia. Deutsche Ztschr
13 Hayward J. The treatment of fibrous stricture of the esophagus Chir 1937; 249: 311–16.
associated with hiatal hernia. Thorax 1961; 16: 45–64. 27 Nissen R. Gastropexy as the lone procedure in the surgical repair
14 Harrington SW. The surgical treatment of the more common types of hiatus hernia. Am J Surg 1956; 92: 389–92.
of diaphragmatic hernia. Ann Surg 1945; 122: 546–68. 28 Dunne DP, Paterson WG. Acid-induced esophageal shortening
15 Findlay L, Kelly B. Congenital shortening of the esophagus and in humans: a cause of hiatus hernia? Can J Gastroenterol 2000;
the thoracic stomach resulting therefrom. J Laryngol Otol 1931; 10: 847–50.
46: 797–816. 29 Lau WY, Leow CK, Li AKC. History of endoscopic and laparoscopic
16 Kelly AB. Some oesophageal affections in young children. surgery. World J Surg 1997; 21: 444–53.
J Laryngol Otol 1936; 51: 78–99. 30 Awad ZT, Filipi CJ. Commentary: the short esophagus, pathogenesis,
17 Allison PR, Johnstone AS, Royce GB. Short esophagus with simple diagnosis and current surgical options. Arch Surg 2001; 136:
peptic ulceration. J Thorac Surg 1943; 12: 432–57. 113–14.
24
MARK A. REINER
Anatomy 179 Conclusion 185

Physiology 183 References 185
Surgical considerations for diaphragmatic repair
in patients with gastroesophageal reflux disease 184
In an attempt to elucidate the etiological factors that the first three lumbar vertebrae.1 These segments have
contribute to gastroesophageal reflux disease (GERD), it four components: the medial and lateral lumbosacral
is necessary to have a full understanding of normal dia- arches or internal and lateral arcuate ligaments, and the
phragmatic anatomy and physiology. Pathological reflux right and left crura.1,3 The medial lumbosacral arch (inter-
occurs when there are anatomical and physiological nal arcuate ligament) drapes over the psoas muscle; it is
abnormalities at the gastroesophageal junction and crura. fixed to the transverse processes of the first and second
These abnormalities are influenced by postural changes lumbar vertebra, and fuses into the lateral portion of the
and gradients between intra-abdominal and intrathoracic contiguous crus. The lateral lumbosacral arch (external
pressures. Corrective surgery must include a proper arcuate ligament) covers the quadratus lumborum and
diaphragmatic repair in order to minimize the potential becomes fixed to the first lumbar vertebrae and twelfth
for recurrence. Postoperative management must be rib.1,3 The crura originate as tendons that are a direct
tailored to the patient’s age, the size of the hiatal defect, extension of the longitudinal ligament of the vertebral col-
and the patient’s lifestyle. umn 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
ANATOMY stronger and longer of the two, originates from the ventral
surfaces and intervertebral cartilages of L1, L2 and L3. The
The diaphragm separates the abdominal and thoracic cav- crura muscular fibers, originating from their respective
ities. It is composed of a non-contractile central tendon tendons, then merge and surround the esophageal hiatus
and three peripheral or skeletal muscular components, the at the level of T10.1,3,4 Before doing this, the medial mar-
sternal, costal, and lumbar or crural.1 The central tendon gins of the crura pass ventrally and then merge medially
connects all of the muscular components by acting as a near the midline to surround the anterior surface of the
central focal point from which these three muscle groups aorta. The muscular fibers coming off the crural tendons
radiate. The sternal portion of the muscular component then integrate and connect into the central tendon. The
originates from the undersurface of the sternum and may right crus muscular fibers split into two segments. The
be considered as an independent structure or as the medial medial segment completely surrounds the esophageal hia-
aspect of the costal segment.1,2 The costal portion origi- tus, while the lateral segment merges directly into the cen-
nates from the undersurface of the lower six costochon- tral tendon. The muscular fibers of the left crus enter
dral junctions, extending on to these ribs, and then ending directly into the central tendon. Occasionally, muscle bun-
by interdigitating with the transversus abdominis muscles dles will overlap and may be derived from both tendons
bilaterally. The lumbar or crural segment originates from (Figure 24.1).1,3,5,6
Costal origin Esophageal hiatus
Vena cava foramen Median arcuate ligament
Lumbar crural
Aortic hiatus
Right crus
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 the inferior vena cava and along the right side of its hia-
centrally into the central tendon. This structure is a tus. The vessel divides into a medial and lateral branch.
strong aponeurosis broken down into three components. The medial branch angles further anteriorly and anasto-
The largest is the right component, followed by the cen- moses with the same branch of the opposite side, as well
tral and left components. The entire structure is slightly as the musculophrenic and pericardiophrenic vessels.
off-center, being biased slightly anteriorly and to the The lateral branch courses laterally to anastomose with
right.1 The tendon gets its considerable strength because the posterior intercostal arteries.1 The left vessel is signi-
the fibers merge at different angles (Figure 24.2). ficantly more medial and runs anterior to the esophagus
Anatomical rents in the diaphragm exist so that pas- and ventrally along the left side of the esophageal hia-
sage of structures can occur between the thoracic and tus.1,4 It must be noted carefully at this site to prevent
abdominal cavities. There are three main and five minor inadvertent injury during anti-reflux procedures, espe-
defects or apertures in the diaphragm. The minor defects cially when closing the diaphragmatic rent. Branches of
serve for passage of small vessels, such as the superior the inferior phrenic vessels and occasionally an arterial
epigastric artery and vein anteriorly, and the hemiazygos branch off the left gastric artery will pass just anterior
vein and splanchnic and sympathetic nerves posteriorly. to the ventral margin of the esophageal hiatus.5 These
The three major apertures are for the vena cava, the vessels can be injured when mobilizing the left lateral
aorta, and the esophagus. segment of the liver or when a probe is placed in the
The innervation of the diaphragm is from the phrenic hiatus for anterior displacement aiding visualization
nerves, which arise mainly from the fourth and to a lesser during an anti-reflux procedure. If this vessel is near the
degree the third and fifth cervical nerves. The blood apex, I prefer to use a more flat or fan retractor to help
supply is from the inferior phrenic arteries. The right prevent injury.
phrenic artery is more lateral, while the left phrenic The next integral anatomical component in prevent-
artery is more medial. The right vessel passes anterior to ing 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 con- of GERD. The etiology of this laxity remains obscure,
tinuation of the subperitoneal fascia. Its attachments are but it has been attributed to a variety of factors, including
the anterior portion of the cardia of the stomach, the atrophic changes as seen with age, chronic stretching
lower 4 cm of the esophagus, and the left and right sides secondary to each peristaltic contraction,10 obesity, preg-
of the crura around the esophageal hiatus. It terminates nancy, surgical destruction, and trauma. Since the physio-
on the left by merging into the gastrophrenic ligament logical benefits of the phreno-esophageal ligament are
and on the right into the pars condensa of the lesser diminished in the presence of a hiatus hernia, wide
omentum (Figure 24.3).4,7 The phreno-esophageal liga- dissection of the ligament in anti-reflux surgery has
ment is the only structure that establishes a direct con- no detrimental effect. Adequate dissection of the crura,
nection between the lower esophageal sphincter and the proximal stomach, and lower esophagus are mandatory
crural diaphragm. This structure has been considered an in order to perform an adequate repair. This condition
important factor in preventing reflux. It tends to be is not present in patients having upper-esophageal sur-
stretched and distracted in hiatal hernias.7–10 When this gery for conditions other then reflux disease, such as a
occurs, it minimizes or eliminates any positive effect Heller myotony for achalasia. Minimal dissection of the
that a normal ligament will have on reflux prevention. phreno-esophageal ligament in these cases may help
This stretching, when seen in conjunction with a hiatus minimize postoperative GERD.
hernia, allows a segment of gastric cardia to herniate The structural anatomy of the normal esophageal
through the hiatus into the mediastinum, shortening the hiatus has a significant impact in preventing reflux disease.
length of the abdominal esophagus. When this occurs in In its normal form, it is elliptical in shape and present
the presence of a hypotensive or atonic lower-esophageal in the muscular portion of the diaphragm (Figure 24.4).
sphincter (LES), the patient will experience the symptoms 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 lateral muscular fibers of the hiatal borders stretch, espe-
the muscular fibers of the right crus with only minor rein- cially as the phreno-esophageal ligaments elongate. This
forcement on the left side by the left crus. The anterior sur- causes a circular deformity of the esophageal hiatus with-
face of the hiatus is supported by a sling of muscle fibers out significantly enlarging its cross-sectional diameter.
and tendinous attachments merging into the junction The weakest portion of the hiatus is formed at the triangu-
between the medial and lateral leaflets of the central ten- lar shaped merging of the right crus fibers posteriorly
don. The posterior segment of the esophageal hiatus is (Figure 24.7).7,9 This is an inherent site of anatomical
supported only by a sling of muscular tissue that is com- weakness that cannot be overcome by the extra support
prised almost exclusively of fibers originating from the provided by the prevertebral fascia. Forces that influence
right crus. The presence of a hiatus hernia reflects a break- the development of a hiatal hernia cause the rounding or
down in the anatomical structures of the hiatus. As the separation of these V-shaped muscular fibers, with the
hernia enlarges, the defect becomes more oval in shape subsequent effect of increasing the size of the esophageal
(Figure 24.5).9 Stress on the hiatus causes an enlarging hiatus. Since the majority of the defect seen in hiatal her-
defect in the muscular boundaries. The anterior border is nias occurs dorsally, repair should be performed posterior
more resilient, being supported by interlocking muscle to the esophagus in order to re-establish normal anatomy.
fibers reinforced by tendinous fibers of the central and left I prefer to do the repair in the presence of a 56–60 French
leaflets of the central tendon (Figure 24.6). This area tends dilator so that I do not inadvertently make the new hiatal
to resist forces that would cause the hiatus to enlarge. The 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
Figure 24.8 Anatomy of the lower
esophageal sphincter.
aorta at this stage because of its proximity to the posterior play. The first two are the normal average pressure and
aspect of the defect. 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 posi-
PHYSIOLOGY tions, ingestion of moderate amounts of food and drink,
and physical activity that results in significant increases in
The physiology of diaphragmatic function has a direct intra-abdominal pressures. A functional change in any
effect on the presence or absence of symptomatic reflux. one of these components, without a corresponding com-
A brief review of the etiological factors causing GERD pensatory adjustment in another of the other compo-
is warranted before we consider how to integrate the dia- nents, will result in GERD. An example of this adjustment
phragmatic repair into the surgical treatment of reflux can be demonstrated in a patient with a shortened LES
disease. Reflux occurs when gastric contents are regurgi- segment. Reflux would occur unless there was a compen-
tated into the esophagus. The normal stomach resides in satory rise in the LES pressure. There is, however, one
an area of higher pressure than the thoracic esophagus. In situation in which there is an alteration in the balance
order for reflux not to occur, a pressure barrier must exist between these three factors that is physiologically normal
between these areas of low and high pressure. A segment and the most common cause of non-pathological reflux:
of esophagus approximately 2 cm long, of which at least transient lower esophageal sphincter relaxation (tLESR).
1 cm usually resides intra-abdominally, called the LES, is This occurs when there is gastric distention secondary to
the junction between the two different pressure zones ingestion of excess food, air, or gas, such as is seen with
(Figure 24.8). The presence of pathological reflux is carbonated beverages. This is unrelated to swallowing or
dependent on failure of the LES. Three factors come into esophageal peristalsis, and it may have a neuromuscular
component, a purely mechanical component, or combi- pressures are also affected by the contraction of the
nations of both.10–12 diaphragm. The presence of a large hiatal hernia, with the
The presence of the LES is not defined by any specific subsequent stretching of the phreno-esophageal ligament,
anatomical landmarks, but it is well demonstrated by will disrupt the angle of His and diminish the length of
placing an intragastric pressure monitor and withdraw- intra-abdominal esophagus. This, in conjunction with
ing it into the distal esophagus. A high-pressure zone will intrinsic LES factors, will affect the development of GERD.
exist in the lower esophagus as compared with the gastric The size of a hiatal hernia has been shown to affect the
baseline.11 In normal individuals, this will fall only severity of GERD.10,14,16 A larger defect will have a shorter
during swallowing or when the gastric fundus overfills sphincter length and lower LES pressures. Not surpris-
with gas or food. This segment of elevated pressure is ingly, the amount of reflux will be greater, with decreased
partially dependent on the length of the distal esophagus efficiency of acid clearance and a higher degree of
exposed to intra-abdominal pressure. This length can be esophagitis.
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
SURGICAL CONSIDERATIONS FOR
seen in chronic reflux. Once the pressure of the high-
DIAPHRAGMATIC REPAIR IN PATIENTS
pressure zone falls below an average of 6 mmHg, an aver-
WITH GASTROESOPHAGEAL REFLUX
age intra-abdominal length of 2 cm or less and/or an
average length exposed to the positive intra-abdominal
DISEASE
pressure of 1 cm or less than the LES is permanently
destroyed.11 These patients require surgical intervention Patients with hiatal hernias and GERD have a large poste-
when they cannot be controlled adequately by medical rior diaphragmatic defect. In these patients, the phreno-
management. esophageal ligament has lost its anatomical importance
A number of explanations have been postulated in an due to stretching or laxity developed as a result of the
effort to explain the relationship between the diaphragm, increasing size of the hiatus. In this condition, the lower
the lower esophageal pressure, and the intra-abdominal or esophagus and stomach can herniate into the chest. This
distal few centimeters of esophagus. Allison believed that will then alter the angle of His and diminish or eliminate
when the right crus of the diaphragm contracts during the incursion of the lower esophagus into the abdomen.
inspiration, it compresses the esophagus together at the These anatomical changes reduce the LES pressure,
same time increasing its angulation.6 This action com- shorten the abdominal esophagus, and diminish the total
bined with a normal phreno-esophageal ligament pro- length of the LES. Reflux can occur and, if treated inade-
duces adequate intra-abdominal esophageal length, thus quately, can result in chronic esophagitis with extensive
allowing an acceptable LES pressure to be generated fibrosis and total irreversible atony of the LES. Surgical
to prevent reflux. Delattre and colleagues believe that repair is directed at increasing the efficacy of the malfunc-
diaphragmatic contraction causes the changes in LES tioning LES and re-establishing the presence of the
pressures and should not be attributed solely to changes in abdominal esophagus. The laparoscopic gold standard is
intra-abdominal pressure.5 Most authors, however, believe the Nissen fundoplication coupled with an adequate
that there is both an intrinsic and an extrinsic mechanism crural repair. In their reviews of fundoplication failures,
to prevent esophageal relux.4,11,13–15 The intrinsic com- Soper and Dunnegan17 and Hunter and coworkers18
ponent is made up of the smooth muscle of the distal showed that the most frequent anatomical cause for fail-
esophagus under a variety of neuro-hormonal controls. ure was transdiaphragmatic herniation. The correct sur-
This component is referred to as the LES. A variety of gical approach for diaphragmatic repair is mandatory in
pathophysiological conditions affect this non-anatomical order to minimize operative failures in the treatment of
sphincter. These effects can be mostly asymptomatic and reflux disease. The repair should be done posterior to the
normal, as found with physiological reflux associated with esophagus, using a mattress suture of adequate strength
tLESR. They can also be pathological, causing symptoms nonabsorbable suture material (Figure 24.9). Pledgets are
of GERD, as demonstrated by patients with a hypotensive not usually needed, but in elderly patients or in excep-
or atonic LES. The extrinsic component is comprised of tionally large defects their use may be warranted. The size
the diaphragm, with its reaction to respiration, position, of the defect should be just large enough to easily fit a
varying intra-abdominal pressures, and the phreno- 56–60 French dilator. To prevent crural disruption in the
esophageal ligament. GERD is most often expressed as a immediate postoperative period, extubation should be
result of a combination of intrinsic and extrinsic compo- smooth to prevent bucking against the endotracheal tube.
nents. The tLESRs are affected by diaphragmatic contrac- Anti-emetics should be used generously to prevent vio-
tions and relaxations mediated partially by their mutual lent postanesthesia retching. Delayed disruption can be
attachments to the phreno-esophageal ligament.15 LES 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 5 Delattre JF, Palot JP, Ducasse A. The crura of the diaphragmatic
significant and rapid rise in intra-abdominal pressure. passage. Anat Clin 1985; 7: 271.
6 Allison PR. Reflux esophagitis, sliding hiatal hernia, and the
Caution must also be given to weight-lifters, who possess anatomy of repair. Surg Gynecol Obstet 1951; 92: 419–31.
thicker and stronger muscular diaphragms, about lifting 7 Postlethwait RW. Surgery of the Esophagus, 2nd edn. Norwalk, CT:
practices that could disrupt the repair. Appleton-Century-Crofts, 1986.
8 Eliska O. Phrenoesophageal membrane and its role in
the development of hiatal hernia. Acta Anat (Basel) 1973; 86:
137–50.
CONCLUSION 9 Marchand P. A study of the forces productive of gastroesophageal
regurgitation and herniation through the diaphragmatic hiatus.
Thorax 1957; 12, 189–202.
The surgical treatment of GERD can be addressed suc-
10 Kahrilas PJ. Suoraesophageal complications of reflux disease and
cessfully and safely only after fully understanding the hiatal hernia. Am J Med 2001; 111: 51S–5S.
normal anatomy and physiology of the diaphragm, the 11 DeMeester TR, Peters JH, Bremner CG, Chandrasoma P. Biology
lower esophageal forces that prevent and cause reflux, and of gastroesophageal reflux disease: pathology relating to
the abnormal anatomical defects found in patients with medical and surgical management. Annu Rev Med 1999; 50:
469–506.
hiatus hernias. Failures can be kept to a minimum by the
12 Richter J. Do we know the cause of reflux disease? Eur J
diligent performance of a meticulous posterior repair of Gastroenterol Hepatol 1999; suppl 1: 83–9.
the diaphragm before completing the fundoplication. 13 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: 2687–94.
REFERENCES 14 Kahrilas P. The role of hiatus hernia in GERD. Yale J Biol Med 1999;
72: 101–11.
15 Orlando RC. Overview of the mechanisms of gastroesophageal
1Goss CM, ed. Gray’s Anatomy, 28th edn. Philadelphia: Lea & reflux. Am J Med 2001; suppl 8A: 174S–7S.
Febiger, 1966. 16 Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size
2 Poole DC, Sexton WL, Farkas GA, et al. Diaphragm structure and affects lower esophageal sphincter function, esophageal acid
function in health and disease. Med Sci Sports Exerc 1997; 29: exposure, and the degree of mucosal injury. Am J Surg 1995;
738–54. 171: 182–6.
3 Agur AMR, Lee MJ, eds. Grant’s Atlas of Anatomy, 10th edn. 17 Soper NJ, Dunnegan D. Anatomic fundoplication failure
Philadelphia: Lippincott Williams & Wilkins, 1999. after laparoscopic antireflux surgery. Ann Surg 1999; 229:
4 Delattre JF, Aviss C, Marcus C, Flament JB. Functional anatomy of 669–77.
the gastroesophageal junction. Surg Clin North Am 2000; 80: 18 Hunter JG, Smith CD, Branum GD, et al. Laparoscopic
241–60. fundoplication failures. Ann Surg 1999; 230: 595–606.
25
Preoperative evaluation
MARCO G. PATTI AND PIERO M. FISICHELLA
Preoperative evaluation for anti-reflux surgery 187 Evaluation for failed anti-reflux surgery 190
Esophageal manometry 188 References 191
Ambulatory pH monitoring 189
Laparoscopic Nissen fundoplication is one of the opera- PREOPERATIVE EVALUATION FOR

tions performed most frequently by general surgeons ANTI-REFLUX SURGERY
today. The past decade has seen a progressive increase in
the number of laparoscopic Nissen fundoplications per-
formed throughout the USA due to the recognition that All patients who are candidates for laparoscopic fundopli-
although the laparoscopic approach gives results similar cation should undergo the following preoperative evalua-
to those obtained with the open approach (excellent con- tion in order to determine whether abnormal reflux is
trol of symptoms in about 90 per cent of patients), it is present, whether the symptoms are caused by the reflux,
also associated with shorter hospital stay, less postopera- and whether complications of GERD, such as Barrett’s
tive discomfort, and faster recovery time.1–5 The increased esophagus, are present, and to define the anatomy and
number of patients referred for surgical treatment has pathophysiology of the disease in the individual patient.
allowed us to improve the understanding of the patho-
physiology of the disease and to define the technical ele- Symptomatic evaluation
ments that play a role in the performance of an effective
and durable fundoplication.2 Patients are questioned regarding the presence of typical
Traditionally, gastroenterologists have referred patients and atypical symptoms (Table 25.1). The severity of the
for surgery based on clinical evaluation and findings of symptoms is scored from 0 (asymptomatic) to four
endoscopy, particularly if they had a poor response to acid- (severely affecting quality of life). Symptoms alone, how-
reducing medication. Today, however, this approach is ever, are not diagnostic of GERD. Unfortunately, many
unacceptable for the following reasons: (1) many patients clinicians are overly confident that a diagnosis of GERD
undergo surgery for control of symptoms in the absence of can be based firmly on the clinical findings, even though
esophagitis; (2) more patients are referred for treatment it has been shown that symptoms are unreliable in diag-
of atypical symptoms of gastroesophageal reflux disease nosing GERD.8–10 For instance, our group found that
(GERD) such as cough or chest pain;6,7 and (3) because of among 822 consecutive patients referred for esophageal
the efficacy of proton-pump inhibitors, in patients who do function tests with a clinical diagnosis of GERD (based on
not respond to these medications a diagnosis other than symptoms and endoscopic findings), 30 per cent had no
GERD should be sought.8,9 Therefore, a careful and com- abnormal reflux by pH monitoring (GERD⫺ patients).8
plete preoperative evaluation is of key importance for the Heartburn and regurgitation were as frequent in
success of the operation. GERD⫹ and GERD⫺ patients, so symptoms alone could
Table 25.1 Symptoms of gastroesophageal reflux disease 247 patients with negative pH studies, 60
(25 per cent) had been found to have grade I or II
Typical symptoms Atypical symptoms
esophagitis.8
Heartburn
Regurgitation
Cough
Wheezing
• Major interobserver variation exists for esophageal
endoscopy, particularly for the low grades of
Dysphagia Chest pain esophagitis.14
Hoarseness
Otitis media Therefore, we feel that the major value of endoscopy
Enamel problems is to exclude other pathology and to detect the presence
of Barrett’s esophagus, which occurs in about 12 per cent
of patients with GERD.15
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, ESOPHAGEAL MANOMETRY
respectively.9
The response to proton-pump inhibitors is a better This test provides information about the length and rest-
predictor of the presence of abnormal reflux. For example, ing pressure of the LES and the quality of esophageal
in our study 75 per cent of GERD⫹ patients but only peristalsis (amplitude, duration and velocity of the peri-
26 per cent of GERD⫺ patients reported a good or excellent staltic waves). In most patients with GERD referred for
response to these medications.8 Similarly, in a multivariate surgery, the LES is hypotensive. However, in some
analysis of factors predicting outcome of laparoscopic patients, the resting pressure of the LES is normal, and it
fundoplication, Campos and colleagues found that a clin- is assumed that transient LES relaxations account for the
ical response to acid-suppression therapy was one of three majority of reflux episodes.16 Regardless of the mecha-
factors predictive of a successful outcome, along with an nism underlying the abnormal reflux, a fundoplication
abnormal 24-hour pH score and the presence of a typical restores the function of the LES by increasing the pres-
primary symptom, such as heartburn or regurgitation.11 sure and length of the sphincter1–3 or by decreasing the
frequency of episodes of transient LES relaxation.17 In
Barium swallow addition, esophageal manometry provides information
about esophageal peristalsis, which is the most impor-
This test provides information about the presence and tant factor in acid clearance.18 Among 1006 consecutive
size of a hiatal hernia, the presence and length of a stric- patients with GERD confirmed by pH monitoring, we
ture, and the length of the esophagus. The test is not diag- found that peristalsis was normal in 56 per cent of
nostic of GERD, as a hiatal hernia or reflux of barium can patients, severely abnormal in 21 per cent of patients
be present in patients who do not have GERD. However, it (ineffective esophageal motility, IEM), and mildly abnor-
has been shown that among patients with proven GERD, mal in 23 per cent of patients (non-specific esophageal
a large hiatal hernia impairs the function of the lower- motility disorder, NSEMD) (Figure 25.1). Patients with
esophageal sphincter (LES) and prolongs esophageal acid
clearance, producing more severe mucosal injury and
increasing the risk of pulmonary symptoms.12
Endoscopy
23%
Endoscopy is usually the first test performed to confirm
56%
a symptom-based diagnosis of GERD. However, the
approach has the following pitfalls:
• Even though the goal of endoscopy is to assess the 21%

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 Normal NSEMD IEM
• The sensitivity of endoscopy is low, particularly for
low grades of esophagitis.9 In our study, among Figure 25.1 Esophageal peristalsis in 1006 patients with GERD.
Preoperative evaluation 189
IEM had more severe reflux, slower acid clearance, worse • It establishes a correlation between symptoms and
mucosal injury, and more frequent respiratory symp- episodes of reflux. This is particularly important
toms.18 Thus, manometry (and pH monitoring) can help when atypical symptoms such as cough or wheezing
in staging the severity of the disease, identifying patients are present, as 50 per cent of these patients do not
who might benefit most from surgical treatment. experience heartburn and 50 per cent do not have
Finally, esophageal manometry allows proper place- esophagitis on endoscopy.13 In these patients, we use
ment of the pH probe for ambulatory pH monitoring a pH probe with two antimony sensors spaced 15 cm
(5 cm above the upper border of the LES), avoiding the apart (5 and 20 cm above the upper border of the
false positive and negative results that occur in about 75 manometrically determined LES) in order to
per cent of patients when the probe is placed with the determine the proximal extent of the reflux.21 The
‘step technique’.19 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
AMBULATORY pH MONITORING 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
Ambulatory pH monitoring is the most reliable test in the
esophagus (Figure 25.2). In a study of the effect of
diagnosis of GERD, with a sensitivity and specificity of
laparoscopic fundoplication on GERD-induced
about 92 per cent.20 The results of the test are reproducible,
respiratory symptoms, we found that pH monitoring
and false positive or negative results are rare. Acid-
helped to identify the patients most likely to benefit
suppressing medications are discontinued three days
from anti-reflux surgery. Following surgery,
(H2-blocking agents) or 14 days (proton-pump inhibitors)
respiratory symptoms resolved in 83 per cent of
before the study. Diet and activity are unrestricted during
patients when a temporal correlation between cough
the study in order to mimic a typical day in the patient’s
and reflux was found on pH monitoring, but in only
life. This test is of key importance for the following reasons:
57 per cent when this correlation was absent.6
• It determines whether abnormal reflux is present. Ambulatory pH monitoring with symptom
In our study, 30 per cent of patients with a clinical correlation is also the single best test for evaluating
diagnosis of GERD had a normal pH-monitoring non-cardiac chest pain.22 In our experience, the test
test.8 Therefore, in these patients, the test avoided the helps in predicting the outcome of a fundoplication.
continuation of inappropriate and expensive drugs, Following laparoscopic fundoplication, chest pain
such as proton-pump inhibitors, or the performance improved in 85 per cent of patients when a temporal
of a fundoplication. In addition, it prompted further correlation between chest pain and reflux was found
investigation that pointed to other diseases, such as on pH monitoring (Figure 25.3), and specifically in
cholelithiasis, irritable bowel syndrome, or primary 96 per cent of patients when a strong correlation
esophageal motility disorders. (⬎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.
Horgan and colleagues from the University of Washington,

• It stages the disease according to severity.
three types of configuration are usually present:23
Ambulatory pH monitoring and esophageal
manometry allow us to stratify patients according to • Type I hernia: the gastroesophageal junction is above
the severity of the disease, identifying a subgroup the diaphragm (type IA, both the gastroesophageal
characterized by worse esophageal motor function junction and the wrap are above the diaphragm; type
(defective LES, abnormal esophageal peristalsis), IB, only the gastroesophageal junction is above the
more acid reflux in the distal and proximal diaphragm).
esophagus, and slower acid clearance. As a • Type II hernia: para-esophageal configuration.
consequence, these patients experience more • Type III hernia: the gastroesophageal junction is
stricture formation and Barrett’s metaplasia.18 It is below the diaphragm, there is no evidence of hernia,
very important to identify these patients, as they but the body rather than the fundus of stomach has
should benefit from early anti-reflux surgery. been used to perform the wrap.
EVALUATION FOR FAILED Endoscopy

ANTI-REFLUX SURGERY
This determines whether esophagitis is present and
whether there is distortion of the gastroesophageal
During the past five years, we have seen an increased junction.
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
Esophageal manometry
essential to repeat the entire preoperative work-up while
This determines the length and pressure of the LES and
trying to answer the following questions:
its ability to relax in response to swallowing. In addition,
• Are the symptoms due to persistent gastroesophageal it assesses eventual changes in peristalsis.
reflux?
• Are the symptoms due to the fundoplication per se?
Ambulatory pH monitoring
• Can a cause of the failure be identified and corrected
by a second operation?
It is often assumed that if a patient has heartburn after a
fundoplication, then this is due to a failed operation, so
Barium swallow acid-reducing medications are restarted. However, this
approach is wrong in the majority of patients, as postop-
A barium swallow is essential in order to define the erative pH monitoring is abnormal in only about 20 per
anatomy of the gastroesophageal junction. As shown by cent of patients.24 In addition, this test determines whether
Preoperative evaluation 191
a correlation exists between symptoms experienced by 11 Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis
the patient and episodes of reflux. If abnormal reflux is of factors predicting outcome after laparoscopic Nissen
fundoplication. J Gastrointest Surg 1999; 3: 292–300.
present, then the choice is between medical therapy and 12 Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size affects
a second operation. lower esophageal sphincter function, esophageal acid exposure,
and the degree of mucosal injury. Am J Surg 1996; 171: 182–6.
13 Richter JE. Typical and atypical presentations of gastroesophageal
REFERENCES reflux disease. The role of esophageal testing in diagnosis and
management. Gastroenterol Clin North Am 1996; 25: 75–102.
14 Bytzer P, Havelund T, Hansen JM. Inter-observer variation in the
1 DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for endoscopic diagnosis of reflux esophagitis. Scand J Gatroenterol
gastroesophageal reflux disease: evaluation of primary repair in 1993; 28: 119–25.
100 consecutive patients. Ann Surg 1986: 204; 9–29. 15 Patti MG, Arcerito M, Feo CV, et al. Barrett’s esophagus: a surgical
2 Patti MG, Arcerito M, Feo CV, et al. An analysis of operations for disease. J Gastrointest Surg 1999; 3: 397–403.
gastroesophageal reflux disease: identifying the important 16 Doods WJ, Dent J, Hogan WJ, et al. Mechanisms of
technical elements. Arch Surg 1998; 133: 600–6. gastroesophageal reflux in patients with reflux esophagitis.
3 Peters JH, DeMeester TR, Crookes P, et al. The treatment of N Engl J Med 1982; 307: 1547–1552.
gastroesophageal reflux disease with laparoscopic Nissen 17 Ireland AC, Holloway RH, Toouli J, Dent J. Mechanisms underlying
fundoplication: prospective evaluation for 100 patients with the antireflux action of fundoplication. Gut 1993; 34: 303–8.
‘typical’ symptoms. Ann Surg 1998; 228: 40–50. 18 Diener U, Patti MG, Molena D, et al. Esophageal dysmotility and
4 Hunter JG, Smith DC, Branum GD, et al. Laparoscopic gastroesophageal reflux disease. J Gastrointest Surg 2001; 5: 260–5.
fundoplication failures: patterns of failure and response to 19 Molena D, Patti MG, Diener U, Way LW. Esophageal manometry is
fundoplication revision. Ann Surg 1999; 230: 595–604. a prerequisite for pH monitoring. Gastroenterology 2000;
5 Eubanks TR, Omelanczuk P, Richards C, et al. Outcomes of 118: 715.
laparoscopic antireflux procedures. Am J Surg 2000; 179: 391–5. 20 Fuchs KH, DeMeester TR, Albertucci M. Specificity and sensitivity
6 Patti MG, Arcerito M, Tamburini A, et al. Effect of laparoscopic of objective diagnosis of gastroesophageal reflux disease. Surgery
fundoplication on gastroesophageal reflux disease-induced 1987; 102: 575–80.
respiratory symptoms. J Gastrointest Surg 2000; 4: 143–9. 21 Patti MG, Debas HT, Pellegrini CA. Clinical and functional
7 Patti MG, Molena D, Fisichella PM, et al. GERD and chest pain. characterization of high gastroesophageal reflux. Am J Surg 1993;
Results of laparoscopic antireflux surgery. Surg Endosc 2002; 165: 163–8.
16: 563–6. 22 Hewson GE, Sinclair JW, Dalton CB, et al. Twenty-four hour pH
8 Patti MG, Diener U, Tamburini A, et al. Role of esophageal function monitoring: the most useful test for evaluating non-cardiac chest
tests in diagnosis of gastroesophageal reflux disease. Dig Dis Sci pain. Am J Med 1991; 90: 576–83.
2001; 46: 597–602. 23 Horgan S, Pohl D, Bogetti D, et al. Failed antireflux surgery. What
9 Johnsson F, Joelsson B, Gudmundsson K, Greiff L. Symptoms and have we learned from reoperations? Arch Surg 1999;
endoscopic findings in the diagnosis of gastroesophageal reflux 134; 809–15.
disease. Scand J Gastroenterol 1987; 22: 714–18. 24 Lord RVN, Kaminski A, Oberg S, et al. Absence of gastroesophageal
10 Costantini M, Crookes PF, Bremner RM, et al. Value of physiologic reflux disease in a majority of patients taking acid suppression
assessment of foregut symptoms in a surgical practice. Surgery medications after Nissen fundoplication. J Gastrointest Surg
1993; 114: 780–7. 2002; 6: 3–10.
26
Gastroesophageal reflux disease
J. BARRY McKERNAN AND CHARLES R. FINLEY
Treatment 193 References 200

Discussion 200
Over the past decade, there has been a significant shift in reflux and prevent the development of complications asso-
the role of surgery for the treatment of gastroesopha- ciated with GERD. The laparoscopic approach, as in chole-
geal reflux disease (GERD). Anti-reflux surgery, once reser- cystectomy, adrenalectomy and splenectomy, has replaced
ved for severe disease refractory to medical therapy, is the open technique as a method of choice. Patients consid-
now considered appropriate for many patients without ered candidates for laparoscopic anti-reflux surgery are
mucosal complications. Several factors have contributed those who have failed medical therapy, those who cannot
to the growing acceptance of surgery for reflux disease. afford medical therapy, those who have recurrence of
One such factor is the appreciation that abnormal reflux symptoms, those with extra-esophageal manifestations or
can result in serious esophageal complications, such as strictures, and those with para-esophageal hernias. Previous
ulcerations, strictures, and the development of Barrett’s open abdominal surgery, either for reflux disease or for
metaplasia. It is well recognized that many of the extra- other reasons, does not prevent the patient from having
esophageal symptoms observed in patients with GERD, a successful laparoscopic anti-reflux procedure.
including laryngitis, erosion of dental enamel, and pul-
monary disorders (asthma, chronic cough, bronchitis),
are due to refluxed gastric material entering the oropha-
TREATMENT
ryngeal cavity and lungs. Although medical therapy with
proton-pump inhibitors is fairly effective in controlling
heartburn and esophagitis, it is less effective in control- Non-surgical therapy
ling these extra-esophageal symptoms.
Current evidence suggests that treatments directed at Although this chapter focuses primarily on the laparo-
restoring normal competence to the lower esophageal scopic treatment of GERD, several other non-surgical
sphincter (LES) will be more effective than those aimed treatment modalities for GERD and related disorders
at controlling acid secretion.1,2 The introduction of safe deserve mention. Patients are becoming more knowl-
and effective minimally invasive anti-reflux procedures edgeable and inquisitive about their disease, in particular
has contributed greatly to the shift in the role of sur- through the use of the Internet. Two recent procedures
gery for treating GERD. Medical therapy is directed at have caught the attention of patients with reflux disease
alleviating uncomfortable symptoms, whereas surgery is who are seeking non-surgical alternatives to the treat-
directed towards repairing the functional defect. Laparo- ment of GERD. The first is the Stretta Procedure™
scopic anti-reflux procedures are comparable to their (Curon Medical), which involves endoscopic delivery of
open counterparts in terms of high rates of symptom radiofrequency energy to the gastroesophageal junction.
relief coupled with low rates of complications, but they Indicated in patients with minimally active esophagitis
offer advantages in terms of shorter hospital stay, quicker and a hiatal hernia of less than 2 cm in size, one study
recovery, and cost-savings.3–5 revealed a significantly improved quality of life and
For many patients, operative therapy has become an esophageal acid exposure while eliminating the need for
alternative rather than a last resort to treat their abnormal antisecretory medication in the majority of patients
studied.6 Another recently studied modality for patients primary surgeon and the assisting surgeon utilize a two-
with minimal esophagitis and hiatal hernia less than handed technique. This enhances exposure and speeds up
2 cm in size is the use of an endoscopic suturing device the operation. The patient is placed in the Trendelenburg
to perform endoscopic gastroplasty. The authors noted position, with the back elevated to approximately 30
an improvement in heartburn severity score and an degrees. The 10-mm, zero-degree laparoscope is then
improvement in postoperative 24-hour pH monitoring.7 replaced with a 45-degree laparoscope. An angled laparo-
scope is used on every case as it provides optimum
Surgical therapy exposure to the areas of the gastroesophageal junction,
the splenic hilum, the posterior esophageal area, and the
We employ a selective approach to treating GERD, tailor- posterior mediastinum. Initially, peritoneal attachments
ing the anti-reflux procedure to each patient’s underlying between the fundus of the stomach and the diaphragm
anatomical and functional defect. The most commonly are divided with the surgeon’s energy system of choice.
performed procedures for GERD are Nissen fundoplica-
tion, modified Toupet fundoplication, and Collis gastro-
plasty combined with a fundoplication. Additionally, we
have chosen a team approach for the treatment of GERD,
Liver retraction
utilizing an ambulatory surgical center focused on endo-
scopic surgery as well as a team of nursing staff and anes-
thesiologists intimately familiar with the perioperative Surgeon left hand 15 cm Assistant right hand
care of patients undergoing laparoscopic foregut surgery.
Patients are admitted to the outpatient surgery center Surgeon right hand
Assistant left hand
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 com-
pression hose to prevent deep venous thrombosis.8
Operative techniques
10 mm
Mobilization optical
trocar
Patients are placed on the operating table in the supine 5 mm trocar
position. Six trocars are utilized routinely, as shown in
Figure 26.1 Typical trocar placement for laparoscopic
Figure 26.1. Some surgeons prefer the semi-lithotomy
fundoplication, with patient in supine position.
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 peri-
toneal 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 Figure 26.2 Locking Allis clamp through the epigastric port on
retraction (Figure 26.2). It is very important that both the the diaphragm for liver retraction.
Gastroesophageal reflux disease 195
Attention is now turned to the lesser omentum, which at the level of the LES. Intraoperative esophagogastro-
is opened over the caudate lobe of the liver. There is one duodenoscopy (EGD) is performed in all ‘redo’ fundopli-
vascular anomaly that deserves mention. In approximately cations, in patients with para-esophageal hernias, and in
ten per cent of cases, a large branch of the left hepatic any cases in which there is uncertainty as to the location
artery traverses the lesser omentum in this area. This ves- of the LES at the time of surgery. EGD is also carried out
sel should be preserved if it is felt to be larger than 5 mm in after the performance of a Collis gastroplasty to verify
diameter. If there is any doubt about this vessel’s con- that there are no leaks at the site of the staple lines.
tribution to hepatic blood flow, then it may be occluded Furthermore, intraoperative EGD is performed follow-
temporarily with a grasper and any color change noted in ing all cases of esophageal myotomy.
the liver. Next, the right crus of the diaphragm is identi- Once the esophagus has been mobilized, the short
fied, along with its peritoneal attachment, or ‘the white line gastric vessels are divided. Various methods of division
of the right crus of the diaphragm’. This dissection of the and ligation have been utilized, including clips, the har-
right crus of the diaphragm is carried down to the point monic scalpel, vascular staplers, and bipolar cautery for-
at which the median arcuate ligament is identified. Now, ceps. The use of bipolar cautery forceps with monopolar
dissection proceeds along the left crus of the diaphragm division seems to be the most efficient method, with both
until a retro-esophageal window is created. A grasper is surgeons using the two-handed technique. Routine divi-
passed behind the esophagus, and a blue silastic vessel loop sion of the short gastric vessels ensures a loose, floppy
is grasped, encircling the esophagus and secured in place fundus. A recent prospective, double-blind, randomized
with a chromic endo-loop. Occasionally, a branch of the trial with five-year follow-up showed no improvement in
inferior phrenic artery is encountered, requiring cauteri- any measured clinical outcome by division of the short
zation. Also, a few cases of thoracic duct injury have been gastric vessels at the time of laparoscopic Nissen fundo-
reported, which presumably resulted from its location in plication.10 If the surgeon chooses not to divide the
proximity to this portion of the dissection. The assistant short gastric vessels, then adequate mobilization of the
gently grasps the vessel loop providing traction and excel- posterior surface of the fundus should include division
lent exposure for the surgeon. Dissection is begun along of congenital adhesions, adhesions encountered in
the right crus, dividing the phreno-esophageal ligament patients with prior pancreatitis, and the occasional vas-
circumferentially, until the esophagus is completely mobi- cular anomaly in which there is a direct branch from the
lized. Both anterior and posterior vagus nerves are identi- splenic artery to the posterior fundus of the stomach.
fied at this point of the dissection. It should also be noted
that in nearly all cases, the esophageal dissection is per-
Crural closure
formed bluntly without the use of cautery for fear of
esophageal, vagal or pleural injury (Figure 26.3). We routinely measure the size of the crural opening with an
Care must be taken to adequately mobilize the esoph- endoscopic ruler. This has significance with respect to
agus in such a way that the fundoplication will be placed 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 dia-
phragm (Figures 26.4 and 26.5). The angled laparoscope
provides visualization into the chest, just above and
Figure 26.3 Complete mobilization of the distal esophagus, to the right of the right crus of the diaphragm. The inci-
with blue silastic vessel loop for gentle anterior retraction. The sion is then made with the harmonic scalpel over the
right and left crus and the vagus nerve are visualized. liver. The crura of the diaphragm are then approximated
Figure 26.4 Location of relaxing incision in the diaphragm for Figure 26.6 Buttressed closure of the relaxing incision in the
a very large hiatal hernia. diaphragm. Sutures or staples (surgeon’s 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 anesthesi-
ologist 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 fre-
quently, 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

Esophageal motility is performed in all patients preop-
eratively. A careful history of any difficulty in swallowing
is also elicited. A modified Toupet fundoplication is utilized
Figure 26.5 Relaxing incision in the diaphragm performed with in patients with poor esophageal motility, as demonstrated
harmonic scalpel and closure of the hiatus. Crural sutures are by esophageal manometrics or in patients with significant
rarely placed anteriorly. 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
with Ethibond sutures and the relaxing incision can be
esophagus anteriorly, creating a 180-degree fundoplication.
buttressed with one of the above-mentioned prosthetic
Theoretically, this caused an unusual degree of tension
materials (Figure 26.6).11
and mobility between the esophageal and fundic suture
lines, which resulted in a high incidence of recurrence. The
Nissen fundoplication
modified Toupet fundoplication requires only crural
Up to this point in the operation, no bougie dilator has closure, and the two most cephalad sutures anchor the
been placed during the procedure. The assistant gently esophagus to the fundus and the crura. In the event that a
Fundus
Right crus
Esophagus
Left crus
Figure 26.9 The 1 o’clock anchoring suture, incorporating the

left crus, fundus and esophagus (mirroring the previously placed
11 o’clock 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 o’clock 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 Figure 26.10 Completion of the modified Toupet
photograph) and then to the right crus (just to the left of the fundoplication.
fundus in the photograph).
to this suture between the esophagus and the fundus.
modified Toupet fundoplication is indicated, a grasper is Attention is then turned laterally, and a number 38 French
placed behind the esophagus and the fundus is grasped and bougie dilator is advanced into the stomach. At the
retracted medially behind the esophagus, such that a 270- 1 o’clock position, approximately 2–3 cm from the esopha-
degree wrap can be performed. The first suture in the mod- gus, a suture is passed through the fundus, through the
ified Toupet fundoplication is placed through the fundus left crus of the diaphragm, and finally though the esopha-
posteriorly and through the left crus using a 0-Ethibond gus, thus anchoring the wrap laterally (Figure 26.9).12
suture (Figure 26.7). A second suture is placed through the Additional sutures are then placed between the fundus and
wrap posteriorly and through the right crus. Next, the the esophagus, thus completing the left side of the fundo-
esophagus is anchored to the right crus of the diaphragm plication (Figure 26.10). Usually, three sutures incorporate
by passing the suture through the esophagus at 11 o’clock, fundus to crura, two sutures anchor esophagus to fundus to
then through the fundus, and finally through the crus crura at 11 and 1 o’clock, and there are two sutures on each
(Figure 26.8). Additional sutures are then placed caudad side between fundus and esophagus.
Collis gastroplasty Esophagomytomy

The true occurrence of shortened esophagus is debatable. Achalasia is secondary to a loss of ganglion cells in
In our experience, it occurs in one to two per cent of cases. the lower esophagus, resulting in failure of relaxation
Adequate esophageal mobilization well into the chest will of the LES with subsequent hypertrophy of the muscle
usually allow the creation of an intra-abdominal fundopli- and aperistalsis of the esophageal body. The diagnosis of
cation without the need for a Collis gastroplasty. If there is achalasia is made primarily utilizing esophageal manome-
any doubt as to the location of the gastroesophageal junc- try along with the typical radiographic findings on barium
tion, then intraoperative esophagoscopy is performed. If esophagogram of the bird-beak appearance of the esopha-
the LES, after maximal retroperitoneal mobilization, can- gus. The surgeon generally sees these patients after the fail-
not be brought below the planned crural closure, then a ure of standard medical therapy, esophageal dilation, and
Collis gastroplasty may be indicated. The Collis gastro- possibly botulinum toxin injection. Surgical treatment
plasty 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 midclavi-
cular 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 curva-
ture to a point approximately 3–4 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 4–5 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 fun-
dus 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 selec- Figure 26.12 Creation of the neo-esophagus.
tive vagotomy in the neo-esophagus to prevent gastritis.
5 cm
Figure 26.13 Remaining fundus utilized for either modified

Figure 26.11 Initial application of linear cutting device. Toupet or Nissen fundoplication.
involves esophagomyotomy and an anti-reflux procedure, keep the field clear for dissection. Once the circular fibers
typically a modified Toupet fundoplication or Dor ante- are divided down to the mucosa, the mucosa can be
rior fundoplication. pushed bluntly inferiorly, and the dissection can proceed
Spastic disorders of the esophagus include nutcracker in a cephalad direction. The total length of the myotomy
esophagus, diffuse esophageal spasm (DES), and hyper- will depend on the indication for the procedure. For a
tensive LES. DES and nutcracker esophagus primarily primary motility disorder such as achalasia, nutcracker
involve the lower third of the esophagus. Nutcracker esophagus, or diffuse esophageal spasm, a length of
esophagus is typified by significant chest pain and, to a 6–8 cm is usually sufficient. For a hypertensive LES, typi-
lesser extent, dysphagia. Esophageal manometry gener- cally only a 4-cm myotomy is needed (length of the LES)
ally shows slightly elevated resting LES pressures and to relieve the obstruction.
normal relaxation, combined with average esophageal Once the proximal portion of the myotomy is com-
pressures of greater than 180 mmHg. Nutcracker esoph- pleted, the more distal segment, which involves the gastro-
agus is usually identified easily on standard manometry, esophageal junction, is approached. Dissection is carried
as it is a fairly continuous disorder. Diffuse esophageal inferiorly until it impinges upon the decussating fibers of
spasm, on the other hand, may not be identified on stan- the stomach wall and the presumed location of the gastro-
dard or ambulatory esophageal manometry, due to its esophageal junction. It is our practice, in patients under-
episodic nature. DES is characterized by simultaneous, going esophageal myotomy, to perform an intraoperative
mostly high-amplitude esophageal contractions. Each EGD to determine accurately the location of the gastro-
case should be treated on an individual basis, and esophageal junction. The intraoperative EGD serves two
patients should be selected carefully for surgical therapy. purposes: it ensures that the myotomy extends beyond
We usually perform a laparoscopic esophagomyotomy the gastroesophageal junction to totally relieve any distal
combined with an anti-reflux procedure (either a Nissen obstruction, and it ensures that there is no iatrogenic per-
or a modified Toupet fundoplication). foration of the mucosa prior to closure. Once the myotomy
Hypertensive LES, less common than the other spastic is complete, the muscular layer is swept laterally to expose
disorders of the esophagus, is characterized by high rest- approximately 1.5 cm of mucosa. The site is inspected for
ing LES pressures (⬎40 mmHg or more than two stan- bleeding and the fundoplication is performed. When per-
dard deviations above normal) and normal relaxation of forming a myotomy with a modified Toupet fundoplica-
the LES, combined with relatively normal esophageal tion, the fundus is sutured to the divided muscular edges
body motility. Reflux does occur in this population, of the esophageal myotomy, taking care not to injure the
presumably as a result of transient relaxation of the LES bulging mucosa.
with subsequent delayed esophageal clearing of the
refluxed acid. Considerable controversy surrounds the
Pyloroplasty
appropriate management of this condition. The various
treatment options include pharmacological agents to Approximately 10–50 per cent of patients with GERD
decrease LES pressure, esophageal dilation, and surgery. have delayed gastric emptying. This frequently manifests
Only a small number of these patients require surgery. itself in the form of recurrent reflux symptoms after a suc-
We most commonly perform an esophageal myotomy cessful anti-reflux procedure. The patient’s history, EGD,
and modified Toupet fundoplication when treating this upper gastrointestinal radiological studies, and a nuclear
group of patients surgically. medicine gastric-emptying scan are all helpful in making
the diagnosis of delayed gastric emptying. Once the diag-
Technique nosis is made, the patient is treated initially with endo-
scopic pneumatic dilation of the pylorus. If the patient
Once esophageal and fundic mobilization has been com- responds favorably to this treatment, then the definitive
pleted, and before closure of the esophageal hiatus, the treatment by laparoscopic pyloroplasty can be offered.
anterior esophagus is exposed between 11 and 12 o’clock. Trocars are placed similarly as for laparoscopic fundo-
This area avoids the anterior vagus nerve. Beginning plication, although usually in a more caudad position on
approximately 2 cm above the gastroesophageal junc- the abdominal wall. The duodenum is then mobilized
tion, the longitudinal fibers in the first muscular layer of (Kocher maneuver) utilizing the harmonic scalpel and
the esophagus are sharply dissected and separated with blunt dissection. The pylorus is identified, and a longi-
scissors. We use disposable endoscopic scissors with no tudinal incision is made on the anterior surface of the
cautery, since we find that cautery is needed only rarely duodenum, through the pylorus and then on to the stom-
on the small vessels in the esophagus. Once the longi- ach. This longitudinal incision is now closed transversely
tudinal fibers have been bluntly separated, the circular in one layer utilizing 0-Ethibond sutures. Following the
fibers become exposed. These are divided under direct completion of the pyloroplasty, intraoperative EGD is
visualization. The assistant uses a suction irrigator to performed to check for air leaks, and additional sutures
are placed as necessary. The EGD is also valuable in deter- roles. Additionally, good-quality and well-maintained
mining the adequacy and patency of the pyloroplasty. equipment makes for a better experience for the physi-
cian. The patient ultimately reaps the benefit from the
smaller, more patient- and physician-friendly setting.
DISCUSSION
The technical steps presented in this chapter represent REFERENCES

the authors’ preferred methods of performing anti-reflux
procedure. It should be emphasized that each patient 1 Orlando RC. The pathogenesis of gastroesophageal reflux
should be treated individually. As surgeons, we love to disease: the relationship between epithelial defense, dysmotility,
adhere to rules, but we often forget the true intent of and acid exposure. Am J Gastroenterol 1997; 92 (suppl 4):
3S–5S, 5S–7S.
such rules. For example, the intent of dividing the short
2 Stein HJ, Barlow AP, DeMeester TR, Hinder RA. Complications of
gastric vessels was to allow adequate mobilization of the gastroesophageal reflux disease: role of the lower esophageal
fundus of the stomach. We now know that the fundus sphincter, esophageal acid and acid/alkaline exposure, and
can be mobilized adequately and the patient can obtain a duodenogastric reflux. Ann Surg 1992; 216: 35–43.
good result without division of the short gastric vessels, 3 Bowry, DJ, Peters JH. Current state, techniques, and results of
laparoscopic antireflux surgery. Semin Laparosc Surg 1996; 6:
as discussed earlier. Certainly, one can mobilize the fun-
194–212.
dus posteriorly by dividing the posterior gastric attach- 4 Dallemagne B, Weerts JM, Jeahes C, Markiewics S. Results of
ments. What is important is that minimal tension be laparoscopic Nissen fundoplication. Hepatogastroenterology 1998;
placed on the fundoplication. 45: 1338–43.
Much has been said about the results of preoperative 5 Spechler SJ. Veterans Affairs Gastroesophageal Reflux Disease
Study Group. Comparison of medical and surgical therapy for
esophageal motility. Again, by individualizing each
complicated gastroesophageal reflux disease in veterans.
patient, the history of possible dysphagia is much more N Engl J Med 1992; 326: 786–92.
important to us than the fact that they can generate a 6 Triadafilopoulos G, Dibaise JK, Nostrant TT, et al. Radiofrequency
pressure of 30 mmHg in the body of the esophagus, as it energy delivery to the gastroesophageal junction for the treatment
relates to the decision to perform a complete or partial of GERD. Gastrointest Endosc 2001; 53: 407–15.
fundoplication. 7 Filipi CJ, Lehman GA, Rothstein RI, et al. Transoral, flexible
endoscopic suturing for treatment of GERD: a multicenter trial.
Lastly, our tendency as surgeons often to adhere Gastrointest Endosc 2001; 53: 416–22.
rigidly to tradition has made the question of performing 8 Finley CR, McKernan JB. Laparoscopic antireflux surgery at an
the above procedures in an ambulatory surgical center a outpatient surgery center. Surg Endosc 2001; 15: 823–6.
controversial issue. However, the outpatient setting is our 9 McKernan JB, Finley CR. Experience with optical trocar in
preference in performing anti-reflux procedures (includ- performing laparoscopic procedures. Surg Laparosc Endosc
Percutan Tech 2002; 12: 96–9.
ing ‘redos’, para-esophageal hernias and Collis gastro- 10 O’Boyle CJ, Watson KI, Jamieson GG, et al. Division of short
plasties). Available data support the fact that this can be gastric vessels at laparoscopic Nissen fundoplication. A prospective
done with similar morbidity and mortality, as compared double-blind randomized trial with 5-year follow-up. Ann Surg
with the inpatient setting. We feel strongly that a dedi- 2002; 235: 165–70.
11 Huntington TR. Laparoscopic mesh repair of the esophageal hiatus.
cated team approach is the single most important factor
J Am Coll Surg 1997; 184: 399–400.
to the success of any advanced laparoscopic procedure. 12 Thor KB, Silander T. A long-term randomized prospective trial of
The team must be composed of individuals who are both the Nissen procedure versus a modified Toupet technique.
expertly trained and self-motivated in their respective Ann Surg 1989; 210: 719–24.
27
Para-esophageal hernias
HUGO BONATTI, BEATE NEUHAUSER AND RONALD A. HINDER
Treatment of para-esophageal hernias 201 Postoperative management 207

Preoperative management 202 Conclusion 208
Surgical procedure 203 References 208
Hiatal hernias are common disorders in the western pop- Indications for surgical repair
ulation.1 The overall incidence of hiatal hernias has been
reported to lie between ten and over 20 per cent.2 Hiatal PEH may occur with or without symptoms. PEH can
hernias are categorized into four groups, as determined remain asymptomatic for long periods, but these patients
by Hill and Tobias in 1968.3 Type I hiatal hernias, also require close observation.4 On closer examination, the
known as sliding hiatal hernias, account for the most patient may eventually report distinct symptoms, such as
common group (⬎80 per cent) and are characterized by coughing, chest pain or epigastric pain, which the patient
a sliding herniation of the gastroesophageal junction may relate to other causes.5 The more common com-
through the hiatus into the chest. Para-esophageal her- plaints associated with symptomatic PEH are dysphagia,
nias (PEHs) account for the remaining three groups: gastroesophageal reflux (GER), epigastric pain, chest pain,
type II represent a herniation of the fundus of the regurgitation and vomiting, shortness of breath, and
stomach through the hiatus with a fixed gastroeso- coughing; there is also chronic anemia in up to 38 per cent
phageal junction in the normal position; type III are the of patients with PEH.6,7 Symptomatic PEH is always an
most common PEHs, and represent a combination of indication for elective surgical repair in order to avoid the
type I and type II with a displaced gastroesophageal junc- potentially serious complications, such as acute strangula-
tion as well as herniation of parts of the stomach into the tion, volvulus, massive hemorrhage, and perforation.8,9
chest; type IV are composed of a large PEH combined
with a large hiatal defect containing not only the stomach
Contraindications to surgical repair
but also other intra-abdominal organs, such as colon or
spleen. PEHs are observed more commonly in the elderly
Patients with PEH are usually of an older age than
population. In our series of 117 patients undergoing
patients with type I hiatal hernias. A meticulous cardio-
laparoscopic PEH repair, the median age was 68 years
pulmonary investigation is necessary in most cases. One
(range 39–95); 12 patients were over the age of 80 years.
must bear in mind that symptoms consistent with PEH
Sixty per cent of patients were female.
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
TREATMENT OF PARA-ESOPHAGEAL not see any major contraindications for the procedure,
HERNIAS regardless of age. It has been shown that laparoscopic
anti-reflux procedures can be performed safely in elderly
The only curative treatment available for PEH is surgery. patients.11 We recently published a series of 30 octo- and
The principles are complete reduction of the hernia from nonagenarian patients undergoing laparoscopic fundo-
the chest, repair of the hiatal defect, and fundoplication. plication, with zero mortality.12 Although considered by
some to be a contraindication to the procedure, we do PREOPERATIVE MANAGEMENT

not hesitate to use a laparoscopic approach for recurrent
PEH or in patients with a history of previous abdominal
surgery.13 Anatomy/pathology
Whereas GER symptoms are present in most patients

Laparoscopic versus open approach with type I hiatal hernias, the presence of reflux in type II
PEH is variable and dependent on the esophageal length
A variety of studies have shown that the laparoscopic and function. Type III hernias are usually accompanied
approach is as effective as the open approach in terms of by GER. The presence of dysphagia can be explained by
recurrence rate and perioperative complications, if an the fact that the PEH tends to rotate along the long axis
experienced laparoscopic surgeon carries out the pro- of the stomach, resulting in gastric volvulus, which can
cedure.14–16 However, hospitalization was shorter after cause obstruction at the esophagogastric or gastroduode-
laparoscopy and patients experienced less pain.17 Recent nal junction. In patients with a large type IV PEH, the
studies based on symptomatic outcomes analyses have likelihood of pulmonary symptoms is greatest. Coughing,
shown that the laparoscopic repair of large PEHs is safe, shortness of breath, asthma-like symptoms, and lower-
successful, and equivalent to open repair.18 A disturbingly respiratory-tract infections result not only from recurrent
high (42 per cent) prevalence of recurrent herniation fol- aspiration but also from compression of the lung by the
lowing laparoscopic repair of type III hiatal hernias has intrathoracic mass.
been reported recently in a single study.19 However, more
than half of such recurrences had few, if any, symptoms, Preoperative testing
and recurrence rates in other series were considerably
lower.20 In our own series, we observed a recurrence rate A substantial number of PEHs are diagnosed incidentally
of 15 per cent; there was no mortality.2 Other authors on thoracic radiography (Figure 27.1a). Usually, a gas
have also concluded that the laparoscopic approach is bubble within the mediastinum – in most cases on
superior to a transthoracic approach due to less pain the left side – can be observed. Preoperative evaluation
and shorter hospitalization.2,17 Gastrostomy or gastropexy, includes a barium esophagogram (Figure 27.1b), upper-
although suggested for high-risk patients, cannot provide intestinal endoscopy, esophageal manometry, and some-
results comparable to surgical PEH repair.21 times 24-hour ambulatory pH monitoring. The lower
(a) (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
Figure 27.4 After the ports are placed, the stomach is retracted
good intra-abdominal working space. The laparoscopic
to the left, exposing the large hiatal defect.
procedure is performed using 5–11-mm ports in similar
positions to those used for Nissen fundoplication (Figure
27.3). Instrumentation includes a zero-degree laparo-
repair is to completely reduce the hernia contents (Figure
scope, atraumatic graspers, a liver retractor, a small hook
27.4). Dissection is commenced by dividing the gastro-
attached to the electrocautery, the harmonic scalpel, and
hepatic ligament at its flaccid part. The right crus is visual-
two needle-holders. A nasogastric tube is inserted only if
ized, and the hernia sac is divided along the free edge of the
there is excessive gas within the stomach.
hiatus. This is extended on to the left crus, ensuring that
the sac is freed far posteriorly on the left (Figure 27.5).
Operative technique Thereafter, the peritoneum is completely mobilized within
the mediastinum and the sac is pulled caudally (Figures
A transverse 1-cm incision is made above the umbilicus in 27.6 and 27.7). This can usually be achieved easily without
the midline, the Veress needle is introduced, and a pneu- the need to divide any adhesions within the mediastinum.
moperitoneum is created. After placement of the other Once the sac is reduced from the chest, it remains adherent
ports, the abdomen is inspected. The first step of PEH to the anterior surface of the stomach. Dissection in this
Figure 27.5 The peritoneum along the edge of the right crus is Figure 27.8 This dissection is continued from the right side
divided. behind the esophagus but inferior to the left crus of the
diaphragm.
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
Figure 27.9 A window is created behind the esophagus, firstly
mediastinum.
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 medi-
astinum 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
Figure 27.7 The peritoneal incision is continued far posterior defect (Figure 27.10). The first stitch should be placed
on the left crus. This allows access to the connective tissue immediately above the point where the two crura join.
behind the lower esophagus. 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 ‘U’-
stitch 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.
Figure 27.13 The completed fundoplication with an additional
tearing the muscle. A tension-free reconstruction should be silk suture placed inferior to the ‘U’-stitch to secure it in position.
achieved. Stenosis of the hiatus around the esophagus must
be avoided (Figure 27.11). The hiatal defect can be rein- (Figures 27.12 and 27.13). The decision as to which proce-
forced with mesh, such as polypropylene, Marlex® dure to perform is based on preoperative esophageal motil-
(BARD), Gore-Tex®DualMesh (W.L. Gore & Associates), ity. If a severe motility disorder was diagnosed, then a
or denatured animal tissue (Surgisis ES® , Cook Surgical Toupet fundoplication is indicated. With the Nissen repair,
Inc.) fixed to the diaphragm using metallic staples or the fundoplication should be tacked to the diaphragm
stitches. The mesh measures about 4 ⫻ 5 cm; it is cut with on either side to prevent recurrence of a sliding hernia.
a keyhole to enclose the esophagus and is overlapped pos- Gastrophrenic anchorage can be added by suturing the
teriorly. The mesh is placed on the hiatal musculature. We peritoneum of the hernia sac to the diaphragm.
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
Operative pitfalls
lumen or stricture formation. Following repair of the hiatal
Para-esophageal hernia repair in patients with
defect, the short gastric vessels are divided using the har-
previous abdominal surgery
monic scalpel (Ethicon Endosurgery, Inc.). The procedure
is completed by a fundoplication, which can be performed An increasing number of PEHs are seen in patients
as a 360-degree Nissen or a 270-degree Toupet procedure who have undergone previous surgery. As in other
laparoscopic procedures, insertion of ports can be diffi- Large defects at the hiatus
cult, and placement at non-standard sites might be neces-
In some patients, the defect at the hiatus is too large to be
sary. If a previous midline incision is present, then the
closed primarily. This occurs most frequently in type IV
Veress needle can usually be placed safely in the left sub-
hernias. In other cases, the fibrous tissue at the hiatus in
costal area. After division of adhesions between the pari-
this elderly patient population is not compliant and cannot
etal peritoneum and intra-abdominal organs, placement
be approximated adequately. This can result in large dis-
of the other trocars can be achieved. Occasionally, patients
secting tears in the crura, which must be managed by the
must undergo PEH repair following an unsuccessful anti-
use of mesh (Figures 27.14–27.16). These patches should
reflux operation. Dissection of the left liver lobe from the
be cut with a keyhole defect and positioned to lie circum-
stomach and diaphragm can be particularly difficult in
ferentially around the esophagus. The keyhole technique
these cases. Nevertheless, in ‘redo’ operations, conversion
allows for overlapping of the mesh posteriorly. There is
to laparotomy is required rarely.22,23
the risk of erosion of the mesh into the esophagus if non-
absorbable materials are used. They must be attached to
Left accessory or replaced hepatic artery the diaphragm using staples or interrupted sutures. Some
These arteries originate from the left gastric artery and authors suggest the universal use of such patches to allow
are found in up to 25 per cent of patients. Some accessory for tension-free repair.25 Diaphragmatic stitches placed
arteries are small and can be divided without conse- anterior to the esophagus have been suggested to close
quence; however, large vessels suggest that there is com- large defects; however, tension is usually even greater in
plete replacement of the arterial blood supply to the left this area. Others have used a relaxing incision made lateral
lateral liver segments. If this is suspected, the vessel
should be preserved intact in order to avoid ischemic
damage of the biliary tree.24
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 Figure 27.14 Giant hiatal defect with a tear in the right crus
These hernias can contain colon or the spleen. Injuries to after failed primary closure.
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 impor-
tance to avoid atelectasis and pneumonia.
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 ten-
sion in the pneumothorax if necessary. Generally, how-
ever, most cases do not require a chest tube, as the gas in
the pleural space may be expelled by forceful lung infla-
tion 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 mobilization.6 In most cases, dissection of the esophagus
and mesh repair of the relieving incision. far up into the mediastinum allows for adequate mobi-
lization. Dissection can be performed as high as the
Hernia sac bronchial bifurcation. If adequate intra-abdominal
length of the esophagus without tension cannot be
Some controversy exists as to whether to excise the sac or obtained, then an esophageal-lengthening procedure,
mobilize it fully with complete excision.26 We feel that a such as Collis gastroplasty, followed by a fundoplication
remnant of the sac in the mediastinum might cause an should be performed. This can be achieved laparoscop-
effusion or lead to recurrent herniation. We always mobi- ically, but in our opinion the best approach for this pro-
lize the sac completely from the mediastinum. On dissec- cedure is through the chest. Hashemi and colleagues have
tion, care must be taken not to injure the esophagus, reported the need for thoracotomy in over 33 per cent of
stomach, vagus nerve, or blood vessels. The sac is left cases.27 A novel approach for esophagus lengthening has
anterior and to the left of the cardia and can be used as a been suggested by Champion and coworkers (personal
plug to help avoid recurrent herniation of the stomach. communication, 2002): they laparoscopically flap the
fundus of the stomach to the right and then carry out a
Division of short gastric vessels stapled fundectomy to a point 3 cm inferior to the angle
It is our preference that the short gastric vessels are of His. This is then stapled off along the left side of the
divided along the upper 10 cm of the greater curvature of esophagus, achieving a Collis gastroplasty (see Chapter 26).
the stomach to allow for a tension-free wrap. In most
cases, these vessels have been stretched by the gastric Para-esophageal hernia repair in obese patients
herniation, allowing the fundus to be brought behind In obese patients there may be excessive fat in the opera-
the esophagus easily and without tension. tive field, and/or the left lateral liver segments may be
very large. This might hinder retraction of the liver. Such
Possible kinking of the esophagus fatty livers are rigid and the capsule can be injured easily,
resulting in hemorrhage. Local appliance of argon-beam
Following the posterior approximation of the crura, the
coagulation or electrocautery may be used, followed by
esophagus might be forced anteriorly, causing kinking
insertion of a collagen plug to control such hemorrhage.
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 symp-
toms related to such a kink in the follow-up of our
patients.
In general, we do not place a nasogastric tube. For the
Short esophagus majority of patients, this represents an unnecessary incon-
venience and is tolerated poorly. Patients are encouraged
In type III hernias, insufficient intra-abdominal length of to ambulate early and to use incentive spirometry. A gas-
the esophagus has been reported following attempted trografin esophagogram is performed only if the dissec-
tion 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 satisfacto-
rily 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 pre-
ferred 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 com-
pleted 120 laparoscopic repairs of large PEH with zero
mortality and a 15 per cent recurrence rate. These recur-
Figure 27.16 Closure of a large defect using a polypropylene rences are usually asymptomatic type I hernias. Others
mesh. reported higher rates of mortality (three per cent28) and
morbidity (30 per cent29). Dahlberg and colleagues28 and 7 Moskovitz M, Fadden R, Min T, et al. Large hiatal hernias, anemia,
Trus and colleagues29 also report the need for conversion and linear gastric erosion: studies of etiology and medical therapy.
Am J Gastroenterol 1992; 87: 622–6.
to an open procedure in 1.3–5.4 per cent of cases. We feel, 8 Maruyama T, Fukue M, Imamura F, Nozue M. Incarcerated
however, that with adequate experience, these rates of paraesophageal hernia associated with perforation of the
morbidity and mortality should be reduced. fundus of the stomach: report of a case. Surg Today 2001; 31:
454–7.
9 Nattakom T, Schuerer D, Batra S, et al. Emergency
laparoscopic repair of a paraesophageal hernia. Surg Endosc 1999;
CONCLUSION 13: 75–6.
10 Richter JE. Noncardiac (unexplained) chest pain. Curr Treat Options
Gastroenterol 2000; 3: 329–34.
Currently, the only effective treatment available for PEH 11 Kamolz T, Bammer T, Granderath FA, et al. Quality of life and
is surgery. This is successful in most cases if appropriate surgical outcome after laparoscopic antireflux surgery in the
principles of operative therapy are followed. Surgical elderly gastroesophageal reflux disease patient. Scand J
reduction of the hernia results in the relief of dysphagia Gastroenterol 2001; 36: 116–20.
in 91 per cent of patients. The principles of PEH repair 12 Bammer T, Hinder RA, Klaus A, et al. Safety and long term
outcome of laparoscopic antireflux surgery in patients in their
include reducing the stomach, mobilizing the hernia eighties and older. Surg Endosc 2002; 16: 40–42.
sac from the mediastinum, effectively closing the hiatus, 13 Neuhauser B, Hinder RA. Laparoscopic reoperation after failed
and achieving a sufficient gastropexy. Open repair using antireflux surgery. Semin Laparosc Surg 2001; 8: 281–6.
laparotomy or thoracotomy was the standard procedure a 14 Freeman ME, Hinder RA. Laparoscopic paraesophageal hernia
decade ago. The development of laparoscopic anti-reflux repair. Semin Laparosc Surg 2001; 8: 240–5.
15 Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000;
surgery has stimulated interest in laparoscopic para- 80: 1243–52.
esophageal hiatal hernia repair. Minimally invasive tech- 16 Buenaventura PO, Schauer PR, Keenan RJ, Luketich JD.
niques today offer a better treatment option with lower Laparoscopic repair of giant paraesophageal hernia. Semin Thorac
risk. Laparoscopic repair of PEH is safe, technically feasi- Cardiovasc Surg 2000; 12: 179–85.
ble, and well tolerated, with rapid relief of symptoms. The 17 Oelschlager BK, Pellegrini CA. Paraesophageal hernias: open,
laparoscopic, or thoracic repair? Chest Surg Clin North Am 2001;
laparoscopic approach allows for excellent visualization 11: 589–603.
of the hiatus and superior esophageal mobilization, with 18 Basso N, Rosato P, De Leo A, et al. ‘Tension-free’ hiatoplasty,
significantly less surgical insult to this often aged and gastrophrenic anchorage, and 360 degrees fundoplication in the
debilitated patient population. PEH repair remains a laparoscopic treatment of paraesophageal hernia. Surg Laparosc
challenging surgical procedure. We feel that an anti-reflux Endosc Percutan Tech 1999; 9: 257–62.
19 Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of
procedure is necessary because the LES is mobilized large type III hiatal hernia: objective followup reveals high
extensively during the dissection and is likely to be recurrence rate. J Am Coll Surg 2000; 190: 553–60, 560–1.
incompetent as a result. This does not add significantly to 20 Edye MB, Canin-Endres J, Gattorno F, Salky BA. Durability of
the time required for this operation, and it provides an laparoscopic repair of paraesophageal hernia. Ann Surg 1998;
excellent anchoring mechanism for the stomach on to the 228: 528–35.
21 Kercher KW, Matthews BD, Ponsky JL, et al. Minimally invasive
diaphragm. We consider laparoscopic PEH repair with management of paraesophageal herniation in the high-risk
Nissen fundoplication to be the procedure of choice in surgical patient. Am J Surg 2001; 182: 510–14.
appropriately selected patients with PEH. 22 Seelig MH, Hinder RA, Klingler PJ, et al. Paraesophageal herniation
as a complication following laparoscopic antireflux surgery.
J Gastrointest Surg 1999; 3: 95–9.
23 Floch NR, Hinder RA, Klingler PJ, et al. Is laparoscopic reoperation
REFERENCES for failed antireflux surgery feasible? Arch Surg 1999;
134: 733–7.
1 Ilves R. Hiatus hernia. The condition. Chest Surg Clin N Am 1998; 24 Edoga JK, Willekes CL. Laparoscopic fundoplication and the
8: 401–9. aberrant left hepatic artery. Arch Surg 1997; 132: 448–9.
2 Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophageal 25 Hui TT, David T, Spyrou M, Phillips EH. Mesh crural repair of large
hernia repair. Arch Surg 1997; 132: 586–9, 590–1. paraesophageal hiatal hernias. Am Surg 2001; 67: 1170–4.
3 Hill LD, Tobias JA. Paraesophageal hernia. Arch Surg 1968; 96: 26 Athanasakis H, Tzortzinis A, Tsiaoussis J, et al. Laparoscopic repair
735–44. of paraesophageal hernia. Endoscopy 2001; 33: 590–4.
4 Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic 27 Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of
stomach. Presentation and results of operation. J Thorac large type III hiatal hernia: objective follow-up reveals high
Cardiovasc Surg 1993; 105: 253–8, 258–9. recurrence rate. J Am Coll Surg 2000; 190: 553–60.
5 Akdemir I, Davutoglu V, Aktaran S. Giant hiatal hernia presenting 28 Dahlberg PS, Deschamps C, Miller DL, et al. Laparoscopic repair of
with stable angina pectoris and syncope – a case report. Angiology large paraesophageal hiatal hernia. Ann Thorac Surg 2001; 72:
2001; 52: 863–5. 1125–9.
6 Hashemi M, Sillin LF, Peters JH. Current concepts in the 29 Trus TL, Bax T, Richardson WS, et al. Complications of
management of paraesophageal hiatal hernia. J Clin Gastroenterol laparoscopic paraesophageal hernia repair. J Gastrointest Surg
1999; 29: 8–13. 1997; 1: 221–8.
28
Traumatic and unusual herniation
SERGIO G. SUSMALLIAN AND ILAN CHARUZI
Diaphragmatic injuries 209 Surgical treatment of chronic diaphragmatic injuries 213

Acute diaphragmatic herniation 210 Conclusion 214
Surgical treatment of acute diaphragmatic injuries 211 References 215
Chronic diaphragmatic hernia 212
The diaphragm is a thin muscle with a full-time job. It colon through a small defect in the diaphragm. In 1853,
is innervated by the ipsilateral phrenic nerve and has Bowditch became the first physician to diagnose a post-
an abundant blood supply.1 The anatomical role of the traumatic diaphragmatic hernia in vivo.11 In 1886, Riolfi
diaphragm consists of dividing the two large cavities of performed the first repair of a diaphragmatic herniation
the human body and maintaining its different pressures.2 after a stab wound,12 while Walker in 1900 was the first sur-
Its presence separates and contains the viscera of the geon to repair a diaphragmatic hernia after blunt trauma.13
abdominal and thoracic cavities. The symptoms related The aim of this chapter is to provide a clear concept of
to diaphragmatic injuries are caused by the incapacity to the various diaphragmatic lesions and the approaches for
contain the abdominal viscera in the cavity favored by successful diagnosis and treatment.
the pressure gradient.1
During inspiration, the diaphragm contracts physio-
logically, acquiring a flat shape. During expiration, it
DIAPHRAGMATIC INJURIES
relaxes passively and acquires a dome shape. This con-
cept is important for understanding and diagnosing
diaphragmatic injury in the various chest and abdominal Injuries of the diaphragm can be classified into two
levels of penetrating trauma. groups: acute and chronic. Acute injuries (from blunt or
Diaphragmatic injury is not common, but its inci- penetrating trauma) detected in the first 24 hours are
dence has increased over the past few years, probably called ‘early diagnosed’; after the first 24 hours, they are
because of the increased frequency of high-speed motor- called ‘delayed diagnosed’. If the diaphragmatic lesion
vehicle accidents.3–5 Additionally, early recognition has was missed in the acute phase, then the second latent
become more feasible with the diagnostic procedures that phase occurs. In this variable time (months to years), the
are now available. It is also conceivable that early recogni- injury may be asymptomatic. The chronic phase begins
tion of signs and symptoms of a possible diaphragmatic with the appearance of symptoms related to the hernia-
injury can result in the correct treatment being given, so tion of the abdominal viscera into the thoracic cavity.
avoiding chronic injuries. The diagnosis of diaphragmatic This, in turn, will affect respiratory patterns or cardio-
injury is influenced strongly by the severity of the associ- vascular performance or cause digestive symptoms,
ated lesions.6–8 such as gastric distention, gastric or colonic obstruction,
Sennertus in 1541 was the first to report a diaphrag- volvulus, and perforation.14–17 Each of the three phases
matic injury, in a postmortem examination.9 He described of diaphragmatic injury has a relevant importance in the
a strangulated stomach herniated through a left diaphrag- operative strategy decision.
matic defect seven months after a stab wound. In 1579, Paré The early-diagnosed acute phase accounts for about
described the consequences of diaphragmatic herniation in 90 per cent of diaphragmatic injuries. These patients will
blunt and penetrating injuries.10 He found a strangulated typically have associated injuries and are treated by the
open approach.18 Delayed-diagnosed acute injuries differ Abdominal contents were found to invade the thorax
from early-diagnosed injuries in that patients with the in 58 per cent of patients with a left-sided diaphragmatic
former are generally more stable and have fewer severely tear and in 19 per cent with a right-sided defect. These
associated injuries. In this subgroup of acute patients, findings can be explained by the presence of the liver in
laparoscopic approach and repair can be achieved.19–21 the upper right abdominal cavity, thereby protecting the
Laparoscopic treatment for chronic diaphragmatic herni- passage of the viscera. Because of this anatomical differ-
ation is quickly becoming widely accepted and performed. ence, 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
ACUTE DIAPHRAGMATIC HERNIATION
Coma Scale was 8 for patients with right diaphragmatic
tear compared with 11 for those with left diaphragmatic
The etiology of diaphragmatic injuries can be classified tear.18 Patients with a right diaphragmatic injury had
as penetrating or blunt trauma. Diaphragmatic injury more significant amounts of blood loss than patients with
in trauma patients is not uncommon: its incidence injuries elsewhere in the diaphragm.
is 0.8 per cent of all trauma patients admitted, 5 per cent The injuries associated with blunt diaphragmatic
of all blunt abdominal traumatic admissions, and 9.5 trauma are shown in Table 28.1.29–31 The figures shown in
per cent of all thoracoabdominal penetrating trauma this table indicate that hemothorax occurs in 78.5 per cent
admissions.8,22,23 of patients with blunt trauma. Table 28.2 outlines the over-
Penetrating diaphragmatic hernia during thoraco- all rate of abdominal injuries associated with blunt trauma.
abdominal trauma, such as in shotgun wounds, has a The overall mortality rate in the blunt diaphragmatic
different incidence of severity. This massive destructive injuries group of patients is 16–20 per cent, depending on
effect requires laparotomy or thoracotomy and laparotomy the associated injuries. Bilateral rupture of the diaphragm
to repair visceral or vascular damage. Stab wounds and is associated with the highest rate of mortality, followed
iatrogenic diaphragmatic injuries are usually less severe, by traumatic rupture of the right hemidiaphragm.
and if vascular penetration is ruled out laparoscopic repair Intrapericardial diaphragmatic rupture is a rare condition
is feasible. Blunt trauma is more common in motor-vehicle that can mimic cardiac tamponade during the acute diag-
accidents, especially during high-speed impact.7,24 nosed phase of herniation; most commonly, it is the stom-
The physiological pressure of the abdominal cavity ach that protrudes into the pericardium.32–34
varies from 4 to 20 cm of water, and it can climb to Posterior rupture of the diaphragm is an infrequent
100 cm of water during a forced inspiration. Elevation of lesion that can compromise the crura and the hiatus.35
the abdominal pressure up to 400 cm of water occurring Recently, we had the opportunity to treat a patient with a
during motor-vehicle accidents can explain the rupture known hiatal hernia after a motor-vehicle accident. He
of the diaphragm and the herniation of the viscera into presented with a posterior transverse rupture of the
the thorax, which has a negative pressure (⫺2 to ⫺10 cm
of water). Blunt diaphragmatic injury is seen more fre-
Table 28.1 Injuries associated with blunt trauma
quently after motor-vehicle accidents than after pedes-
trian or motorcycle accidents or falls from great heights. Injury Percentage
During blunt trauma, the rupture of the diaphragm can
Hemothorax 78.5
occur in the right, left or both sides, the central tendinous Rib fracture 51
area (opening into the pericardium), or into the posterior Pelvic fracture 46
area, thereby compromising the hiatus. Diaphragmatic Extremity fracture 40
injury is an indicator of an impact with high-energy Pneumothorax 28
transmission. Spinal fracture 16.5
Each of the affected areas demonstrates differing charac- Thoracic aortic tear 7
teristic 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 Table 28.2 Overall rate of abdominal injuries in blunt trauma
affected.18 Rupture of the diaphragm is effected, generally,
Abdominal injury Percentage
by an impact that occurs on the ipsilateral side of the
injury.25 An associated injury has been reported in 90 per Liver 63.5
cent of patients with diaphragmatic tear. Mortality varies Spleen 51
between three and 30 per cent, and depends upon the sever- Hollow viscus 25.5
ity of the trauma and associated injuries. The differences Kidney 11
Bladder 9
between right and left side on admission were well defined
Pancreas 6.5
in the literature.26–28
Traumatic and unusual herniation 211
diaphragm, which included a total avulsion of the right diaphragm and discontinuity of the diaphragmatic edge.
crura. A primary repair by open approach was per- On the right side, ultrasonography can be sensitive to
formed, and the crura was sutured with non-absorbable detection of diaphragmatic rupture with liver herniation.
sutures. In these cases, esophageal perforation must be Spiral computerized tomography (CT) and magnetic res-
ruled out either before (with preoperative testing) or onance imaging (MRI) are the most accurate diagnostic
during operation by irrigation with saline solution or methods for finding diaphragmatic ruptures.38,39 Diag-
methylene blue solution through a nasogastric tube. nostic peritoneal lavage (DPL) is a controversial tool for
Manifestations of diaphragmatic injury during the diagnosing diaphragmatic injury.1 DPL in the presence of
acute phase depend upon the severity of pulmonary isolated diaphragmatic injury may be falsely negative, and
compromise and the associated clinical manifestations. the positive results depend upon the status of the abdom-
The symptoms of thoracic pain referred to the scapula, inal viscera.
dyspnea, and decreased breath sounds are present in Laparoscopy and thoracoscopy are the best invasive
more than 70 per cent of these patients. Specific symp- techniques for diagnosing diaphragmatic lesions and
toms of diaphragmatic rupture may be absent in 25–37 eventual treatment of the rupture.40–42 However, the diag-
per cent of the patients.36 Abdominal tenderness, disten- nosis and treatment of this problem can also be accom-
sion and rebound can also be present. Almost half of plished with the use of a thoracotomy and/or laparotomy
the victims are admitted to the emergency room with when necessary.
symptoms of shock.
Following historical and physical examination, the
initial assessment of a trauma patient with suspected SURGICAL TREATMENT OF ACUTE
diaphragmatic injury should be a chest radiograph. DIAPHRAGMATIC INJURIES
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 When diaphragmatic injuries are diagnosed, repair is
visceral herniation, indistinct diaphragmatic lines, eleva- mandatory. If, during the acute phase, early diagnosis is
tion of the diaphragm, and position of a nasogastric tube confirmed, then the approach to the repair must be dic-
within the thorax (Figure 28.1). Indirect signs of dia- tated by any associated injuries. Generally in this case,
phragmatic injury on chest X-ray are rib fractures, sternal laparotomy will be the preferred method to treat addi-
fracture, pneumothorax, hemothorax, lung contusion, tional visceral injuries. The repair of the diaphragm will
atelectasis, gastric dilation, and subcutaneous air. usually be accomplished with simple suturing of the
Ultrasonography can demonstrate diaphragmatic defect with nonabsorbable sutures in one or two layers.43
rupture by the presence of fluids above and below the 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 visu-
alization, even in the posterior areas.
Operative technique
The patient is placed in lithotomy and Fowler’s 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 mid-
clavicular 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
Figure 28.1 Chest X-ray, showing nasogastric tube in the left remember that in obese patients, this first trocar must be
thorax after trauma. introduced in a slightly higher position between the
(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 con-
taminated 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 proce-
dure 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
10 mm trocar esophagus in either a ‘U’- or ‘O’-shape, depending on the
5 mm trocar size of the defect. The ePTFE patch is then attached to the
diaphragm with titanium spiral tacks posterior to the
Figure 28.2 Schematic position of trocars for laparoscopic esophagus and to the crura (using special care not to
treatment of diaphragmatic herniation. injure the aorta). Lateral and anterior to the esophagus,
the fixation of biomaterial should be performed with
umbilicus and the xiphoid process. Another 11- or 12-mm sutures or an endo-stapler. Regardless of the method of
trocar is introduced in the left upper quadrant, higher than choice, one must be careful in the tendinous area to avoid
the first one, in the midclavicular line, with direct visuali- penetration of the myocardium. In our experience, we
zation with the laparoscope. A third trocar (5 mm) is have demonstrated by echocardiogram one case of peri-
placed in the left upper quadrant subcostally. The place- cardial effusion after laparoscopic repair of a diaphrag-
ment of two more trocars is optional, one for liver retrac- matic hernia induced by a stapler in the pericardial area.
tion in the subxiphoid area and one in the left flank for Intrapericardial rupture of the diaphragm is rare,
retraction (Figure 28.2). The herniated abdominal viscera with fewer than 60 cases having been reported in the
are returned gently into the abdominal cavity using atrau- literature.32–34 Generally, these were long, transverse
matic graspers. Any devitalized tissue that is found along wounds that occurred during blunt abdominal trauma.
the edge of the laceration should be debrided. The defect CT and echocardiography were used for diagnosis.44
is then sutured with endo-stitches. These can be made Primary suture is recommended in these cases. The
free-hand or placed with a device designed to suture myocardium must be protected from injury, which could
laparoscopically. occur at the time of repair.
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
CHRONIC DIAPHRAGMATIC HERNIA
Corp.) or Vicryl®knitted mesh (Ethicon, Inc.), fixing it
to the diaphragm with endo-staplers. We believe that the Diaphragmatic injury represents one of the most com-
placement of such prostheses can help to relieve any exces- monly missed pathologies in trauma patients.1 Undetected
sive tension on the suture line if the patient develops high acute diaphragmatic injuries begin as small lacerations
abdominal pressure or abdominal compartment syndrome without associated serious damage. During the post-
in the immediate postoperative period. traumatic phase, the positive abdominal pressure causes
Treatment of diaphragmatic rupture when diagnosis the viscera to herniate into the pleural space, resulting in an
is delayed (more than 24 hours) differs from treatment increase in the size of the diaphragmatic defect.6,45,46
during the early diagnosis phase because of the greater Because of a delay in diagnosis, only ten per cent
possibility of failure of primary repair due to tension of diaphragmatic hernias are diagnosed in the acute
on the suture line. In this condition, the fibers of the phase. Consequently, 90 per cent of these injuries become
diaphragm are contracted. Primary suture of the defect chronic.47 The time interval to diagnosis varies from
will be performed under tension, thereby increasing the months to years and depends upon the appearance of
possibility of recurrence. symptoms after the latent phase. The size of the original
We prefer to treat these defects with nonabsorbable disruption, localization (left, right, central or posterior),
material, such as an expanded polytetrafluoroethylene 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 her-
niation 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 Figure 28.5 Diaphragmatic hernia repair with ePTFE mesh by
DIAPHRAGMATIC INJURIES laparoscopy.
pressure of 15 mmHg. Some surgeons prefer a lateral posi-

The diaphragm is a muscle, and its insertions are around tion of the surgeon and the use of one of the optical view-
the inferior chest wall. Physiologically, the injured muscle ing trocars.
experiences eccentric retraction, with a tendency to A supraumbilical trocar is inserted for the introduc-
increase the diameter of the edges. The muscle can also tion of a 30-degree scope (5- or 10-mm). One 11-mm
undergo atrophy. Therefore, primary repair in chronic trocar is then inserted in the left upper quadrant at the
defects has a high index of failure, with subsequent lateral border of the rectus abdominis muscle under
recurrence of the hernia. Additionally, the diaphragmatic vision to avoid injury to the epigastric vessels. Two more
hernia does not have a sac, unlike the classical concept of 5-mm trocars are used, one on the right abdominal side
the more commonly seen hernias (Figures 28.4 and 28.5). subcostally, and one in the left flank for the assistant. One
The choice between the two methods of repair, thora- more 5-mm trocar can be inserted in the epigastrium for
coscopic or laparoscopic, is the object of debate.50–53 We liver retraction if this is necessary.
strongly recommend an abdominal approach, which pro- Meticulous adhesiolysis is the first step in the repair,
vides for better management of the adhesions and abdom- avoiding injury to any viscus. Careful reduction of the
inal viscera. The technique includes placing the patient in hernia contents from the pleural space to the abdominal
the lithotomy position and carrying out abdominal insuf- cavity is performed during this dissection. A complica-
flation through a Veress needle with carbon dioxide at a tion, such as a perforation, during these procedures can
can be performed using ePTFE mesh fixed by nonab-

sorbable sutures alone to avoid injury to the myocardium.
The complicated diaphragmatic hernia is an emer-
gency 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 pri-
mary suture or exteriorization of the injured bowel, and
the definitive repair delayed. Contamination is a contra-
indication for definitive repair. Treatment during an acute
presentation consists of the management of the compro-
mised viscera (reduction, resection, colostomy, etc.). The
defect in the diaphragm is closed by primary suture if pos-
sible 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 CONCLUSION

stomach in the left chest. The presentation of this patient was
incarceration of the stomach.
Traumatic diaphragmatic hernia is an indicator of the
severity of injury in blunt trauma patients, who have high
contaminate the operative field. The retracted edges of rates of mortality and morbidity. Penetrating trauma of
the laceration must be identified and cleared from the the diaphragm is generally a smaller injury of the
adhesions. The definitive repair is then performed with diaphragm but is usually associated with injury of vital
nonabsorbable mesh materials. organs of the chest and abdomen. During blunt trauma of
We use either ePTFE mesh as the sole prosthesis or the diaphragm, the injury is a long tear caused by the high
polypropylene mesh placed on to the diaphragm, which pressure of the forces originated. Preoperative diagnosis
is then covered by an ePTFE mesh to avoid contact of diaphragmatic injuries in trauma patients is low
between the polypropylene and the viscera (Figure 28.6). (39 per cent) and missed injuries are seen in ten per cent.
We recommend an overlap of the mesh size of at least Acute repair can be performed by laparoscopy in stable
3 cm. The mesh is folded into a cylindrical shape and patients without severe associated injuries. The technique
introduced into the abdominal cavity through the lumen includes primary repair with separate stitches using a
of the 11-mm trocar. nonabsorbable material.
After unfolding the mesh in the abdominal cavity, fix- Delayed diagnosis (more than 24 hours) and chronic
ation commences in the posterior muscular diaphragm diaphragmatic hernias require prosthetic repair with non-
with titanium spiral tacks. In the lateral, central and absorbable mesh, fixed to the diaphragm with titanium
anterior portions, we use several interrupted nonab- spiral tacks, sutures and/or EMS staples. If incarceration is
sorbable sutures and EMS staples. For a posterior lacera- present without contamination and the reduction can be
tion mimicking a para-esophageal hernia, the repair performed without complication, then the repair will be
consists of a total reduction of the stomach and dissec- similar to that seen in chronic diaphragmatic hernia.
tion of the crura. In these cases, a sac may be present if During strangulation, life-saving procedures must be
the patient had a hiatal hernia before the injury; removal performed, such as resection, colostomy, or feeding tubes.
of the sac, if present, is recommended. The hiatus is In this situation, absorbable materials are recommended
repaired by closure of the crura posterior to the esopha- as a means to effect a temporary repair until definitive
gus with endoscopic sutures. repair is possible.
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 REFERENCES
this area of the diaphragm must include the esophagus,
the ePTFE mesh must be cut into either an ‘O’- or a 1 Schumpelick V, Steinau G, Schluper I, Prescher A. Surgical
‘U’-shape. If an intrapericardial hernia is present in the embryology and anatomy of the diaphragm with surgical
tendinous area of the diaphragm, then a meticulous repair applications. Surg Clin North Am 2000; 80: 213–39.
2 Feliciano DV, Moore EE, Mattox KL. Trauma, 3rd edn. Stamford: 29 Lee WC, Chen RJ, Fang JF, et al. Rupture of the diaphragm after
Appleton & Lange, 1996: 461–85. blunt trauma. Eur J Surg 1994; 160: 479–83.
3 Rubikas R. Diaphragmatic injuries. Eur J Cardiothorac Surg 2001; 30 Jackimczyk K. Blunt chest trauma. Emerg Med Clin North Am 1993;
20: 53–7. 11: 81–96.
4 Simpson J, Lobo DN, Shah AB, Rowlands BJ. Traumatic 31 Meyers BC, McCabe CJ. Traumatic diaphragmatic hernia. Occult
diaphragmatic rupture: associated injuries and outcome. Ann R marker of serious injury. Ann Surg 1993; 218: 783–90.
Coll Surg Engl 2000; 82: 97–100. 32 Colliver C, Oller DW, Rose G, Brewer D. Traumatic intrapericardial
5 Schneider C, Tamme C, Scheidbach H, et al. Laparoscopic diaphragmatic hernia diagnosed by echocardiography. J Trauma
management of traumatic ruptures of the diaphragm. 1997; 42: 115–17.
Langenbecks Arch Surg 2000; 385: 118–23. 33 Muysoms F, Verhelst H, Schroe H, De Jongh R. Traumatic
6 Lin YK, Huang BS, Shih CS, et al. Traumatic diaphragmatic hernia intrapericardial diaphragmatic hernia. J Accid Emerg Med 1997;
with delayed presentation. Chung Hua Hsiao Hua Tsa Chih 1999; 14: 156.
62: 223–9. 34 Aldhoheyan A, Jain SK, Hamdy M, Alsebayel MJ. Traumatic
7 Athanassiadi K, Kalavrouziotis G, Athanassiou M, et al. Blunt intrapericardial diaphragmatic hernia. Injury 1992; 23: 331–2.
diaphragmatic rupture. Eur J Cardiothorac Surg 1999; 15: 469–74. 35 Naunheim FS. Adult presentation of unusual diaphragmatic
8 Mansour KA. Trauma to the diaphragm. Chest Surg Clin North Am hernias. Chest Surg Clin North Am 1998; 8: 359–69.
1997; 7: 373–83. 36 Sukul DM, Kats E, Johannes EJ. Sixty-three cases of traumatic
9 Reed J. Diaphragmatic hernia produced by a penetrating wound. injury of the diaphragm. Injury 1991; 22: 303–6.
Edinburgh Med Surg J 1840; 53: 104. 37 Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic
10 Hamby WB. The Case Reports and Autopsy Records of Ambroise injuries: spectrum of radiographic findings. Radiographics 1998;
Pare. Springfield, IL: Charles Tomas, 1960: 50–51. 18: 49–59.
11 Bowditch HI. Diaphragmatic hernia. Buffalo Med J 1853; 9: 165. 38 Israel RS, McDaniel PA, Primack SL, et al. Diagnosis of
12 Hedblom CA. Diaphragmatic hernia. A study of three hundred and diaphragmatic trauma with helical CT in a swine model. Am J
seventy eight cases in which operation was performed. JAMA Roentgenol 1996; 167: 637–41.
1925; 85: 947. 39 Worthy SA, Kang EY, Hartman TE, et al. Diaphragmatic rupture:
13 Walker EW. Strangulated hernia through a traumatic rupture CT findings in 11 patients. Radiology 1995; 194: 885–8.
of the diaphragm. Laparotomy: recovery. Trans Am Surg Assoc 40 Kamelgard JI, Harris L, Reardon MJ, Reardon PR. Thoracoscopic
1900; 18: 246. repair of a recurrent diaphragmatic hernia four years after initial
14 Somers L, Szeki I, Hulbert D. Late presentation of diaphragmatic trauma, laparotomy and repair. J Laparoendoscop Adv Surg Tech
hernia and gastric volvulus. J Accid Emerg Med 2000; 17: 230. 1999; 9: 171–5.
15 Andrade Alegre R. Chronic diaphragmatic hernia. Chest 1999; 41 Domene CE, Volpe P, Santo MA, et al. Laparoscopic treatment of
116: 1838–9. diaphragmatic hernia. J Laparoendosc Adv Surg Tech 1998; 8:
16 Montresor E, Procacci C, Guarise A, et al. Strangulated traumatic 225–9.
hernia of the diaphragm. A report of two cases. Chir Ital 1999; 42 Yoshida J, Iwai T, Koike E, et al. Thoracoscopic repair of
51: 471–6. diaphragmatic eventration sustained at knife injury: a case report.
17 Mehanna D, Young CJ, Solomon MJ. Large bowel obstruction due Kyobu Geka 1998; 51: 197–200.
to diaphragmatic hernia. Aus N Z J Surg 1998; 68: 544–5. 43 Mouroux J, Padovani B, Poirier NC, et al. Technique for the repair
18 Boulanger BR, Milzman DP, Rosati C, Rodrigues A. A comparison of of diaphragmatic eventration. Ann Thorac Surg 1996; 62: 905–7.
right and left blunt traumatic diaphragmatic rupture. J Trauma 44 Wenzel DJ, Hamilton JD. Cross sectional CT of strangulating
1993; 35: 255–60. intrapericardial diaphragmatic hernia. Am J Roentgenol 2001;
19 Degiannis E, Levy RD, Sofianos C, et al. Diaphragmatic herniation 177: 686–8.
after penetrating trauma. Br J Surg 1996; 83: 88–91. 45 Zieren J, Enzweiler C, Muller JM. Tube thoracostomy complicates
20 Frantzides CT, Carlson MA. Laparoscopic repair of a penetrating unrecognized diaphragmatic rupture. Thorac Cardiovasc Surg
injury to the diaphragm: a case report. J Laparoendosc Surg 1994; 1999; 47: 199–202.
4: 153–6. 46 Faul JL. Diaphragmatic rupture presenting forty years after injury.
21 McNamee CJ, Meyns BP, Pagliero KM. Laparotomy vs thoracotomy Injury 1998; 29: 479–80.
for acute diaphragmatic injuries. Br J Hosp Med 1990; 43: 411. 47 Smithers BM, O’Loughlin B, Strong RW. Diagnosis of ruptured
22 Van Vugt AB, Schoots FJ. Acute diaphragmatic rupture due to diaphragm following blunt trauma: results from 85 cases. Aus N Z
blunt trauma: a retrospective analysis. J Trauma 1989; 29: 683–6. J Surg 1991; 61: 737–41.
23 Mathews JA, Somberg LB, Barker DE. Diaphragmatic rupture. 48 Warren MJ. Delayed presentation of traumatic diaphragmatic
J Tenn Med Assoc 1996; 89: 117–19. hernia. Clin Radiol 1991; 44: 436.
24 Nursal TZ, Ugurlu M, Kologlu M, Hamaloglu E. Traumatic 49 Wataya H, Tsuruta N, Takayama K, et al. Delayed traumatic hernia
diaphragmatic hernia a report of 26 cases. Hernia 2001: 5: 25–9. diagnosed with magnetic resonance imaging. Nihon Kyobu
25 Thakore S, Henry J, Todd AW. Diaphragmatic rupture and the Shikkan Gakkai Zasshi 1997; 35: 124–8.
association with occupant position in right-hand drive vehicles. 50 Matz A, Alis M, Charuzi I, Kyser S. The role of laparoscopy in the
Injury 2001; 32: 441–4. diagnosis and treatment of missed diaphragmatic rupture. Surg
26 Sadeghi N, Nacaise N, De Backer D, et al. Right diaphragmatic Endosc 2000; 14: 537–9.
rupture and hepatic hernia: an indirect sign on computed 51 Slim K, Bousquet J, Chipponi J. Laparoscopic repair of missed blunt
tomography. Eur Radiol 1999; 9: 972–4. diaphragmatic rupture using prosthesis. Surg Endosc 2000; 12:
27 Wuirbel RJ, Mutschler W. Blunt rupture of the right hemi- 1358–60.
diaphragm with complete dislocation of the right hepatic lobe: 52 Zantut LF, Machado MA, Volpe, et al. Bilateral diaphragmatic
report of a case. Surg Today 1998; 28: 850–52. injury diagnosed by laparoscopy. Rev Paul Med 1993; 111: 430–32.
28 Aoki AA, Mock CN, Talner LB. Traumatic rupture of the right 53 Meyer G, Huttl TP, Hatz RA, Schildberg FW. Laparoscopic repair
hemidiaphragm in an automobile accident. Am J Roentgenol 1998; of traumatic diaphragmatic hernias. Surg Endosc 2000;
171: 386. 14: 1010–14.
29
Etiology of recurrent gastroesophageal
reflux disease
ZIAD T. AWAD AND CHARLES J. FILIPI
Clinical presentation 217 Wrong diagnosis 221

Mechanisms of failure 219 Discussion 222
Wrong operation 221 References 224
Gastroesophageal reflux disease (GERD) is a common reflect the fact that laparoscopic fundoplication is a rela-
disease that accounts for approximately 75 per cent of the tively new technique rather than it being intrinsically bet-
pathology of the esophagus. Forty per cent of the adults in ter. However, the early adopters of the laparoscopic
the USA have occasional heartburn, and ten per cent expe- approach were usually more skillful individuals who were
rience heartburn daily.1,2 It is estimated that 20 per cent of likely to be quite compulsive in the indications and tech-
patients with GERD develop serious complications, such niques of these operations. Therefore, it is hoped that with
as ulceration, stricture, and Barrett’s metaplasia. Although longer follow-up this procedure will reveal its superiority.
medical therapy may be effective, it is often required for a Reoperations for failed or recurrent GERD are techni-
protracted period of time. In addition, prolonged therapy cally more demanding due to adhesions from previous sur-
often requires escalated dosages, and discontinuation of gery and obscured anatomy. The relatively fragile walls of
medications may result in an early recurrence of symp- the esophagus, gastric cardia, and fundus are easily dam-
toms. Surgery has improved because of a better under- aged or breached, leading to postoperative leak with poten-
standing of the underlying pathophysiology of GERD and tially lethal complications. In addition, the recognized and
technical refinements of operative techniques.3,4 A con- repaired injury may impair the precise reconstruction
trolled, randomized trial showed superiority of surgical required to obtain a good functional result. Reoperative
therapy for the treatment of severe GERD, with less fre- anti-reflux surgery has a morbidity and mortality of 4–40
quent side effects than with non-surgical management.5 per cent and 0–4.9 per cent, respectively.17 The overall clin-
Other investigators have provided evidence to favor anti- ical results after reoperation – even those obtained by expe-
reflux surgery over medical treatment.6,7 rienced surgeons – are significantly less favorable than
The advent of minimally invasive surgery has revolu- outcomes for first-time repairs. The incidence of unsat-
tionized the surgical treatment of GERD, leading to a sig- isfactory results is at least doubled after reoperation.
nificant increase in the number of cases performed. Studies Furthermore, the greater the number of previous failed
have shown that the functional results of laparoscopic repairs, the greater the incidence of poor results.
anti-reflux procedures are equal to those of open surgery,
but with significantly less postoperative morbidity and
CLINICAL PRESENTATION
a shorter hospital stay.8–10 The surgical management of
GERD sometimes fails, whether performed open or
laparoscopically, and may require reoperation for optimal Dysphagia
results. Failure of open fundoplication occurs in 9–30 per
cent of patients,3,11,12 whereas published failure rates of Approximately 30–40 per cent of patients suffer from
laparoscopic Nissen fundoplication are 2–17 per cent.6,13–16 some form of dysphagia in the early postoperative
The lower published rates for laparoscopic surgery probably period. This, however, decreases to approximately five
per cent at long-term follow-up. It is believed that early after the anti-reflux surgery, resulting in the so-called
short-term dysphagia is due to distal esophageal edema ‘gas-bloat syndrome’. The symptoms can be treated with
and transient esophageal dysmotility. We generally rec- gas-binding agents or prokinetics. Very rarely, it is neces-
ommend that the patient stays on a liquid diet for two sary to take down the fundoplication or convert it to a
days after surgery and then maintains a soft diet for three partial fundoplication.
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 Pain
esophageal dilation and, in extreme cases, placement of a
gastrointestinal feeding tube. Postoperative gastrografin Some patients complain of pain, mainly in the lower tho-
or barium esophagogram helps to define acute postoper- racic region, the epigastrium or the left shoulder, follow-
ative events, such as para-esophageal herniation of the ing fundoplication. This is believed to be due to suture
stomach producing obstruction at the lower esophagus. placement in the diaphragmatic hiatus, producing referred
This finding warrants emergency surgical intervention. pain; it may also be the result of esophageal muscle
Patients with dysphagia that persists past three months spasm. These symptoms can be treated expectantly, and
represent a complex problem that warrants careful analysis occasionally they respond to a calcium-channel blocker
and interpretation. Common causes include slipped such as nifedipine or diltiazem.
fundoplication, para-esophageal hernia formation, tight or
fibrotic fundoplication, hiatal stenosis, twisted fundoplica- Diarrhea
tion, missed tumors at the gastroesophageal junction, low-
amplitude esophageal waves, incomplete propagation of After fundoplication, approximately eight per cent of
contractile waves, and undiagnosed achalasia. A barium patients have diarrhea. The reason for this may be
esophagram with a 12.5-mm barium pill will differentiate increased gastric emptying, excessive liquid intake, or a
anatomical abnormalities at the gastroesophageal junction post-vagotomy effect. In those cases in which the cause is
(slipped or para-esophageal hernia) from other causes not clear, gastric-emptying studies or, for completeness
of dysphagia, such as esophageal dysmotility. The latter of vagotomy, a sham feeding pancreatic polypeptide test
diagnosis is confirmed by an esophageal motility study. may help to resolve the question.19 A pyloroplasty is
Patients who are still confined to liquids at three months appropriate when the gastric-emptying study has a half-
postoperatively, and patients who are losing weight because time of more than 150 minutes. Most patients can be
of dysphagia, should be offered reoperation. If the solid treated effectively with anti-diarrhea medication; only
dysphagia is mild or moderate with few dietary restrictions, rarely is surgical intervention, such as the reversal of a
and there is little or no weight loss, then conservative 10-cm jejunal loop, necessary.
management is a viable option.
Alkaline reflux gastritis

Recurrent reflux
Some patients complain of epigastric discomfort in con-
This occurs in up to eight to ten per cent of patients fol-
junction with their preoperative complaints of heart-
lowed for ten years after the open procedure.3 Common
burn and acid regurgitation. Careful evaluation of these
causes of recurrent reflux are slipped fundoplication,
patients may identify excessive bile in the stomach at
intrathoracic fundoplication with partial disruption, and
endoscopy and on testing with the Bilitec probe. Twenty-
fundoplication that is too loose. Barium esophagogram,
four-hour gastric pH monitoring and hepatobiliary
esophageal manometry, endoscopy, and 24-hour pH
scanning with technetium 99 m-labeled derivatives of
monitoring studies are valuable adjuncts in the evalua-
iminodiacetic acid to show the presence of radioactive
tion of these patients.
material in the stomach help to define the problem fur-
ther. In carefully selected patients, bile-diversion surgery
Abdominal bloating is useful. The duodenal switch consists of division of the
duodenum at the juncture of the first and second portion
This frequent entity is believed to be due to the trapping with a roux-en-Y jejunal loop anastomosed to the proxi-
of swallowed air, which may not be belched easily in the mal duodenum in addition to a highly selective vago-
presence of a competent fundoplication. Many patients tomy. Medical management using a prokinetic and a
after anti-reflux surgery complain of increased epigastric binding agent such as cholestyramine, however, usually
discomfort and flatulence.18 It is likely that patients who suffices. It is important that the patient is advised
undergo anti-reflux surgery habitually swallow air to preoperatively of the probability of continued gastric
clear the esophagus of refluxed acid. This habit continues symptoms after fundoplication.
Etiology of recurrent gastroesophageal reflux disease 219
MECHANISMS OF FAILURE Preoperative diagnosis of the short esophagus,

although not standardized, is currently based on demon-
strating a non-reducing 5-cm or larger hiatal hernia on
Failed repairs requiring reoperation may be the result of an upright barium esophagram, endoscopic demonstra-
technical errors, selection of the wrong operation, or tion of stricture formation or Barrett esophagus, or short
incorrect primary diagnosis. Technical failure undoubt- esophageal length as measured by manometry. Awad and
edly relates to the inexperience of the individual surgeon. colleagues showed that neither a single preoperative test
The restoration of a functional acid barrier while avoid- nor any combination of tests was completely accurate.26
ing dysphagia and side effects, such as diarrhea and When each of the preoperative tests was evaluated indi-
gastroparesis, requires precise surgical technique and vidually, endoscopy had the highest sensitivity (61 per
careful preoperative assessment. cent) and a positive predictability rate of 26.6 per cent;
manometric length measurement had the highest speci-
Crural disruption ficity rate (78 per cent) and a positive predictability rate
of 36.3 per cent. The combination of two or more tests
This disorder results in an intrathoracic migration of resulted in a specificity ranging from 63 to 100 per cent
the wrap or a para-esophageal hernia and is particularly but a low sensitivity (28–42 per cent).
common after laparoscopic anti-reflux procedures for The only reliable way to confirm or exclude esophageal
large hiatal hernias.20,21 Contributing factors, in theory, shortening is to demonstrate intraoperatively that the
include operator inexperience, short esophagus, inade- gastroesophageal junction rests in the abdominal envi-
quate mobilization of the esophagus, and physiological ronment allowing for a tension-free repair. If this precau-
factors that would increase pressure or tension at the tion is not observed, then an anti-reflux repair has
diaphragmatic hiatus.21 This is particularly true if the a failure rate of approximately 25 per cent.27 The most
patient vomits or retches during the early postopera- effective treatment for the shortened esophagus is a
tive period or encounters excessive intra-abdominal pres- lengthening procedure using a Collis gastroplasty. This
sure secondary to a fall, heavy lifting, or a car accident. We operation can be done by an open transthoracic approach;
advise inclusion of the overlying crural peritoneum when alternatively, a totally laparoscopic or a combined laparo-
closing the hiatus. The subdiaphragmatic fascia, which is scopic and thoracoscopically assisted approach can be
identified easily on the left limb of the right crus, is used. Currently, the primary problem with laparoscopic
included in our crural repair. Although some surgeons esophageal mobilization is exposure, as only 6–8 cm of
advocate an anterior crural closure and others recom- distal esophagus can be freed easily when using the
mend a prosthetic reinforcement,22,23 we prefer to place laparoscopic approach. The use of longer instruments, an
deep 0-Ethibond sutures 1 cm apart that include the peri- incision of the arch of the diaphragm to allow a mediasti-
toneum and subdiaphragmatic fascia. A concerted effort nal retractor, and division of the vagal branches to the left
is made to preserve the fascia and avoid a muscle-to-mus- lung aid in circumferential esophageal dissection up to
cle closure. In addition, patients are placed on an anti- the aortic arch.
emetic regimen intraoperatively, which is continued All patients with a possible short esophagus undergo
during the first 48 postoperative hours. Restricted activity circumferential esophageal mobilization followed by intra-
and lifelong avoidance of weight-lifting are advised. operative 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
Missed short esophagus the esophagus without tension, but after experiencing one
recurrent slipped Nissen we subsequently have used a 3-cm
Pathological acid reflux initially produces an inflamma- intraperitoneal length requirement.
tory 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 Two-compartment stomach
including the circular muscle level. Eventually, transmural
inflammation causes fibrosis of the outer longitudinal A partitioned stomach is unique to laparoscopic anti-
muscle, creating a shortening effect and, in some cases, an reflux surgery and occurs when a point too low on the
inability to reduce the gastroesophageal junction to its nor- anterior greater curvature of the stomach is used as
mal subdiaphragmatic position. A foreshortened esopha- the anterior wing or a point too distal on the posterior
gus may also be found in patients with a failed anti-reflux wing of the fundoplication is selected. This creates a
procedure and in those with type III (mixed) hiatal her- pouch of fundus that is isolated from the corpus, created
nias. Between three and 14 per cent of patients undergoing by a partitioning line of tension. There is a characteristic
anti-reflux surgery have the so-called short esophagus.24,25 X-ray picture at esophagography (Figure 29.1) and
Twisted fundoplication
This disorder may be associated with the Nissen–Rosseti

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 proxi-
mal 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 fundopli-
cation. The twisted fundoplication is often resistant to
esophageal dilation and requires reoperation.
Hiatal stenosis
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 forma-
Figure 29.1 The proximal compartment is filled with barium tion, which in turn constricts the esophagus at the hiatal
and the distal compartment is filled with air. level. It is easily recognized at reoperation by intraopera-
tive endoscopy, after taking down the gastric-hepatic
adhesions. It can be corrected by incising the hiatus ante-
riorly. We also inject the hiatoplasty with dexametha-
sone. 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 use-
ful adjunct in these circumstances, especially in patients
who exhibit weight loss and are suspected to have a
benign disorder. All patients with Barrett’s esophagus
should undergo a biopsy protocol before operation. At
laparoscopic reoperation, one should suspect a malig-
nancy if the dissection is difficult and the tissue is
excessively hard.
Figure 29.2 A retroflexed view of the stomach with two Slipped Nissen
compartments separated by a fold/partition of tissue.
This well-known problem occurs after protrusion of the
gastric fundus through the fundoplication. It may be the
the endoscopy is diagnostic (Figure 29.2). Patients with result of esophageal foreshortening, failure to anchor the
this deformity often have dysphagia, and manometric fundoplication to the esophagus, or incorrect position-
evaluation shows a hypertensive fundoplication with ing of the fundoplication on to the stomach rather than
incomplete relaxation. The gastric body does not relax the lower esophagus. Esophageal mobilization to achieve
with swallowing, thus dysphagia results when the gastric a sufficient intra-abdominal length of esophagus allow-
body is used for the fundoplication. Reoperation is ing for a tension-free repair is essential to minimize the
required. occurrence of this complication.
Vagal-nerve disruption Fundoplication disruption
Injury to both vagus nerves can lead to a marked delay in This is the Achilles heal of Nissen fundoplication and
gastric emptying, which in turn may in turn require a may not be avoidable. Disruption may be the incorrect
pyloroplasty. Familiarity with the anatomy and careful term in many instances. Clearly, the fundoplication folds
dissection of the arch of the right crus will minimize the and tucks are lost with time in some patients and
risk of anterior nerve injury. Posterior nerve injury is recurrent reflux disease occurs, but this is based on the
probably more common when the nerve is displaced retroflexed endoscopic view. In fact, at reoperation many
from the posterior esophagus and is unrecognized as patients have a seemingly intact fundoplication with
such. Single-nerve injury or excessive nerve stretching to sutures still holding the right and the left wing serosal
make an ample window behind the gastroesophageal surfaces in continuity. Apparently, the suture has pulled
junction may create transient gastroparesis. A gastric- out of the full thickness of the stomach wall in one or
emptying study should be performed; our criteria for both of the wings, and an effective barrier has been lost.
pyloroplasty is a half-time of more than 150 minutes for Tissue attenuation may also be responsible for this pheno-
solids or liquids. Vagal-nerve injury is the reason for legal menon. Consequently, Tom DeMeester has recommended
consultation and action more frequently than any other a pledgeted repair, which the main author (CJF) of this
post-Nissen problem. chapter incorporates with every Nissen fundoplication
he performs.
Too loose, too tight, or too long
fundoplication
WRONG OPERATION
If the wrap is too floppy, then the pressure created in the
distal esophagus is low, favoring recurrent reflux symp- Selection of the optimal operation may be influenced by
toms. Conversely, if the fundoplication is too tight, dys- the presence of esophageal foreshortening, defective
phagia may occur. Calibration of the fundoplication has esophageal motility, or gastric-outlet or duodenal obstruc-
been standardized and shown to prevent long-term dys- tion. The acquired short esophagus is an indication for an
phagia.3 A 60F bougie should be introduced, and the esophageal-lengthening procedure to reduce undue ten-
right and left wing lead points should be chosen with the sion on the repair. Significant impairment of esophageal
dilator in place. We prefer to overlap the lead points by peristaltic amplitude of contraction, propagation, or
3 cm to create a floppy Nissen fundoplication (Figure 29.3). 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 duo-
denal stricture is best treated by gastrojejunostomy and
Posterior
Anterior vagotomy.
3 cm
WRONG DIAGNOSIS
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 fundo-
Anterior plication and adding myotomy is required. Preoperative
manometry is imperative in this case but is often forgotten
by the casual esophageal surgeon.
Posterior
Esophageal cancer or a malignancy at the gastro-
esophageal junction can be missed at endoscopy. Care in
obtaining a good retroflexed view of the squamocolum-
nar 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
Figure 29.3 An end-on view of the gastric fundus wings hernia to obtain the view needed. Any suspicion of a neo-
overlapped to assure a floppy Nissen fundoplication. plasm warrants biopsy. If the patient is combative when
the endoscope is retroflexed within the hernia, then possible. More importantly, the esophagus can be mobi-
esophageal perforation can occur. Improved sedation or lized up to the aortic arch and a lengthening procedure,
repeat endoscopy at another session is warranted. We if needed, can be performed easily.
have discovered four patients with malignancy who had A disrupted fundoplication, a repair that is too tight,
been endoscoped recently by an experienced physician or a patient with crus closure failure and an intrathoracic
and referred for anti-reflux surgery. Endoscopy by the fundoplication more than 2 cm above the diaphragmatic
operating surgeon is a must in our opinion. crus and without additional risk factors for a short
esophagus are our primary indications for laparoscopic
reoperative surgery. The patient’s symptoms must be
uncontrollable despite aggressive medical therapy (includ-
DISCUSSION ing dilations) to warrant reoperative surgery. Satisfactory
results have been shown with laparoscopic reoperative
The reasons for poorer outcomes after repeat surgery are surgery (Table 29.2).
hypothetical and perhaps uncorrectable (Table 29.1). A Detractors of the laparoscopic approach for reopera-
specific classification of mechanisms of failure has not tive surgery are concerned primarily about incomplete
been agreed upon, and the best method of correction for dismantling of the fundoplication. This can be difficult, as
each mechanism has yet to be determined. Many failures the posterior wing is often densely adherent to the crural
are the result of technical errors, whereas others result closure and retroperitoneum. Safe dissection in this area
from deteriorating foregut motility or wear and tear on is not possible for inexperienced surgeons. However,
the fundoplication. after mobilization, an intraoperative endoscopy with full
The best approach for reoperative anti-reflux surgery insufflation and the J-maneuver can prove or disprove
is debatable. Currently, we prefer the transthoracic complete dismantling. If blood is seen within the lumen,
approach for patients with two or more failed anti-reflux one should check carefully for a perforation. Obviously, if
procedures, for any patient with an irreducible hiatal the stomach cannot be inflated fully then a larger perfora-
hernia more than 2 cm in size, and for patients with a tion may be present.
suspected short esophagus (short esophageal manomet- Vagal-nerve injury is also a concern, as the nerve
ric length, stricture formation, or Barrett’s esophagus). is not palpated so easily during laparoscopic surgery.
The left transthoracic approach provides maximum Attention to detail and sharp dissection immediately
exposure of the hiatus and makes dissection of the adjacent to identifiable structures will usually prevent
esophagus from the surrounding tissues safer; with a cir- this complication. If there is suspicion of a vagal nerve
cumlinear incision of the diaphragm near its rib attach- injury, then percutaneous endoscopic gastrostomy place-
ment, excellent exposure of the abdominal contents is ment is appropriate at the end of the operation.
Table 29.1 Reported series of reoperations with more than 30 cases
Cases More than one Mortality Good/excellenta Satisfactoryb

Reference (n) prior repair (%) (%) (%)
Skinner (1967)28 43 0
Orringer (1972)29 45 0 3 73
0 85
Hill (1971)30 63 12 3 81
Polk (1980)31 36 28 4 80
0 50
Henderson and Marryatt (1981)32 121 0 0 94
Maher et al. (1984)33 55 6 4 80
Little et al. (1986)34 61 27 5 72
Stirling and Orringer35 87 25 3 67
0 76
Pearson et al. (1987)36 118 22 0 80
Low et al. (1989)37 116 3 86
Siewert et al. (1995)38 50 9 2 70
Stein et al. (1996)39 71 11 1 86
Ellis et al. (1996)40 101 43 1 80
Deschamps et al. (1997)41 185 0.5 88
a
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
Repairs Conversion Complications Results Follow-up

Reference (n) (%) Cause (%) (%) (months)
DePaula et al. (1995)17 19 5 Gastric strangulation preventing safe Intraoperative, 15.8; Excellent (84.3) Mean 13 (range 1–26)
mobilization of the distal esophagus postoperative, 21
Frantzides and Carlson (1997)8 9 0 – Postoperative, 100 Excellent (100) Range 4–14
O’Reilly et al. (1997)42 8 25 Dense adhesions between left lobe of Intraoperative, 33; Excellent (100) Range 12–42
liver and stomach postoperative, 16.6
Watson et al. (1999)43 27 22 Intra-abdominal adhesions, 0 Good (92.6) Median 12 (range 3–48)
perihiatal adhesions
Alexander et al. (1996)44 2 0 – 0 Excellent (100) Not clear
Croce et al. (1997)45 5 20 Intrathoracic cuff and short esophagus 0 Excellent (100) Range 6–20
Schauer et al. (1999)46 22 4.5 Not mentioned Intraoperative, 13.6; Excellent (73); fair (27) Mean 5.7 (range 0–14)
postoperative, 4.5
Curet et al. (1999)47 27 3.7 Poor visualization, gastric perforation Intraoperative, 44.4; Excellent (96); fair (4) Mean 22 (range 1–60)
postoperative, 44.4
Soper et al. (1999)21 6 16.6 Dense mediastinal adhesions 0 Excellent (75); poor (25) Not mentioned
Floch et al. (1999)48 46 20 Adhesions, bleeding, perforation, Intraoperative, 30.4; Significant improvement 17.1 ⫾ 11.8
tension pneumothorax postoperative, 20 in wellbeing score
Szwerc et al.(1999)49 15 0 – 0 Significant improvement ⬎3
in symptom score
Pointner et al. (1999)50 30 7 Bleeding from the spleen, Intraoperative, 18 Significant improvement Median 29 (range 12–45)
gastric perforation in quality of life
Hunter et al. (1999)51 75 8 Adhesion, gastric perforation Intraoperative, 2.6; Excellent/good (87); Not clear
postoperative, 5 fair/poor (13)
Awad et al. (2001)52 38 13 Adhesions, bleeding, big PEH, Intraoperative, 16; Excellent (65); Mean 26.5 (range 4–101)
calcified Angelchik prosthesis postoperative, 38 fair (21.5); poor (13.5)
Serafini et al. (2001)53 28 7 Dense adhesions Intraoperative, 46; Excellent (89); Mean 20 ⫾ 14
postoperative, 21 fair (11)
PEH, para-esophageal hernia.

As more series of reoperative laparoscopic surgery sensory function of the proximal stomach. Br J Surg 2000; 87:
become available for review, a consensus concerning 338–43.
20 Dallemagne B, Weerts JM, Jehaes C, Markiewicz S. Causes of
treatment for the various mechanisms of failure should failures of laparoscopic antireflux operations. Surg Endosc 1996;
result. Until that time, careful attention to preoperative 10: 305–10.
evaluation, intraoperative technical detail, and post- 21 Soper NJ, Dunnegan D. Anatomic fundoplication failure after
operative care are necessary to minimize the morbidity laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–76.
of anti-reflux surgery. 22 Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior
cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc
1997; 11: 769–71.
23 Paul MG, DeRosa RP, Petrucci PE. Laparoscopic tension-free repair
REFERENCES of large paraesophageal hernias. Surg Endosc 1997; 11: 303–7.
24 Johnson AB, Oddsodottir M, Hunter JG, et al. Laparoscopic Collis
gastroplasty and Nissen fundoplication. A new technique for the
1 Gallup Organization. National survey: heartburn across America. management of esophageal foreshortening. Surg Endosc 1998;
Princeton, NJ: Gallup Organization, 1988. 12: 1055–60.
2 Nebel OT, Fornes MF, Castell DO. Symptomatic gastroesophageal 25 Ritter MP, Peters JH, DeMeester TR, et al. Treatment of advanced
reflux: incidence and precipitating factors. Am J Dig Dis 1976; gastroesophageal reflux disease with Collis gastroplasty and
21: 953–6. Belsey partial fundoplication. Arch Surg 1998; 133: 523–9.
3 DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication 26 Awad ZT, Mittal SK, Roth TA, et al. Esophageal shortening during
for gastroesophageal reflux disease. Evaluation of primary repair the era of laparoscopic surgery. World J Surg 2001; 25: 558–61.
in 100 consecutive patients. Ann Surg 1986; 204: 9–20. 27 Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty and
4 Donahue PE, Samelson S, Nyhus LM, Bombeck CT. The floppy fundoplication for complex reflux problems. Ann Surg 1987;
Nissen fundoplication. Effective long-term control of pathologic 206: 473–81.
reflux. Arch Surg 1985; 120: 663–8. 28 Skinner DB. Surgical management of esophageal reflux and hiatal
5 Spechler SJ. Comparison of medical and surgical therapy for hernia: long term results with 1,030 patients. J Thorac Cardiovasc
complicated gastroesophageal reflux disease in veterans. The Surg 1967; 53: 33–54.
department of Veteran Affairs Gastroesophageal Reflux Disease 29 Orringer MB. Long-term results of the Mark IV operation for hiatal
study group. N Engl J Med 1992; 326: 786–92. hernia and analyses of recurrences and their treatment. J Thorac
6 Cadiere GB, Himpens J, Rajan A, et al. Laparoscopic Nissen Cardiovasc Surg 1972; 63: 25–33.
fundoplication: laparoscopic dissection technique and results. 30 Hill LD. Management of recurrent hiatal hernia. Arch Surg 1971;
Hepatogastroenterology 1997; 44: 4–10. 102: 296.
7 Isolauri J, Luostarinen M, Viljakka M, et al. Long-term comparison 31 Polk HC. Jejunal interposition for reflux esophagitis and
of antireflux surgery versus conservative therapy for reflux esophageal stricture unresponsive to valvuloplasty. World J Surg
esophagitis. Ann Surg 1997; 225: 295–9. 1980; 4: 731.
8 Frantzides CT, Carlson MA. Laparoscopic redo Nissen 32 Henderson RD, Marryatt G. Recurrent hiatal hernia. Management
fundoplication. J Laparoendosc Adv Surg Tech A 1997; 7: 235–9. by thoracoabdominal total fundoplication gastroplasty. Can J Surg
9 Hinder RA, Perdikis G, Klinger PJ, DeVault KR. The surgical option 1981; 24: 151–7.
for gastroesophageal reflux disease. Am J Med 1997; 103: 33 Maher JW, Hocking MP, Woodward ER. Reoperation for
144S–8S. esophagitis following failed antireflux procedures. Ann Surg
10 Laine S, Rantala A, Gullichsen R, Ovaska J. Laparoscopic vs 1984; 201: 723–7.
conventional Nissen fundoplication. A prospective randomized 34 Little AG, Ferguson MK, Skinner DB. Reoperation for failed
study. Surg Endosc 1997; 11: 441–4. antireflux operations. J Thorac Cardiovasc Surg 1986; 91:
11 Hiebert CA, O’Mara CS. The Belsey operation for hiatal hernia: a 511–17.
twenty-year experience. Am J Surg 1979; 137: 532–5. 35 Stirling MC, Orringer MB. Surgical treatment after the
12 Shirazi SS, Schulze K, Soper RT. Long-term follow-up for failed antireflux operation. J Thorac Cardiovasc Surg 1986; 92:
treatment of complicated chronic reflux esophagitis. Arch Surg 667–72.
1987; 122: 548–52. 36 Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty and
13 Cuschieri A, Hunter J, Wolfe B, et al. Multicenter prospective fundoplication for complex reflux problems. Ann Surg 1987; 206:
evaluation of laparoscopic antireflux surgery. Preliminary report. 473–81.
Surg Endosc 1993; 7: 505–10. 37 Low DE, Anderson RP, Ilves R, Hill LD. 15 to 20 year results after
14 Hunter JG, Trus TL, Branum GD, et al. A physiologic approach to the Hill operation. J Thorac Cardiovasc Surg 1989; 98: 444.
laparoscopic fundoplication for gastroesophageal reflux disease. 38 Siewert JR, Stein HJ, Feussner H. Reoperations after failed
Ann Surg 1996; 223: 673–85. antireflux procedures. Ann Chir Gynaecol 1995; 84: 122.
15 Jamieson GG, Watson DI, Britten-Jones R, et al. Laparoscopic 39 Stein HJ, Feussner H, Siewert JR. Failure of antireflux surgery:
Nissen fundoplication. Ann Surg 1994; 220: 137–45. causes and management strategies. Am J Surg 1996; 171: 36–40.
16 Peters JH, Heimbucher J, Kauer WK, et al. Clinical and physiologic 40 Ellis FH, Gibb SP, Heatley GJ. Reoperation after failed antireflux
comparison of laparoscopic and open Nissen fundoplication. surgery: review of 101 cases. Eur J Cardiothorac Surg 1996;
J Am Coll Surg 1995; 180: 385–93. 10: 225–33.
17 DePaula AL, Hashiba K, Bafutto M, Machado CA. Laparoscopic 41 Deschamps C, Trastek VF, Allen MS, et al. Long term results after
reoperations after failed and complicated antireflux operations. reoperation for railed antireflux procedures. J Thorac Cardiovasc
Surg Endosc 1995; 9: 681–6. Surg 1997; 113: 545–51.
18 Low DE, Mercer, CD, James EC, Hill LD. Post Nissen syndrome. 42 O’Reilly MJ, Mullins S, Reddick EJ. Laparoscopic management of
Surg Gynecol Obstet 1988; 167: 1–5. failed antireflux surgery. Surg Laparosc Endosc 1997; 7: 90–3.
19 Vu MK, Ringers J, Arndt JW, et al. Prospective study of the 43 Watson DI, Jamieson GG, Game PA, et al. Laparoscopic reoperation
effect of laparoscopic hemifundoplication on motor and following failed antireflux surgery. Br J Surg 1999; 86: 98–101.
44 Alexander HC, Hendler RS. Laparoscopic reoperation on failed 49 Szwerc MF, Wiechmann RJ, Maley RH, et al. Reoperative
antireflux procedures: report of two patients. Surg Laparosc laparoscopic antireflux surgery. Surgery 1999; 126: 723–8.
Endosc 1996; 6: 147–9. 50 Pointner R, Bammer T, Then P, Kamolz T. Laparoscopic
45 Croce E, Azzola M, Russo R, et al. Laparoscopic re-operation refundoplications after failed antireflux surgery. Am J Surg 1999;
from gastro-oesophageal reflux. Hepatogastroenterology 1997; 178: 541–4.
44: 912–17. 51 Hunter JG, Smith CD, Branum GD, et al. Laparoscopic
46 Schauer PR, Ikramuddin S, Piskun G, et al. Reoperative fundoplication failures: patterns of failure and response to
laparoscopic antireflux surgery. Surg Endosc 1999; 13: S40. fundoplication revision. Ann Surg 1999; 230: 595–604.
47 Curet MJ, Josloff RK, Schoeb O, Zucker KA. Laparoscopic 52 Awad ZT, Anderson PI, Sato K, et al. The laparoscopic reoperative
reoperation for failed antireflux procedures. Arch Surg 1999; antireflux surgery. Surg Endosc 2001; 15: 1401–7.
134: 559–63. 53 Serafini FM, Bloomston M, Zervos E, et al. Laparoscopic
48 Floch NR, Hinder RA, Klingler PJ, et al. Is laparoscopic reoperation revision of failed antireflux operations. J Surg Res 2001;
for failed antireflux surgery feasible? Arch Surg 1999; 134: 733–7. 95: 13–18.
30
Reoperation for recurrent gastroesophageal
reflux disease
THOMAS R. EUBANKS
Characterizing failure 227 Conclusion 234

Patient selection 230 References 234
Operative strategy 230
Successful reoperative anti-reflux procedures are based Esophagitis confirms uncontrolled acid reflux. A tortu-
on three principles: precise characterization of the origi- ous path of the distal esophagus implies abnormalities
nal procedure’s failure, appropriate patient selection, and of fundoplication position. In some cases, a large para-
operative intervention capable of repairing the failure. esophageal hernia can be documented (Figure 30.1).
More than 30 000 anti-reflux procedures were per-
formed 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
1–3.5 per cent of patients,1–3 thus 500–1750 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 malposi-
tioned. 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.
CHARACTERIZING FAILURE
The objective assessment of a patient being considered

for reoperative treatment should include endoscopy, Figure 30.1 Retroflexed view of the gastroesophageal junction
esophagography, esophageal physiological studies, and, at endoscopy. The lesser curve is at the bottom of the photograph.
when indicated, solid-phase gastric-emptying studies. The bulging mucosa above the crus is caused by extrinsic
Endoscopy is useful to assess the state of the esophageal compression of the heart on the herniated stomach. This is a
mucosa and the orientation of the fundoplication. large para-esophageal hernia after an anti-reflux operation.
However, a twisted fundoplication or two-compartment relationships between the esophagus, hiatus, stomach
stomach can also be identified as causes for failure and fundoplication. Figure 30.2 shows early images of
during endoscopy.3 contrast flowing past the cardia of the stomach and
Contrast esophagography is undoubtedly the most into the body. An air-filled fundus can be seen in the pos-
valuable anatomical study for evaluating symptoms terior mediastinum, well above the hiatus. Figure 30.3
after anti-reflux surgery. This study shows the positional 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 30.2 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 Figure 30.3 Later images in the study shown in Figure 30.2.
para-esophageal hernia. Air in the herniated stomach can be The contrast has been cleared from the esophagus and is now
seen in the mediastinum. Note the location of the diaphragm. present in the herniated portion of the stomach. The compression
The gastroesophageal junction appears to be in the abdomen. 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 The lower esophageal sphincter (LES) pressure also
fundoplication, twisted fundoplication, and tight fun- provides helpful information. A defective sphincter sup-
doplication. The addition of a marshmallow swallowed ports the diagnosis of a loose fundoplication in patients
during the study also gives a good impression of lower with symptoms of recurrent reflux. A non-relaxing
esophageal relaxation. sphincter or a sphincter with extremely high pressures
Esophageal manometry is essential in all patients confirms a fundoplication that is too tight. Figure 30.5
being evaluated for postoperative symptoms. In patients demonstrates normal LES pressure and relaxation in a
with dysphagia and chest pain, manometry identifies patient with symptoms of chest pain after a fundoplica-
motility (physiological) abnormalities. Manometry will tion, but no symptoms of reflux.
also help in planning the operative strategy to correct Twenty-four-hour pH monitoring is important in all
the failed procedure. A patient with poor motility may patients (Figure 30.6). Although the symptom of heart-
not be a candidate for a ‘redo’ 360-degree fundoplication. burn would seem to be an accurate predictor of post-
Figure 30.4 shows a typical esophageal body tracing, operative acid exposure, 50 per cent of patients who
with occasional decreased amplitudes of peristalsis in complain of heartburn after a fundoplication will have
the distal esophagus, but confirms the presence of peri- normal acid exposure on pH testing.4 Half of the patients
stalsis, a feature required to proceed with an anti-reflux who complain of heartburn but have normal acid expo-
procedure. sure will have other etiologies identified as a cause of
Figure 30.5 Manometry tracing

showing a normal LES pressure
(17–18 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, Regardless of the reason for reoperation, the compli-
cardiac dysrhythmia, irritable bowel syndrome). In those cation rates are significantly higher for ‘redo’ procedures.
patients who do not complain of heartburn, the study is Major operative complications, such as visceral injury,
useful in documenting subclinical, abnormal acid expo- and postoperative problems, such as dysphagia requiring
sure, which can be present in 20 per cent of cases.4 dilation, occur twice as often during or following reoper-
Solid-phase gastric-emptying studies are helpful in ations compared with primary procedures.8
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 OPERATIVE STRATEGY
pyloroplasty to the reoperation if the study is abnormal;
however, dumping syndrome may occur in up 30 per cent
The patient is placed in the low lithotomy position. The
of patients.5 If the stomach is atonic, then the patient
surgeon stands between the patient’s legs. The assistant
may not be amenable to reoperative anti-reflux surgery
stands on the patient’s left. A static liver retractor (endo-
but instead may require gastrectomy.
scope holder) is attached to the right side of the operat-
Objective testing helps to confirm the clinical suspicion
ing table. A single monitor may be placed at the right
of failure of the previous operation and can influence the
shoulder of the patient. Electrocautery (thin avascular
strategy of the planned corrective procedure. The objec-
tissues) and ultrasonic (thick vascular tissues) dissection
tive findings should support the clinical suspicion. A
capabilities are required.
patient with symptoms of reflux (heart burn and regur-
Five laparoscopic ports are used. The equipment
gitation) will have different objective findings compared
available dictates the size of the ports. If a high-quality,
with a patient with dysphagia and postprandial chest pain.
5-mm laparoscope, a flexible 5-mm liver retractor, and a
5-mm ultrasonic dissector are available, then all five
PATIENT SELECTION 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
Laparoscopic revision of anti-reflux procedures is becom-
based on complete restoration of the anatomy prior to the
ing more common, regardless of whether the original pro-
repair of the hernia. The procedure can be divided into
cedure was performed via laparotomy or laparoscopy.1–3,6,7
three steps: initial dissection, unwrapping, and rewrapping.
The surgeon should be comfortable with the laparoscopic
approach in its use for the initial anti-reflux procedures
before proceeding with ‘redo’ operations. Initial dissection
The selection process in a case with an obvious
anatomical defect is straightforward. With such distorted The first objective is to free the viscera from the hiatus.
anatomy, the patient and surgeon can be confident that Often, this requires mobilization of the inferior aspect of
the repair of the defect will improve symptoms. Less the left lobe of the liver from the fundoplication. The two
subtle defects, such as a small posterior herniation, are most common planes encountered during this dissection
unlikely to be the cause of significant symptoms, and are the subcapsular plane of the liver and the subserosal
reoperation is indicated rarely in these cases. plane of the stomach. Neither is desired, and both are
In patients with recurrent symptoms of reflux and a characterized by the presence of unexpected bleeding.
fundoplication that is too loose, the decision to reoperate Anterior traction of the liver edge and counter traction
is difficult. Symptom control after reoperative therapy is on the stomach facilitate the dissection. Infusing saline
significantly less than after the initial operation.7 Further- irrigant under modest pressure (hydrodissection) can
more, reoperative anti-reflux surgery normalizes acid help to develop the proper plane.
exposure in 74 per cent of patients compared with 83 per After the liver is freed, the next move is to separate the
cent in primary operations.4 The medical management crura from the fundus/esophagus complex. The dissection
of such a patient is often successful and obviates the need can be initiated at any point in which the anatomy is dis-
for operative intervention. cernable. In Figure 30.7, the intraoperative view demon-
Patients with obstructive symptoms caused by a tight strates a large para-esophageal hernia with relatively few
fundoplication (not malposition) may benefit from adhesions to the liver. The left crus and omental attach-
endoscopic dilation. Early dilation (two to six weeks ments to the greater curve could be discerned easily. The
postoperatively) can reduce the need for operative inter- adhesions between the omentum and proximal greater
vention when symptoms are severe. Up to four per cent curve are divided with electrocautery. Since the short
of all patients undergoing anti-reflux procedures will gastric vessels were divided at the original operation, this
require endoscopic dilation, but only one per cent will plane was avascular (Figure 30.8). The para-esophageal
need operative revision for dysphagia alone.7 hernia allowed a clear view of the anterior aspect of the
Figure 30.7 Initial intraoperative view of the esophageal Figure 30.9 Dissection of right crus. The lesser omentum has
hiatus, demonstrating the large para-esophageal hernia. The already been divided (caudate lobe is visible) and adhesions of
liver is out of view to the left, the spleen to the right. Note the subhiatal fat and greater omentum are being freed.
adhesions to the pericardium at the top of the photograph,
which correspond with the endoscopy images in Figure 30.1.
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
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
Figure 30.8 Division of the adhesions between the omentum places traction on the right portion of the fundus while
and the greater curve of the stomach. This plane is usually the assistant places traction on the left. A bougie placed
avascular if the short gastric vessels are divided at the original in the esophagus provides a detectable firmness to the
operation. esophagus. The surgeon and the assistant elevate their
respective aspects of the fundus anteriorly and inferiorly.
crural arch, thus the dissection is carried out from left to Electrocautery, ultrasonic or sharp dissection is then
right. The plane between the right crus and the portion of carried out from the inferior aspect of the fundoplication
herniated stomach is shown in Figure 30.9. In para- to the superior aspect. This plane is avascular and the
esophageal hernias occurring after previous anti-reflux sutures used to construct the prior fundoplication are
surgery, no hernia sac will be encountered. encountered (Figure 30.10). Esophageal and vagal injury
Freeing the fundoplication/esophageal complex from can be avoided at this step if the surgeon and assistant
the crura is an extremely important step for two reasons: focus on proper traction upon the fundoplication.
it provides visual confirmation of the course of the When the sutures have been divided and the dissec-
esophagus as it travels into the fundoplication and it is tion plane is continued to the previously dissected medi-
a safe step, as the fundoplication provides a buffer for astinal esophagus, the fundus should be freed from the
errant dissection and thus aids in the avoidance of cardioesophageal junction. With the bougie still in place,
esophageal injury. the surgeon elevates the right aspect of the fundoplica-
Once the fundoplication/esophageal complex is tion while the assistant provides counter-traction on the
circumscribed by surgical tubing, further mediastinal 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)
Figure 30.12 Series of photographs demonstrating the extent

fundus is freed from the anterior aspect of the cardia and
of stomach herniation. The grasper in (a) remains attached to
esophagus, preserving the anterior vagus (Figure 30.11).
the same portion of stomach throughout the series. The hiatal
This dissection is carried as far posteriorly as possible.
defect can be appreciated in (c).
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 cardia. Once the fundus is restored to its anatomical posi-
space, the entire fundus and gastric body are freed from tion, the cardiac notch should be clearly identifiable, as
the hiatal defect (Figure 30.12). should the smooth transition from the right edge of the
Dissection of the left aspect of the fundoplication does esophagus to the lesser curve of the stomach. Hopefully,
not involve as much work as the right aspect, but it is just the anterior and posterior vagii are visible and intact.
as important. The assistant provides the traction on the With traction applied to the esophagus using surgical
fundus and the surgeon provides the traction on the tubing, the esophagus is mobilized from its mediastinal
Figure 30.13 The esophagus has been mobilized from the Figure 30.14 Closure of the hiatal defect. The first suture has
mediastinum until 3 cm of intra-abdominal esophagus rests in been placed and is about to be cut.
the abdomen without tension.
attachments (Figure 30.13). This allows the gastroesoph-

ageal junction to return to an intra-abdominal position.
Although it is often tempting to avoid complete dissec-
tion of the esophagus and stomach during a ‘redo’ oper-
ation, the surgeon should recall that the best opportunity
for success lies in the first ‘redo’ procedure. Subsequent
procedures have lower success rates and higher compli-
cation rates.
Rewrapping
The ‘redo’ fundoplication is performed similarly to a

primary operation. Techniques to prevent recurrent
herniation should be emphasized. These include adequate Figure 30.15 Re-creating the fundoplication using the
esophageal mobilization, hiatal closure, and anchoring posterior (left) and anterior (right) portions of the fundus. The
the fundoplication to the crura. esophagus and subhiatal fat are in the center, encircled by the
The crura are re-approximated to decrease the hiatal surgical tubing.
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 approx-
imating it to the anterior aspect of the fundus (Figure
30.15). Figure 30.16 shows the completed fundoplica-
tion, 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 reopera-
tive hiatal hernia surgery, these sutures may also be impor- Figure 30.16 The fundoplication is complete. Four sutures placed
tant for initial operations. Four to six sutures are placed 1 cm apart are shown securing the right and left portions of the
between the fundoplication and the crura. The extreme 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 patient’s symptoms, and if
it is correctable.
Figure 30.18 Completed procedure. This view demonstrates

the hiatal closure sutures, several of the anchor sutures
REFERENCES
(fundoplication to hiatus), and the fundoplication sutures.
1 Horgan S, Pohl D, Bogetti, D, et al. Failed anti-reflux surgery: what
have we learned from reoperations? Arch Surg 1999; 134: 809–17.
2 Soper NJ, Dunnegan D. Anatomic fundoplication failure after
right and left sutures can incorporate the muscular wall of
laparoscopic anti-reflux surgery. Ann Surg 1999; 229: 669–77.
the esophagus if it is not too ragged from the previous 3 Hunter JG, Smith D, Branum GD, et al. Laparoscopic fundoplication
dissection. The anterior and posterior sutures should not failures: patterns of failure and response to fundoplication revision.
incorporate the esophagus, to avoid injuring the vagii. Ann Surg 1999; 230: 595–606.
Postoperative care for reoperative anti-reflux pro- 4 Eubanks TR, Omelanczuk P, Richards C, et al. Outcomes of
laparoscopic anti-reflux procedures. Am J Surg 2000; 179: 391–5.
cedures is the same as that for patients undergoing pri-
5 Rieger NA, Jamieson GG, Britten-Jones R, Tew S. Reoperation after
mary repairs. Gastric decompression tubes are not used. failed anti-reflux surgery. Br J Surg 1994; 81: 1159–61.
Patients are allowed liquids by mouth on the day of the 6 Watson DI, Jamieson GG, Game PA, et al. Laparoscopic reoperation
operation. Pharmacological agents are used to suppress following failed anti-reflux surgery. Br J Surg 1999; 86: 98–101.
nausea and emesis. Once the patient is ambulating and 7 Hinder RA, Klingler PJ, Perdikis G, Smith SL. Management of the
oral elixirs are controlling postoperative pain, the patient failed anti-reflux operation. Surg Clin North Am 1997; 77:
1083–1098.
is discharged from hospital. 8 Pohl D, Eubanks TR, Omelanczuk PE, Pellegrini CA. Management and
Patients are instructed to limit exertion (lifting ⬍7 kg) outcome of complications after laparoscopic anti-reflux operations.
to minimize intra-abdominal pressure. A graduated diet Arch Surg 2001; 136: 399–404.
31
Results of laparoscopic treatment
of hiatal hernias
PATRICK R. REARDON AND STIRLING E. CRAIG
Type I hiatal hernia repair 235 References 237

Types II, III and IV hiatal hernia repair 236
Four types of hiatal hernias exist. With type I or sliding were returned. There were no results that dealt specifically
hiatal hernias, the most common type, the gastroesopha- with type I hiatal hernias. There were multiple articles on
geal junction is displaced cranially into the chest. Type II type II, type III, and giant hiatal hernias.
and type III hiatal hernias are para-esophageal hernias. In
type II hiatal hernias, the gastroesophageal junction is in its
TYPE I HIATAL HERNIA REPAIR
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 Intraoperative complications reported during laparoscopic
mixed para-esophageal hernias. In these hiatal hernias, 360-degree fundoplication include esophageal perfora-
both the gastroesophageal junction and a large portion of tion,1–3 gastric perforation,1,2 pneumothorax,2 bleeding,2
the stomach have rolled into the mediastinum. Type IV and conversion to open procedure.2–4 These complications
hiatal hernias include the spleen, the colon, or some other should not be affected by small hiatal hernias. The intra-
intra-abdominal organ within the hernia. operative complications of type I hiatal hernia repair are
When discussing outcomes for laparoscopic repair of outlined in Table 31.1. Postoperative complications include
hiatal hernias, the results should focus on two groups of atelectasis, gastric perforations,4 dysphagia,3,4 substernal
patients. The first group comprises patients with type I chest pain,3,4 heartburn,3,4 regurgitation,3,4 early satiety,3
hiatal hernias, which account for 90–95 per cent of all death,2 and recurrent hiatal hernia.4 The likelihood of a
hiatal hernias. These hernias are generally asymptomatic recurrent hiatal hernia following a laparoscopic 360-degree
and do not require repair. They are repaired primarily as fundoplication with a small hiatal hernia or no hiatal
part of a fundoplication to treat gastroesophageal reflux hernia is affected by whether the crura are closed. Crural
disease. Most surgeons mobilize the distal esophagus in closure has been documented to reduce the occurrence of
order to achieve intra-abdominal esophageal length. This recurrent hiatal hernias.4–7 Larger hiatal hernias are also
process destroys the phreno-esophageal ligament. At this
point, the anatomy resembles the anatomy in the repair of Table 31.1 Type I laparoscopic hiatal hernia repair
a small type I hiatal hernia. Therefore, the outcomes for
Intraoperative complications Percentage
the repair of these hernias are essentially the same as out-
comes for laparoscopic 360-degree fundoplication. The Esophageal perforation 0.2–3.03,1
second group comprises patients with types II, III or IV Gastric perforations 1.61
hiatal hernias. These tend to be larger hernias occurring Pneumothorax ?2
in an older patient population and have different out- Bleeding ?,2 1.030
comes. In an online PubMed literature search using the Superscript figures indicate references.
keywords ‘hiatal hernia’ and ‘laparoscopic’, 220 citations ? ⫽ reported without a percentage.
Table 31.2 Type I laparoscopic hiatal hernia repair Table 31.3 Types II, III and IV laparoscopic hiatal hernia repair
Postoperative complications Percentage Intraoperative

complications Percentage
Gastric perforation 0.3,4 1.06
Dysphagia 7.2,4 4.9,6 4.8,3 9.031 Esophageal perforation 4.0,32 1.9,8 5.0,9 2.3,10 8.3,11 0.512
Substernal chest pain 16.9,4 8.0,3 22.031 Gastric perforations 1.6,32 10.0,14 1.8,13 3.09
Heartburn 5.2,4 2.8,3 12.031 Enterotomy 3.88
Regurgitation 3.5,4 5.43 Pneumothorax 3.6,13 4.0,9
Early satiety 15.63 Hypercarbia 0.832
Atelectasis ?31 Vagus nerve injury 1.813
Pneumothorax 16 Bleeding 1.8,13 1.210
Wound infection 130 Tear of the right crus 2.715
Postoperative herniation 6.2,4 1.0,6 3.4,31, 5.030 Cardiac arrest 0.832
Death 0.31 Death (due to a 1.813
pulmonary embolism)
Superscript figures indicate references.
? ⫽ reported without a percentage. Superscript figures indicate references.
associated with an increased likelihood of recurrent hiatal

hernia.5 Most larger hiatal hernias, however, are type II, III valve during the operation and high-volume ventilation
or IV. The postoperative complications of type I hiatal during desufflation of the abdomen will usually obviate
hernia repair are outlined in Table 31.2. 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
TYPES II, III AND IV HIATAL HERNIA REPAIR increased absorption of carbon dioxide. The problem may
be exacerbated by the frequent occurrence of emphysema
Laparoscopic repair of a large para-esophageal hernia is a or chronic obstructive pulmonary disease in these elderly
technically difficult operation and should be performed patients. During dissection of the large sac associated with
only by a surgeon with significant experience of per- these hernias, bleeding may occur.5,11 Vagus nerve injuries
forming standard laparoscopic 360-degree fundoplica- may occur secondary to failure to recognize the esophagus
tions in patients with no or small type I hiatal hernias. and vagus nerves within the sac.13 Cardiac arrest, and
Large hiatal hernias tend to occur in older patients with death due to pulmonary embolism or other causes are rare
significant associated comorbidities, which make them occurrences intraoperatively.13
higher operative risks. In addition, because of the rotation Numerous postoperative complications have been
of the stomach up into the mediastinum, identification of reported following laparoscopic repair of para-esophageal
the anatomy is difficult. The larger hernia sacs may obscure hernias. Some of these complications are minor, but many
the location of the esophagus and vagus nerves, and these of them are severe. Many of these complications are related
structures are injured more easily in the repair of large or to the fact that these patients present in the sixth and
para-esophageal hernias. seventh decades of life. Frequently, the patients are frail and
The intraoperative complications of types II, III and IV present with significant other diseases. Some of the compli-
hiatal hernias are outlined in Table 31.3. Intraoperative cations may be related to failure to perform an anti-reflux
complications include esophageal perforations,8–12 entero- procedure at the time of the hernia repair. The postopera-
tomy,8 gastric perforations,8,9,13–15 pneumothorax,9,13 tive complications are outlined in Table 31.4. The need to
hypercarbia,13 vagus nerve injury,13 bleeding,11 tearing of perform anti-reflux procedures at the same time remains
the right crus,15 gastric leak,16 myocardial infarction,8 a controversial issue. Some of the most common symp-
cardiac arrest, pulmonary embolism,8 and death due to toms reported after these procedures, such as dysphagia,
pulmonary embolism. When recognized and repaired are related directly to the performance of an anti-reflux
intraoperatively, perforations of the esophagus, stomach procedure. Hernia recurrence remains a problem in laparo-
and intestine add very little morbidity.5 Delayed recogni- scopic hiatal hernia repair. Symptomatic hernias represent
tion of a perforation of a hollow viscus is associated with only a fraction of the total number of recurrences,5,17,18
significant morbidity and a prolonged hospital stay.1,2 and therefore, recurrences in many series may be under-
Most cases of pneumothorax do not involve an actual lung reported. Hernia recurrence is more common in para-
injury. Most are due to inadvertent injuries to the medi- esophageal hernias than in type I hernias. The larger the
astinal pleura during dissection in the chest. Most contain hernia, the more likely is the recurrence.4 Factors associated
only carbon dioxide. Whenever possible, a recognized with increased recurrence include a failure to excise the
pleural injury should be oversewn. Positive-pressure venti- hernia sac,10,15,19 breakdown of the crural repair,20 short-
lation using a positive end expiratory pressure (PEEP) ened 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 achieve a tension-free repair. Recently, there have been
hernia repair increasing reports in the literature of the use of mesh in an
attempt to decrease the recurrence rate following repairs of
Postoperative complication Percentage
hiatal hernias.16,20–28 The mesh may be placed centrally as a
Esophageal perforation 1.333 bolster to an already closed hiatus.16,23,26,28 The mesh may
Gastric perforations 0.8,32 1.98 be used to span the hiatal defect to create a truly tension-
Esophageal stricture 2.633 free repair.16,20,29 The mesh may also be used to close a
Gastric obstruction 1.210 relaxing incision placed laterally in the tendinous
Acute gastric dilation 1.3,33 8.337 diaphragm.
Delayed gastric emptying 1.813 Overall, the surgical literature supports the belief that
Prolonged gastric atony 2.6,33 16.737
the laparoscopic repair of para-esophageal and hiatal
Mesh erosion into stomach 2.321
hernias is technically feasible, safe and effective. Given
Prolonged ileus 1.0,9 2.715
the age and condition of the patients, the morbidity and
Small-bowel obstruction 1.536
Dysphagia 3.6,13 20.0,14 6.0,8 21.0,10
mortality rates are acceptably low. However, the recur-
8.3,11 1.612 rence rates in some series have been unacceptably high.18
GERD symptoms 1.8,13 20.0,14 10.0,8 41.7,11 Recent reports utilizing mesh to reduce the recurrence
3.712 rate are promising and may help reduce the relatively
Early satiety 19.08 high recurrence rate that has been the Achilles heel of
Gas bloat 1.112 laparoscopic hiatal hernia repair.
Hyperflatulence 29.08
Mediastinal seroma 10.014
Transient cervical emphysema 37.5,39 48.834 REFERENCES
Breast mastalgia 8.337
Pneumothorax 3.210 1 Schauer PR, Meyers WC, Eubanks S, et al. Mechanisms of gastric
Atelectasis 10.0,24 8.3,37 10.0,38 and esophageal perforations during laparoscopic Nissen
3.718 fundoplication. Ann Surg 1996; 223: 43–52.
Pneumonia 3.5,10 8.311 2 Bowrey DJ, Peters JH. Laparoscopic esophageal surgery. Surg Clin
ARDS 1.09 North Am 2000; 80: 1213–42, vii.
3 Granderath FA, Kamolz T, Schweiger UM, et al. Long-term results
Pleural effusion 0.8,32 4.09
of laparoscopic antireflux surgery. Surg Endosc 2002; 16: 753–7.
Respiratory failure 1.813 4 Soper NJ, Dunnegan D. Anatomic fundoplication failure after
Deep vein thrombosis 2.0,9 1.210 laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–76, 676–7.
Pulmonary embolus 1.8,13 1.9,8 3.0,9 1.210 5 Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000;
Myocardial infarction 1.6,32 1.9,8 1.09 80: 1243–52.
Atrial fibrillation 6.0,9 16.711 6 Watson DI, Jamieson GG, Devitt PG, et al. A prospective randomized
Cardiac arrhythmia 1.813 trial of laparoscopic Nissen fundoplication with anterior vs
posterior hiatal repair. Arch Surg 2001; 136: 745–51.
Congestive heart failure 1.3,33 1.836
7 Seelig MH, Hinder RA, Klingler PJ, et al. Paraesophageal herniation
Cardiac tamponade 3.718 as a complication following laparoscopic antireflux surgery.
Stroke 1.09 J Gastrointest Surg 1999; 3: 95–9.
Hematoma 1.09 8 Swanstrom LL, Jobe BA, Kinzie LR, Horvath KD. Esophageal motility
Hemothorax 3.718 and outcomes following laparoscopic paraesophageal hernia repair
Bleeding 8.311 and fundoplication. Am J Surg 1999; 177: 359–63.
Retroperitoneal bleeding 3.718 9 Luketich JD, Raja S, Fernando HC, et al. Laparoscopic repair of giant
paraesophageal hernia: 100 consecutive cases. Ann Surg 2000;
Need for transfusion 0.512
232: 608–18.
Urinary retention 1.8,36 2.923 10 Watson DI, Davies N, Devitt PG, Jamieson GG. Importance of
Transient renal failure 1.09 dissection of the hernial sac in laparoscopic surgery for large
Urinary-tract infection 7.4,18 2.321 hiatal hernias. Arch Surg 1999; 134: 1069–73.
Mediastinal abscess 0.8,32 0.512 11 Behrns KE, Schlinkert RT. Laparoscopic management of
Intra-abdominal abscess 2.0,9 0.512 paraesophageal hernia: early results. J Laparoendosc Surg 1996;
Wound infection 4.621 6: 311–17.
12 Livingston CD, Jones HL, Jr, Askew RE, Jr, et al. Laparoscopic hiatal
Clostridium difficile colitis 1.09
hernia repair in patients with poor esophageal motility or
Fever of unknown origin 1.333 paraesophageal herniation. Am Surg 2001; 67: 987–91.
Incisional hernia 2.715 13 Gantert WA, Patti MG, Arcerito M, et al. Laparoscopic repair of
Postoperative herniation 3.6,13 10.0,14 8.0,8 1.0,9 paraesophageal hiatal hernias. J Am Coll Surg 1998; 186: 428–32,
3.5,10 1.112 432–3.
Death 2.4,32 0.512 14 Oddsdottir M, Franco AL, Laycock WS, et al. Laparoscopic repair of
paraesophageal hernia. New access, old technique. Surg Endosc
Superscript figures indicate references. 1995; 9: 164–8.
15 Wu JS, Dunnegan DL, Soper NJ. Clinical and radiologic assessment 24 Athanasakis H, Tzortzinis A, Tsiaoussis J, et al. Laparoscopic repair
of laparoscopic paraesophageal hernia repair. Surg Endosc 1999; of paraesophageal hernia. Endoscopy 2001; 33: 590–4.
13: 497–502. 25 Casaccia M, Torelli P, Panaro F, et al. Laparoscopic physiological
16 Hui TT, Thoman DS, Spyrou M, et al. Mesh crural repair of large hiatoplasty for hiatal hernia: new composite ‘A’-shaped mesh. Surg
paraesophageal hiatal hernias. Am Surg 2001; 67: 1170–74. Endosc 2002; 27: 27.
17 Velanovich V, Karmy-Jones R. Surgical management of 26 Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior
paraesophageal hernias: outcome and quality of life analysis. Dig cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc
Surg 2001; 18: 432–7. 1997; 11: 769–71.
18 Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of 27 Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP.
large type III hiatal hernia: objective followup reveals high A prospective, randomized trial of laparoscopic
recurrence rate. J Am Coll Surg 2000; 190: 553–60, 560–61. polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty
19 Edye M, Salky B, Posner A, Fierer A. Sac excision is essential to for large hiatal hernia. Arch Surg 2002; 137: 649–52.
adequate laparoscopic repair of paraesophageal hernia. Surg Endosc 28 Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic
1998; 12: 1259–63. antireflux surgery with routine mesh-hiatoplasty in the treatment of
20 Basso N, Rosato P, De Leo A, et al. ‘Tension-free’ hiatoplasty, gastroesophageal reflux disease. J Gastrointest Surg 2002; 6: 347–53.
gastrophrenic anchorage, and 360 degrees fundoplication in the 29 Paul MG, DeRosa RP, Petrucci PE, et al. Laparoscopic tension-free
laparoscopic treatment of paraesophageal hernia. Surg Laparosc repair of large paraesophageal hernias. Surg Endosc 1997; 11: 303–7.
Endosc Percutan Tech 1999; 9: 257–62. 30 Zornig C, Strate U, Fibbe C, et al. Nissen vs Toupet laparoscopic
21 Carlson MA, Richards CG, Frantzides CT. Laparoscopic prosthetic fundoplication. Surg Endosc 2002; 16: 758–66.
reinforcement of hiatal herniorrhaphy. Dig Surg 1999; 16: 407–10. 31 Hunter JG, Smith CD, Branum GD, et al. Laparoscopic fundoplication
22 Huntington TR. Laparoscopic mesh repair of the esophageal hiatus. failures: patterns of failure and response to fundoplication revision.
J Am Coll Surg 1997; 184: 399–400. Ann Surg 1999; 230: 595–604, 595–604.
23 Frantzides CT, Richards CG, Carlson MA. Laparoscopic repair of large 32 Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome of
hiatal hernia with polytetrafluoroethylene. Surg Endosc 1999; 13: laparoscopic repair of paraesophageal hernia. Surg Endosc 2002;
906–8. 16: 745–9.
32
SANTIAGO HORGAN AND ROBERT BERGER
Intraoperative complications 239 Conclusion 247

Postoperative complications 243 References 247
Numerous reports detail the benefits of laparoscopic fun- and Pellegrini.8 The left crus is initially identified, and the
doplication, including decreased pain, quicker return to short gastric vessels are divided using an ultrasonic shears.
normal daily activities, and shorter hospital stay. However, A no-touch technique for esophageal dissection is used to
there are also complications related to the treatment of minimize traumatic manipulation of the esophagus. This
gastroesophageal reflux disease (GERD). Mortality reports requires the crura to be separated from the esophagus, and
range from zero to two per cent for initial repairs, increas- not vice versa. After visualizing the right crura, circumfer-
ing to five per cent for second operations.1,2 The morbid- ential dissection of the esophagus proceeds cephalad while
ity, and likewise failure, of laparoscopic fundoplication is using a Penrose drain to manipulate the esophagus.
dependent on its definition and length of follow-up. Most The posterior crura should be re-approximated with inter-
large, single-institution studies report morbidities of two rupted, nonabsorbable sutures to create a snug fit over a
to 26 per cent, with specific identification of failed surgery 56 French Maloney bougie placed within the esophagus.
occurring in four to eight per cent.2–4 Table 32.1 displays A short, floppy, 2-cm fundoplication with three sutures is
the reported causes and frequencies of these failures (see created and secured to the esophagus but not to the crura
also Chapter 29). This chapter discusses the more com- or diaphragm.
mon intraoperative and postoperative complications asso-
ciated with laparoscopic fundoplication, their prevention, Table 32.1 Commonly reported complications and various case
the appropriate work-up for their diagnosis, and the reports following laparoscopic Nissen fundoplication
appropriate course of action. In addition, any reoperation,
whether laparoscopic or open, is known to have a higher Incidence
incidence of complications as well as a higher risk of Complication (%) Case report
recurrence.5–7 It should be stressed that conversion from a Failed Nissen 4–8 Pneumomediastinum
laparoscopic to open surgery for patient safety should not Para-esophageal 0–7 Pulmonary embolism
be considered a complication if performed at the appro- hernia
priate time. Reoperation 2–6 Mesenteric thrombosis
Dysphagia 1–7 Hiatal stenosis
Heartburn/reflux 1–5 Bowel perforation
INTRAOPERATIVE COMPLICATIONS Pneumothorax ⬍2 Delayed gastric
perforation
Gastric perforation 1.5 Cardiac
The ability to adequately visualize and identify the anatomy laceration/tamponade
required for performance of a Nissen fundoplication Delayed gastric 1 Injury to major vessels
cannot be overemphasized. These concepts are discussed emptying
elsewhere and will not be re-addressed here. It is prudent, Splenectomy ⬍1 Late diaphragmatic
rupture
however, to state that our typical fundoplication is per-
Hemorrhage 0.5 Necrotizing fasciitis
formed using a left crus approach, as described by Horgan
Possible intraoperative complications are discussed filled with saline. The esophagus should then be insuf-
below. This is followed by a discussion on ways to avoid flated with air while observing for bubbles as evidence of
encountering these problems initially and what to do if a perforation.
they are encountered.
Bougie perforation
Posterior esophageal dissection
Perforation with a bougie or dilator is a feared complica-
Factors causing increasingly difficult dissection of the
tion. The best safeguard is to ensure active communication
esophagus include prior foregut surgery, extensive history
between the person passing the bougie and the surgeon
of Barrett’s esophagus causing peri-esophagitis, and prior
observing the process. This alone will not guarantee elim-
dilation treatments (in which microperforations may
ination of the risk of perforation, but it will diminish the
have occurred). Meticulous dissection and use of the
risk when both parties involved actively assist each other.
Penrose drain will help to minimize this complication. In
If any resistance is encountered with the passage of the
addition, the use of an angled scope (30 or 45 degrees)
bougie, then force should not be applied. Either a more
will assist in visualizing the posterior aspect of the esoph-
experienced person should attempt to pass the bougie
agus. The ultrasonic shears are well suited for the lysis
and/or re-examination within the abdominal cavity via
of adhesions, whereas monopolar cautery devices can
the laparoscope should occur. First, verify that the appro-
allow for lateral thermal injury and potential delayed
priate bougie size is being used (48–60 French are most
esophageal perforation. In addition, obese patients often
common, depending on the patient’s body habitus and
have significant adipose tissue along the greater curve of
any history of prior dilations or strictures), and ensure
the stomach. In these instances, it is best to place the
adequate lubrication of the bougie with a water-soluble
patient in a steep reverse Trendelenburg position and
jelly. The Penrose drain, typically used to manipulate the
place a 4 ⫻ 4 gauze within the abdomen, just medial to
gastroesophageal junction, should not be manipulated in
the superior tip of the spleen (Figure 32.1). This will assist
any way while advancing the bougie. It is critical that no
in lateral retraction of the adipose for improved exposure
tension is placed on the gastroesophageal junction to
of the left lateral and posterior aspects of the esophagus.
ensure a straight and unobstructed path from the esopha-
Should perforation of the esophagus be suspected, then
gus into the stomach. Using a blunt grasper, palpation
the anesthesiologist should be asked to place an orogastric
along the greater curve of the stomach and anterior gastric
or nasogastric tube and instill 60 cc of methylene blue to
wall will inform the surgeon when the bougie has entered
help localize any injury. If the surgeon cannot visualize
the stomach. The surgeon also needs to be attentive to an
the posterior esophagus adequately, a clean 4 ⫻ 4 gauze
overly aggressive and easy passage of the bougie to ensure
may be placed behind the esophagus before the instilla-
it does not pass too far distally, creating a perforation
tion of the methylene blue. The gauze is then withdrawn
along the greater curve or near the pylorus. Infrequently,
and inspected for any evidence suggestive of a leak. If
the use of the bougie is impossible because it cannot be
methylene blue is not available, then the patient could be
passed easily. It is safer to avoid the use of force for
placed in a level position while the upper abdomen is
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 intra-
abdominal 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 fundoplica-
tion over the injury to reinforce the repair. It is also con-
sidered 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 signifi-
cant 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 esoph-
Figure 32.1 Placing a gauze sponge at the superior splenic agogram is performed. The patient can be fed after this
pole assists in exposure. point.
Pneumothorax Hemorrhage
The incidence of pneumothorax occurring during The development of bleeding is always an unnerving
esophageal dissection is almost 2 per cent.4 Contributing experience, especially as it is visually magnified when
factors are peri-esophagitis from severe Barrett’s disease, performing laparoscopic surgery. Laparoscopic proce-
prior endoscopic therapy, large hiatal hernias, and prior dures have the additional complexity of requiring the
operations upon this area (i.e. prior fundoplication). judgment necessary to know when to convert to an open
There is little to prevent this complication other than operation to obtain control. This question has as many
careful, meticulous dissection. Pneumothorax may pres- answers as there are operative cases. In general, there are
ent in two ways: the first, and most common, is visualiza- three specific situations in which excessive hemorrhage
tion of an opening in the pleura by the operating team. occurs during the performance of laparoscopic fundo-
Usually, the patient has no immediate respiratory complications: retraction of the left liver lobe, division of
promise, such as increasing end tidal carbon dioxide or the short gastric vessels, and dissection of the superior
increased peak airway pressures. Should a rent in the gastrosplenic ligament.
pleura occur, then it might be closed using a stitch or The position and type of the liver retractor vary with
clip, in order to avert ventilatory compromise. The anes- the surgeon performing the operation. Preventing injury
thesiologist may also ventilate the patient manually with is preferable to treating injury, so adequacy and clarity of
several large tidal volume breaths to expel carbon dioxide optics are mandatory. This allows identification of any
trapped in the pleural space. The operation may then adhesions from prior surgeries or inflammation, and
continue while using a lower insufflation pressure then allows the selective division of them with cautery or
(8–10 mmHg). Postoperatively, a chest X-ray can be an ultrasonic scalpel. If a laceration or puncture occurs,
obtained. The majority of patients will not require a tho- several options are available. First, place a 4 ⫻ 4 gauze
racostomy tube, as the carbon dioxide is readily absorbed into the abdomen and apply direct pressure to the injury.
and a repeat chest X-ray will document resolution of If the bleeding is controlled, the gauze may be held in
any pneumothorax. Should the chest radiograph in the place under the liver retractor while the surgery pro-
postanesthesia unit reveal a large pneumothorax (⭓50 ceeds. At the end of surgery, careful removal of the gauze
per cent), then a small chest tube may be necessary, and visualization of the injury will confirm whether
especially if the patient appears symptomatic. the bleeding has stopped. This will be sufficient for the
The second presentation of pneumothorax may be majority of liver injuries. It is also recommended that
more dramatic. In this scenario, the anesthesiologist the intra-abdominal pressure is decreased at the time of
will suddenly comment on increasing end-tidal carbon this inspection to ensure that the pneumoperitoneum is
dioxide, increased peak airway pressures, or decreasing not creating a tamponade effect. If bleeding continues,
hemodynamics. If the presentation is limited to end- then one should try the placement of one of the many
tidal carbon dioxide, then the surgeon should decrease available hemostatic agents, either liquid or solid, at the
the intra-abdominal pneumoperitoneum pressure after site. Other therapies include electrocautery and the
safely removing the instruments from the abdomen. The argon-beam coagulator. Only rarely have we found cases
anesthesiologist should then ventilate the patient manu- of hepatic bleeding that could not be controlled with one
ally to clear any intrapleural collection of trapped carbon or more of these modalities.
dioxide. If the patient is experiencing elevated peak air- Division of the short gastric vessels is another step
way pressures or decreased hemodynamics, then the same that potentially can result in a hemorrhagic complica-
initial approach of lowering the intra-abdominal pressure tion. The majority of surgeons performing fundoplica-
and manual ventilation of the patient should occur. If tions today use ultrasonic scalpels. Other possible
peak airway pressures do not decrease or if the hemo- techniques include the use of clips followed by their divi-
dynamics continue to deteriorate, then tension pneumo- sion or bipolar coagulation. Regardless of the instrument
thorax is likely. The decision to place a thoracostomy employed, the standard warning of careful visualization
tube should not be delayed. If a chest tube is not available and maintaining patience is applicable. The surgeon
immediately, then a 14-gauge angiocatheter needle should elevate the greater curve of the stomach while the
should be placed in the second intercostal space at assistant elevates the omentum. The initial opening of the
the midclavicular line. To determine the appropriate side, greater sac is usually uncomplicated. The greatest occur-
one should auscultate the chest or attempt to visualize the rence of bleeding is seen when approaching the superior
pleural tear. However, the placement of an angiocatheter aspect of the greater curve. In this area are the most super-
needle is only a temporary measure. This should be fol- ior and posterior short gastric vessels. At this level, the
lowed by the introduction of a 28–32 French chest tube assistant should use a blunt grasper to push the greater
connected to a closed suction drain. A postoperative chest curve of the stomach medially and inferiorly. This will
X-ray should confirm the proper location. 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 ves-
sel 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
Figure 32.3 Short esophagus: The gastroesophageal junction
frequent precipitating factor is multiple adhesions from
can be seen easily above the diaphragm. The esophagus does not
the gastric wall to the spleen. In this situation, a quick
show folds, which is usually a sign of a short esophagus. When
remedy is to use an endoscopic linear stapler to transect
the esophagus appears tortuous, the chances of being able to
across the greater curve of the stomach and leave a small
reach the abdomen are very high.
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 sig- of the potential need for a Collis gastroplasty, either laparo-
nificant impact on the patient. Again, depending on the scopically or via a thoracic approach. In our experience,
degree of injury, direct pressure to the injury is the best however, preoperative identification of a shortened esoph-
initial approach if the bleeding is minimal. If bleeding is agus is not always correlated with intraoperative findings
profuse, then one should be comfortable in performing (Figure 32.3). Should the esophagus be found to not have
laparoscopic splenectomy or have a low threshold for the necessary 2–3-cm length within the abdomen, then
conversion to an open surgery to ensure the patient’s proximal circumferential dissection of the esophagus will
safety first and foremost. The latter is preferred. 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
Shortened esophagus
slippage of the fundoplication, migration of the wrap into
the thoracic cavity, or improper placement of the wrap on
The concept of a shortened esophagus generates much
to the upper stomach rather than the esophagus.
controversy. If appropriate preoperative work-up was
performed, then the barium swallow and esophageal
manometry should indicate the length of intra-abdominal Large hiatal hernia
esophagus, ideally 2–3 cm. Patients with severe or long-
standing esophagitis and long-segment Barrett’s esopha- This should be identified preoperatively by barium swal-
gus are at increased risk of esophageal shortening. If low, esophageal manometry, or esophagogastroduodeno-
identified preoperatively, the patient should be informed scopy (EGD). If the hernia is no larger than 4 cm, then it
can be repaired primarily with standard crural closure, and verbal reassurance, as these complaints drop to five
using interrupted nonabsorbable sutures. If the hernia is per cent after three months.12 The surgeon must ques-
large or if the diaphragm is thinned, then closure of the tion patients about their diet and activity in the immedi-
hernia primarily without undue tension may not be pos- ate postoperative period to differentiate between patients
sible. Reinforcement of the repair using pledgets made of who require radiographic studies and patients who
expanded polytetrafluoroethylene (ePTFE; W. L. Gore & require only reassurance. Instructing patients preopera-
Associates) can be attempted. These should be cut into tively about necessary diet restrictions and activity limi-
small rectangular shapes and placed perpendicular to the tations will avert many from overzealous eating or
fibers of the crura to buttress the repair. If the closure exercising. During questioning, often the surgeon can
remains under tension or if the surgeon is still unable identify whether the patient has eaten certain foods
to close the hiatus completely, then a prosthetic patch (breads, meats, raw vegetables) at too early a time and
should be placed. Previously, polypropylene mesh was may be experiencing obstruction, or whether they have
used, but this led to migration and erosion into the overexerted themselves (weight-lifting, heavy manual
stomach and/or esophagus. Currently, most surgeons labor, etc.) too early (before two months). For patients
prefer the use of ePTFE mesh because of the markedly who complain of these symptoms, the easiest and most
decreased risk of erosion. We use the technique described prudent study to obtain is a barium swallow. This reveals
by Huntington.11 A relaxing incision is made to the right the anatomy responsible for the majority of early com-
of the right crus to allow a tension-free primary closure plications. If the barium swallow study is equivocal, then
of the hiatus. This allows the crura to be in direct contact it is reasonable to undertake an EGD examination if the
with the esophagus rather than the mesh. The ePTFE symptoms persist after six to eight weeks. Repeat studies
patch is then placed over the relaxing incision in order to of 24-hour pH monitoring and esophageal manometry
cover the defect, and is secured with either sutures may be pursued if the symptoms of reflux, asthma,
or tacks. It is critical that the placement of these tacks or cough or hoarseness persist after a trial of antisecretory
sutures is not into the esophagus, pericardium, inferior medication. Finally, persistent gastric bloating may
vena cava, or aorta. necessitate gastric emptying studies.
Gastric necrosis/perforation Bloating/nausea/epigastric pain/increased

flatulence
Injury to the gastric fundus is most likely to occur during
the manipulation of the tissues to provide exposure, dur-
A majority of patients will return to the clinic with specific
ing passage of the wrap, or during the division of the
complaints of feeling bloated, occasional nausea, epigas-
short gastric vessels and causing thermal injury. If identi-
tric pain, and generally an increased incidence of flatu-
fied, a primary closure of the perforation is required. This
lence. This is due to the patient’s habit of swallowing saliva
may be accomplished by over-sewing the perforation in a
and air to neutralize the presence of acid in the esophagus.
two-layered fashion using an inner absorbable suture and
Once a fundoplication is performed, this air progresses
a nonabsorbable outer suture. This requires the ability to
through the bowel rather than retrograde through the
perform intracorporeal suturing. The surgeon perform-
esophagus, as before surgery. This is an expected event
ing the laparoscopic fundoplication should possess
postoperatively. Because of this, it is important to inform
this skill. The second option is to use an endoscopic linear
the patient in preoperative counseling to decrease anxiety
stapler. An endoscopic Babcock grasper can be used to
levels when it does occur. Most patients will have signifi-
approximate both edges of the defect and incorporate
cant improvement in these symptoms with just several
them into the stapler line. If one is unsure of the security
weeks of expectant management, which includes a critical
of the repair, then a closed suction drain may be placed
review of their current diet. One important question to
near the site of perforation at the end of the case.
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
POSTOPERATIVE COMPLICATIONS problem once the reflux has been treated.
If the patient is unable to tolerate liquids at any time
Following laparoscopic fundoplication, patients gener- or the patient has persistent nausea and vomiting, then
ally present with complaints in either the early (⬍30 the surgeon should obtain a barium swallow as an initial
days) or late (⬎30 days) timeframe. Early complaints diagnostic test to evaluate the post-surgical anatomy. If
of dysphagia, nausea, bloating, and early satiety are no gross abnormality is seen, an EGD may be warranted.
reported by 20–40 per cent of patients.12,13 A large por- Some patients will self-medicate with previous antacids
tion of these patients will do well after careful questioning or proton-pump inhibitors as they are almost dependent
upon them. If the barium study shows no anatomical careful re-approximation of the posterior crura. Careful
defect and the patient feels better with medical therapy, attention to ensure the closure is tension-free is also para-
then one can continue to follow the patient and treat on mount. We generally close the crura, beginning at the
an as-needed basis. 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
Para-esophageal herniation the crura closure is assessed. Closure is then tailored to
ensure that it is snug, with no obvious gaps, but not overly
An occurrence of para-esophageal hernias of up to seven restrictive. If a para-esophageal hernia develops postoper-
per cent was noted when laparoscopic fundoplication was atively, then the wrap should be taken down completely to
initially performed.9,14 Patients present with persistent assist in visualizing any technical complications that may
nausea, vomiting, and intolerance of solids. This may occur have contributed to the early failure of the wrap. In addi-
at any time following surgery, but usually it is early (within tion, this allows better visualization in the repair and re-
one to two weeks) and generally it follows a report of sus- approximation of the crura while assessing the possibility
tained coughing and/or straining associated with heavy that an overlooked shortened esophagus was present at
lifting or Valsalva-type maneuvers. The best initial work- the initial surgery.
up is to obtain a barium swallow. Abnormal anatomy is
revealed in 90 per cent of patients (Figure 32.4). This radio-
graphic finding alone, with a symptomatic patient, is Slipped Nissen
justification enough to return to the operating room for
urgent repair before strangulation of the herniated viscera The term ‘slipped Nissen’ refers to one of several anatom-
occurs. The incidence of para-esophageal hernia has ical complications following laparoscopic fundoplication.
decreased as more surgeons are routinely performing It is most often discovered by a barium swallow study
after complaints of dysphagia, early satiety, or sympto-
matic complaints of recurrent reflux type symptoms.
The barium swallow may display one of the following
anatomic failures (see Figures 32.5–32.8.):
• 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.
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 pro-
grams are reported to be as high as 85–91 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 com-
pletely. This entails careful and deliberate dissection of
the wrap from the anterior stomach wall, removal of the
posterior crural sutures, and mobilization of the esopha-
gus. This will ensure that there is sufficient esophageal
length within the abdomen and that it is not under signif-
icant tension. If the esophagus does not allow for at least
Figure 32.6 Type IB hernia.
2 cm of intra-abdominal length, then further circumfer-
ential 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 suffi-
cient 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 pre-
vious wrap, then the cause of the patient’s complaint is
generally evident.
Vagal nerve injury
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
Figure 32.7 Type II hernia. 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 gas-
troesophageal junction. The right vagus will course poste-
riorly 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 transec-
tion 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 ulti-
mately decrease complaints of postoperative dysphagia
secondary to postoperative edema.
If a patient suffers a vagal nerve injury, then symp-
toms 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
Figure 32.8 Type III hernia. the initial clinical visit, then it is prudent to obtain a
baseline measurement. Some authors advocate perfor- Diagnosis of achalasia is best confirmed with
mance of a pyloroplasty at the time of fundoplication if esophageal manometric studies. The lower esophageal
the patient has evidence of delayed gastric emptying. sphincter should be identifiable and demonstrate a non-
However, most authors do not advocate this, as studies relaxing and hypertensive pressure value. Development
have shown that gastric emptying times generally improve of achalasia after a fundoplication has been reported, but
following fundoplication. In addition, a symptomatic most cases are probably the result of inadequate pre-
patient may be tried on several prokinetic medications operative evaluation. Treatment for achalasia is dilation,
(e.g. metoclopramide, erythromycin) before undertaking botulism toxin injection, or cardiomyotomy. If a surgical
surgery. cure is undertaken, then the fundoplication will need to
Patients who return with complaints of postprandial be taken down completely, cardiomyotomy performed,
weakness, palpitations, diaphoresis, and feelings of anxiety and a partial fundoplication carried out.
may be experiencing postprandial hypoglycemia. This was Radiographic evidence of a wrap that is too tight is
reported in several cases and confirmed with the perfor- best appreciated with a barium marshmallow-swallow
mance of an oral glucose tolerance test.16 Postprandial study. Liquids may pass easily through the wrap, but
hypoglycemia may be associated with a vagal nerve injury, foods with thicker consistency may become lodged above
thus causing early dumping and a hyperinsulin response the wrap. The best therapy is an initial attempt at dila-
to the glucose load. This probably represents a neuro- tion using either pneumatic dilatation or bougies of an
praxic injury because it resolves with time and does not increasing diameter. Most frequently, this will be success-
require treatment. ful 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
Ileus attempted but it is less likely to be successful.
Finally, the hiatal opening may be the source of dyspha-
Ileus following laparoscopic fundoplication is usually
gia following fundoplication. If the crura are approximated
mild due to the short time of the operation and minimal
too tightly, then complaints will be almost immediate fol-
manipulation of the bowel. Most surgeons will not place
lowing surgery. Several authors have reported scarring at
a nasogastric tube postoperatively as it is rarely required
the hiatal opening, causing a stricture seen on postopera-
and most patients start a liquid diet the same night as
tive barium swallow.17 It is suspected that the use of
surgery. If a patient does experience intolerance of
diathermy near the diaphragm is the source of injury.
liquids, then placement of a nasogastric tube and decom-
Treatment involves surgical incision of the scarred
pression of the stomach is required. In addition, a low
diaphragm to release the tension at this site.
threshold for obtaining a barium swallow with small
Complications arising more than 30 days after suc-
bowel follow-through can rule out any anatomical
cessful fundoplication may originate from anatomical
reason for ileus. Any treatment will be dictated by the
failure or from functional problems. Anatomical failures
clinical condition and results of testing of the patient.
include essentially the same difficulties listed above, in
the ‘early’ categories. Regardless of the timing of presen-
Dysphagia tation, a barium swallow should be the first test obtained,
followed by esophageal manometry, 24-hour pH studies,
Immediate postoperative dysphagia is attributed to post- or EGD, depending upon the symptoms of the patient.
operative edema from the surgical dissection. Late dys- The management of these problems is similar to those
phagia may be from scarring at the hiatus, missed or new presented above.
onset of achalasia, increasing dysmotility, worsening
Barrett’s esophagus, esophagitis, or new development of
esophageal carcinoma. At the time of diagnostic work- Recurrent reflux
up, barium swallow should be the first test performed.
Anatomical deviations from standard surgical results will Patients who return with complaints of persistent or
usually be identified. Occasionally, retained food is noted unrelenting reflux warrant a thorough work-up to
on the study. Whether the dysphagia occurs early or late ensure adequate anatomical integrity and functional
will play a role in the determination of how quickly a success of the fundoplication. Again, start with a barium
patient should be taken back to the operating room for swallow study to assess anatomical changes and any evi-
reconstruction. If it occurs early on, then it is most likely dence of herniation of the stomach or the wrap itself. If
that a technical error has occurred. If it occurs late, then this appears normal, then a 24-hour pH study may show
a trial with antisecretory medications may be warranted, objective data relative to a functional failure of the fun-
as the success of repeat fundoplications decreases with doplication. Finally, EGD may show persistent irritation
each attempt at surgical repair.12,13 of the esophagus from refluxate as well as confirm proper
placement of the wrap. If these studies all appear normal 2 Evans S, Jackson P, Czerniach D, et al. A stepwise approach to
and show no definitive pathology, then it is reasonable to laparoscopic Nissen fundoplication. Arch Surg 2000; 135: 723–8.
3 Soper N, Dunnegan D. Anatomic fundoplication failure after
give the patient a trial of antisecretory medications. If laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–77.
symptomatic relief is obtained from these, then it is best 4 Watson D, de Beaux A. Complications of laparoscopic antireflux
to medicate the patient. Little is to be gained by attempt- surgery. Surg Endosc 2001; 15: 344–52.
ing further surgery if the initial fundoplication is seen 5 Pohl D, Eubanks T, Omelanczuk P, Pellegrini C. Management and
to be anatomically correct and providing a mechanical outcome of complications after laparoscopic antireflux operations.
Arch Surg 2001; 136: 399–404.
barrier towards reflux. 6 Hunter J, Smith D, Branum G, et al. Laparoscopic fundoplication
failures. Patterns of failure and response to fundoplication
revision. Ann Surg 1999; 230: 595–606.
CONCLUSION 7 Horgan S, Pohl D, Bogetti D, et al. Failed antireflux surgery.
What have we learned from reoperations? Arch Surg 1999;
134: 809–17.
Laparoscopic fundoplication affords a good to excellent 8 Horgan S, Pellegrini, C. Surgical treatment of gastroesophageal
result in more than 90 per cent of patients with refractory reflux disease. Surg Clin North Am 1997; 77: 1063–82.
9 Carlson M, Frantzides C. Complications and results of primary
and chronic GERD. There is a 1.3 per cent chance of com- minimally invasive antireflux procedures: a review of 10735
plications.1,9 However, the majority of complications are reported cases. J Am Coll Surg 2001; 193: 428–39.
minor and can be limited in occurrence if careful attention 10 Collet D, Cadiere G. Conversions and complications of laparoscopic
to preoperative symptoms, diagnostic work-up, and app- treatment of gastroesophageal reflux disease. Am J Surg 1995;
ropriate intraoperative techniques are followed. The use 169: 622–6.
11 Huntington T. Laparoscopic mesh repair of the esophageal hiatus.
of careful laparoscopic technique will help minimize J Am Coll Surg 1997; 184: 399–400.
intraoperative complications. Postoperative complications 12 Perdikis G, Hinder R, Wetscher G. Nissen fundoplication
should always be studied with X-ray, endoscopy, 24-hour for gastroesophageal reflux disease: laparoscopic Nissen
pH study, and manometry if an early solution and explana- fundoplication – technique and results. Dis Esophagus 1996; 9:
tion cannot be found. As more surgeons acquire advanced 272–7.
13 Hinder R, Klinger P, Perdikis G, Smith, S. Management of the failed
laparoscopic techniques, the general surgeon’s scope of antireflux operation. Surg Clin North Am 1997; 77: 1083–98.
advanced laparoscopic procedures will also continue to 14 Watson D, Jamieson G, Devitt P, et al. Paraoesophageal hiatus
broaden. Fundamentals, however, will not change; there- hernia: an important complication of laparoscopic Nissen
fore, solid, practical judgment should always be used with fundoplication. Br J Surg 1995; 82: 521–3.
the patient’s safety and outcome at the forefront of the 15 Hunter R, Metz D, Morris J, Rothstein R. Gastroparesis: a potential
pitfall of laparoscopic Nissen fundoplication. Am J Gastroenterol
surgeon’s considerations. 1996; 91: 2617–18.
16 Zaloga G, Chernow B. Postprandial hypoglycemia after Nissen
fundoplication for reflux esophagitis. Gastroenterology 1983;
REFERENCES 84: 840–2.
17 Watson D, Jamieson G, Mitchell P, et al. Stenosis of the esophageal
hiatus following laparoscopic fundoplication. Arch Surg 1995; 130:
1 Rantanen T, Salo J, Sipponen J. Fatal and life-threatening 1014–16.
complications in antireflux surgery: analysis of 5,502 operations.
Br J Surg 1999; 86: 1573–7.
PART
5
Laparoscopy in the pediatric
hernia patient
33 History 251 35 Diaphragmatic herniation 257

34 Anatomy and physiology 255 36 Complications and their management 261
33
History
RAJEEV PRASAD AND THOM E. LOBE
Pediatric laparoscopy 251 Laparoscopic inguinal herniorrhaphy 252

Laparoscopic exploration of the contralateral groin 251 References 254
Laparoscopy in pediatric hernia patients has undergone relatively recent advance. While initially used solely for
a rapid, albeit delayed, evolution. While laparoscopic diagnosis, its use has expanded. It is now used routinely
herniorrhaphy was being popularized in adults, the for cholecystectomy, appendectomy and pyloromy-
approach was considered to be cumbersome, unneces- otomy, as well as more complex procedures, including
sary, and even contraindicated in children. The percep- fundoplication, colectomy, and pull-through procedures
tion that a child would outgrow the repair, particularly for Hirschsprung’s disease and high imperforate anus.
one involving mesh, dominated early thoughts about the Initially, herniorrhaphy was not considered an appro-
laparoscopic approach. Other considerations, such as the priate laparoscopic procedure in infants and children.
physiological stress of laparoscopy in infants and children Pediatric surgeons believed that a child would outgrow
and the size and availability of appropriate instruments, herniorrhaphy as it was applied in adults because the
initially precluded pediatric laparoscopic herniorrhaphy. child had not reached its full development and size. Also,
However, once these barriers were overcome in other the physiological impact of the procedure in infants and
pediatric surgical maladies, it was inevitable that hernior- children was unknown and initially overestimated.
rhaphy would be revisited. With steady progress, pediatric
surgeons have applied their endoscopic skills to pediatric
hernia patients, and today many surgeons prefer this LAPAROSCOPIC EXPLORATION OF THE
approach for the repair of inguinal, ventral and diaphrag- CONTRALATERAL GROIN
matic hernias in infants and children.
Routine open exploration of an asymptomatic con-
tralateral groin during surgery for a clinically apparent
PEDIATRIC LAPAROSCOPY unilateral hernia is common practice among pediatric sur-
geons. Supporters of this approach base their view on the
Gans and Berci were among the first to describe reported 29 per cent incidence of the future development
laparoscopy in pediatric patients when they published of a symptomatic hernia on the unexplored side.2 Others
their experience with ‘visualization of the contents of the cite a lower incidence of bilateral hernia and feel that the
peritoneal cavity by means of a small telescope introduced increased cost and risk of damage to cord structures in
through the anterior abdominal wall after establishment males precludes the safe exploration of a clinically asymp-
of pneumoperitoneum’.1 Since then, this approach has tomatic groin.3
been rediscovered. New instruments and techniques have Many alternative methods of detecting a contralateral
been developed, and there is a greater understanding of hernia have been described, including simple pneumo-
the physiological impact of pneumoperitoneum in infants peritoneum and external inspection of the inguinal canal,
and children. herniography, ultrasonography, and the passage of dilators
Laparoscopy in general has experienced a huge across the lower abdomen through the open hernia sac.4–7
growth in its application in pediatric surgery. This is a 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 con- that this operation should not be carried out in boys as it
tralateral asymptomatic groin during open unilateral was not possible to exclude the cord structures from the
inguinal herniorrhaphy in 1992.8 In this initial series of 22 endoscopic loop ligature. In 1998, Schier described his
patients, an infra-umbilical 3-mm port was placed and a technique of placing two to three Z-sutures laparoscop-
2-mm, zero-degree telescope was used to visually inspect ically using intracorporeal suturing and knot-tying tech-
the contralateral groin. Fifty per cent of the patients with a niques to close the neck of the hernia sac.15 Again, the
clinically negative groin had an occult hernia, and the procedure was limited to girls to avoid the risk of possi-
technique was 96 per cent accurate in detecting such her- ble damage to the spermatic cord in boys.
nias. Wolf and Hopkins used the same method in 38 boys Montupet and Esposito were the first to report
and noted a 52.6 per cent incidence of bilateral hernia.9 successful laparoscopic herniorrhaphy in boys.16 They
Chu and colleagues were the first to perform both insuf- specifically applied the laparoscopic approach to boys to
flation and laparoscopy through the open hernia sac to avoid the risks of inadvertent removal of a segment of the
visualize the contralateral groin, thus introducing non- vas deferens, as well as the possible risk of testicular dam-
puncture laparoscopy;10 in their series of 74 children, 29 age (atrophy or high position in the scrotum), which can
per cent had a second hernia, and there were no false pos- occur with the traditional open repair. In their series, 45
itives or false negatives. Fuenfer and coworkers described boys underwent laparoscopic repair in which an intra-
an improved technique in 1996 in which a 14-gauge corporeal purse-string suture was placed around the
angiocath was introduced through the open hernia sac for neck of the hernia sac. There were no intraoperative or
intraperitoneal insufflation. A second 14-gauge catheter post-surgical complications, but two patients developed
was inserted through the abdominal wall on the contralat- a recurrent hernia that required a second laparoscopic
eral side of the abdomen, and a 1.2-mm laparoscope was repair. Schier reported his further experience of laparo-
passed through this port for direct, in-line visualization of scopic hernia repair in 2000, concluding that the tech-
the contralateral groin.11 They noted a 21 per cent inci- nique was simple for the experienced laparoscopist, that
dence of bilaterality in 110 children. Another technique cosmesis was superb, and that the procedure was safe in
described in 1996 employed a 5-mm, 30-degree or 70- both sexes.17
degree telescope through the open hernia sac.12 This Other reports have described the utility of laparoscopy
report, which stratified patients by age, noted that patients for direct inguinal hernias and suspected recurrent her-
older than 24 months had only a five per cent incidence of nias.18,19 Schier reported that the laparoscopic approach
bilaterality, whereas patients younger than 24 months had allowed for easier detection of direct hernias as compared
a 42.9 per cent incidence of a contralateral hernia. Thus, with the traditional open approach. Out of 109 patients,
they were able to identify patients who might benefit from five (4.5 per cent) had a direct inguinal hernia. Most of
contralateral surgery as well as those in whom surgery and these hernias were in boys and were on the right side. The
its possible complications could be avoided. Other tech- prevalence of direct hernias was higher in this series as
niques have since been described, including the use of a compared with the traditionally accepted rate (0.2–0.9
30-degree rigid bronchoscope with a working channel per cent) based on two large series of open hernia
through which a catheter can be introduced and used to repairs,20,21 suggesting that direct hernias may go unrec-
probe a suspected patent processus vaginalis, providing ognized during open repair, and that these cases may
even better diagnostic accuracy.13 represent some of the recurrences after prior repair for
indirect inguinal hernia. The conclusion was that laparo-
scopic repair for direct inguinal hernias is more reliable
than open surgery as it is unlikely that an incorrect diag-
LAPAROSCOPIC INGUINAL HERNIORRHAPHY nosis will be made using laparoscopy. Regarding recur-
rent hernias, Perlstein and Du Bois noted that 44 per
As laparoscopy evolved in children, pediatric surgeons cent of children undergoing laparoscopy for recurrent
began to investigate the feasibility of laparoscopic repair inguinal hernias were found to have unsuspected find-
of inguinal hernias. Theoretical advantages included ings, including indirect (missed sacs and true recur-
excellent visual exposure, minimal dissection (and thus rences), direct (unilateral and bilateral), and femoral (all
less trauma to the inguinal canal and spermatic cord), bilateral) defects.19
and an improved cosmetic result as compared with the Innovative techniques have recently been described for
traditional open approach. In 1997, El-Gohary reported use in pediatric laparoscopic inguinal hernia surgery. Endo
a series of 28 girls in whom herniorrhaphy was accom- and Ukiyama introduced the endo-needle, a 19-gauge
plished laparoscopically using one or more endoscopic hollow needle with a notched tip and pre-attached suture
loops placed at the base of the inverted hernia sac.14 He designed specifically for laparoscopic extraperitoneal
reported that this was an expeditious, effective, and cos- closure of the patent processus vaginalis.22 They used this
metically superior operation. However, he recommended 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.
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
Figure 33.2 Close-up view of the ligature-passer used in instrument using the grasper so that it can be withdrawn
laparoscopic herniorrhaphy. externally. The ligature is tied extracorporeally, completing
an extraperitoneal high ligation of the sac (Figure 33.4).
recurrences. Lee and Liang performed micro-laparoscopic The vas deferens and spermatic vessels are seen easily dur-
high ligation in 450 patients, with good results.23 They ing the ligature placement in males, and it is a relatively
reported no complications of the surgery and a remark- straightforward task to find the tissue plane between
ably low recurrence rate (0.88 per cent). these structures and the hernia sac, ensuring that they
In 2001, we began to use a unique technique using are not included in the ligature. After cutting the excess
miniature laparoscopic equipment in which a curved suture, the knot retracts subcutaneously. Steri-Strips
stainless steel awl is used to pass a ligature circumferen- (3M Healthcare) are all that are required for skin closure.
tially around the neck of the hernia sac. A 1.7-mm needle The technique adheres to the essential principles of
scope is introduced through a 2-mm port in or near the hernia surgery. We reliably identify and ligate the her-
umbilicus, and the abdomen is insufflated with carbon nia sac at the level of the internal ring. Additionally, there
dioxide gas to 12 mmHg (Figure 33.1). We place a second is no disruption of the tissues of the inguinal canal.
2-mm port in the right lateral abdomen. We find this posi- In males, the spermatic vessels and vas deferens are well
tion to be the most useful for traction for both right- and visualized during the circumferential passage of the
left-sided hernias. A 1.7-mm laparoscopic grasper, placed suture, ensuring that they are excluded from the repair.
through this second port, is used to manipulate the peri- The contralateral inguinal canal is also easily inspected
toneum near the hernia defect (right and/or left sides). for the presence of a hernia, which is repaired if present.
The suture-passer (Figure 33.2), introduced through a Our patients have had minimal postoperative discom-
stab incision anterolateral to the internal ring, is used to fort, and all resume normal activities immediately after
place a 2-0 nonabsorbable ligature circumferentially at the surgery. There is no longitudinal skin incision in the
neck of the hernia sac. To accomplish this, the suture- abdominal wall (only three to four stab incisions), so the
passer, with the tie in place through its eyelet, is passed cosmetic result is superior and the risk of infection is less
4 Powell RW. Intraoperative diagnostic pneumoperitoneum in

pediatric patients with unilateral inguinal hernias: the Goldstein
test. J Pediatr Surg 1985; 20: 418–21.
5 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: 448–51.
6 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: 415–18.
7 Brown RK. Hernia diagnosis by transperitoneal probing of the
contralateral groin. Surg Gynecol Obstet 1964; 118: 123.
8 Lobe TE, Schropp KP. Inguinal hernias in pediatrics: initial
experience with laparoscopic inguinal exploration of the
asymptomatic contralateral side. J Laparoendosc Surg 1992;
2: 135–40.
9 Wolf SA, Hopkins JW. Laparoscopic incidence of patent processus
vaginalis in boys with clinical unilateral inguinal hernias. J Pediatr
Surg 1994; 29: 1118–21.
10 Chu C, Chou C, Hsu T, et al. Intraoperative laparoscopy in
unilateral hernia repair to detect a contralateral patent processus
Figure 33.4 Intraoperative photograph of the closed indirect vaginalis. Pediatr Surg Int 1993; 8: 385–8.
11 Feunfer MM, Pitts RM, Georgeson KE. Laparoscopic exploration
hernia defect after laparoscopic high ligation of the hernia sac. of the contralateral groin in children: an improved technique.
J Laparoendosc Surg 1996; 6 (suppl 1): S1–4.
12 Zitsman JL. Transinguinal diagnostic laparoscopy in pediatric
inguinal hernia. J Laparoendosc Surg 1996; 6 (suppl 1): S15–20.
than that of the open approach. In our experience, we
13 Saad SA, Goldfarb MA, Danikas D. Groin laparoscopy in pediatric
have not noted a single infection in any of the 2-mm stab patients with clinical unilateral hernia: an improved technique
incisions. Finally, there have been no major complica- using the bronchoscope. Pediatr Endosurg Innov Tech 1999;
tions and only one recurrence in our patients. We believe 3: 59–65.
that this technique, as well as others that utilize a circum- 14 El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls.
Pediatr Endosurg Innov Tech 1997; 1: 185–8.
ferential high-ligation of the hernia sac, as opposed to
15 Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;
simple suture closure of the defect with either a purse- 33: 1495–7.
string or similar suture, is the most effective means of 16 Montupet P, Esposito C. Laparoscopic treatment of congenital
repair. There are no gaps in the closure, particularly inguinal hernia in children. J Pediatr Surg 1999; 34: 420–3.
medially, where recurrences might occur. Early data in 17 Schier F. Laparoscopic surgery of inguinal hernias in children –
initial experience. J Pediatr Surg 2000; 35: 1331–5.
the literature suggest a lower recurrence rate with these
18 Schier F. Direct inguinal hernias in children: laparoscopic aspects.
extraperitoneal, high-ligation techniques.22,23 Pediatr Surg Int 2000; 16: 562–4.
19 Perlstein J, Du Bois JJ. The role of laparoscopy in the management
of suspected recurrent pediatric hernias. J Pediatr Surg 2000;
REFERENCES 35: 1205–8.
20 Fonkalsrud EW, de Lorimier AA, Clatworthy HW. Femoral and
direct hernias in infants and children. JAMA 1965; 192: 101–3.
1 Gans SL, Berci G. Peritoneoscopy in infants and children. J Pediatr 21 Wright JE. Direct inguinal hernia in infancy and childhood.
Surg 1973; 8: 399–405. Pediatr Surg Int 1994; 9: 161–3.
2 McGregor DB, Halverson K, McVay CB. The unilateral pediatric 22 Endo M, Ukiyama E. Laparoscopic closure of patent processus
inguinal hernia. Should the contralateral side be explored? vaginalis in girls with inguinal hernia using specially devised
J Pediatr Surg 1980; 15: 313–17. suture needle. Pediatr Endosurg Innov Tech 2001; 5: 187–91.
3 Given JP, Rubin SZ. Occurrence of contralateral inguinal hernia 23 Lee Y, Liang J. Experience with 450 cases of micro-laparoscopic
following unilateral repair in a pediatric hospital. J Pediatr Surg herniotomy in infants and children. Pediatr Endosurg Innov Tech
1989; 24: 963–5. 2002; 6: 25–8.
34
Anatomy 255 References 256

Physiology 255
ANATOMY tissue and has not caused any wound complications in our
experience.
A comprehensive review of the anatomy of the inguinal
canal is beyond the scope of this chapter. Chapter 6
PHYSIOLOGY
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 Physiological factors to consider during pediatric laparo-
the context of laparoscopy. The layers of the abdominal scopic hernia surgery are essentially identical to those for
wall must be traversed during port placement. The initial any other intra-abdominal laparoscopic procedures per-
port that we place is the infra-umbilical port through formed in children. The cardiovascular and respiratory
which the 1.7-mm telescope is placed. We choose to place effects of pneumoperitoneum are the issues that most
this in an infra-umbilical position to reduce the risk of often raise interest for the surgeon and anesthesiologist
infection. Ideally, the port traverses the midline. The fascia alike. The extremes of patient positioning, postoperative
of the external abdominal oblique, internal abdominal pain management, and postoperative nausea and vomit-
oblique, and transversus abdominus muscles, which join ing also deserve consideration.
anterior to the rectus muscles inferior to the arcuate line, Insufflation of carbon dioxide gas is essential for
are penetrated. The urachus, or median umbilical liga- proper visualization during pediatric laparoscopic her-
ment, is in this area and should be avoided. The lateral nia surgery. In general, lower volumes and pressures
port, through which a grasper is placed for traction, (6–12 mmHg) are required than in adult patients. We use
traverses the same muscles. Structures near the internal a Veress needle inferior to the umbilicus for insufflation
inguinal ring, where the hernia sac is ligated, must be con- and placement of the telescope. In our hands, the risks of
sidered. In our technique, the suture is passed through all visceral injury and pre-peritoneal insufflation are low
layers of the abdominal wall that are superficial to the peri- with this technique. Carbon dioxide approaches the ideal
toneum or hernia sac. In males, the spermatic vessels, the insufflating gas, and is the gas used most often.1 It does
genital branch of the genitofemoral nerve, and the vas def- not support combustion, and residual intraperitoneal gas
erens pass superficial to the sac, and great care is taken not is absorbed rapidly and subsequently excreted. The major
to include these structures in the ligature. The external drawback of carbon dioxide is its rapid intravascular
iliac vessels are near but deep to the ligature. They should absorption across the peritoneal lining, which can lead to
be visualized and, obviously, avoided. Similarly, the infe- hypercapnea during long procedures. This is generally
rior epigastric vessels, which are branches of the external not of concern in pediatric laparoscopic inguinal hernia
iliac vessels, are easily identified and avoided. Once tied surgery, as the procedures are relatively short.
and cut, the permanent suture that we use to perform the The pneumoperitoneum itself creates cardiovascular,
high ligation of the sac retracts into the subcutaneous respiratory and neurological effects in infants and
256 Laparascopy in the pediatric hernia patient
children. In an investigation involving 12 healthy infants, anesthesia is our choice. Conversely, Tobias and colleagues
a pressure of 10 mmHg resulted in a decrease in aortic have suggested that general face-mask anesthesia plus
blood flow and cardiac stroke volume and an increase in spontaneous ventilation with concurrent caudal block
systemic vascular resistance, when compared with con- may be useful for short diagnostic procedures.7 However,
trols.2 These changes, however, were reversed after peri- this would likely be cumbersome for actual herniorrha-
toneal exsufflation and caused no clinically deleterious phy, which occasionally can be a difficult and long
effects in healthy infants. In a study of the effects of procedure.
pneumoperitoneum in pediatric hernia patients, a pres- Postoperative pain management is less of a concern
sure between 6 and 12 mmHg did not cause clinically sig- for laparoscopic herniorrhaphy compared with open
nificant changes in cardiac index or systemic vascular inguinal hernia repair. In our experience, patients seem
resistance.3 These cardiac effects may be exaggerated by to have less discomfort and very rarely require a narcotic
patient positioning during laparoscopy, particularly with analgesic. Stretching of the peritoneum and phrenic
the reverse Trendelenburg position when venous return nerves secondary to peritoneal insufflation, which can
and cardiac output are further decreased.4 However, in result in shoulder pain, has not occurred in our experi-
the Trendelenburg position, as may be used for laparo- ence. Complete exsufflation is important in avoiding this
scopic hernia surgery, venous return is augmented and postoperative complaint. Local anesthetic infiltration at
blood pressure returns to normal or supranormal levels. the puncture sites as well as perioperative caudal block
Other potential sources of cardiovascular compromise may be useful adjuncts to ameliorate postoperative pain.
during laparoscopic hernia surgery include vasovagal In the vast majority of cases, our patients have required
reflex, myocardial sensitization by halothane, hypo- only paracetamol (acetaminophen) for pain control. They
volemia, and venous gas embolism.1 are all able to return to immediate unrestricted activ-
Deleterious respiratory effects during laparoscopy are ity. Postoperative nausea and vomiting, which can be
the result of upward displacement of the diaphragm. This problematic after laparoscopy, has not occurred in our
may result in early closure of small airways, an increase experience with pediatric laparoscopic herniorrhaphy.
in peak airway pressure, and a reduction in functional
residual capacity.1 These effects may be accentuated with
positive-pressure ventilation and Trendelenburg posi- REFERENCES
tioning in herniorrhaphy. Tobias and colleagues demon-
strated that an intra-abdominal pressure of 15 mmHg in
1 Pennant JH. Anesthesia for laparoscopy in the pediatric patient.
children during inguinal laparoscopy increased the air- Anesthesiol Clin North Am 2001; 19: 69–88.
way pressure by a mean of 3 cm water, and end-tidal car- 2 Gueugniaud PY, Abisseror M, Moussa M, et al. The hemodynamic
bon dioxide increased by a mean of 3 cm water.5 These effects of pneumoperitoneum during laparoscopic surgery in
values returned to normal within ten minutes of the healthy infants: assessment by continuous esophageal aortic blood
flow echo-Doppler. Anesth Analg 1998; 88: 468–9.
completion of surgery.
3 Sakka SG, Huettemann E, Petrat G, et al. Transoesophageal
Increased intra-abdominal pressure can also result in echocardiographic assessment of haemodynamic changes during
increased intracranial pressure and, thus, a decrease in cere- laparoscopic herniorrhaphy in small children. Br J Anaesth 2000;
bral perfusion pressure.6 Consequently, it may be inadvis- 84: 330–4.
able to perform laparoscopic hernia surgery in patients 4 Joris JN, Noirot DP, Legrand MJ, et al. Hemodynamic changes
during laparoscopic cholecystectomy. Anesth Analg 1993; 76: 1067.
with the potential for neurological complications.
5 Tobias JD, Holcomb GW, Brock JW, et al. Cardiorespiratory changes
Control of pain and anxiety in the perioperative period in children during laparoscopy. J Pediat Surg 1995; 30: 33.
is no different for laparoscopic hernia surgery than for 6 Bloomfield GL, Ridings PC, Blocher CR, et al. Effects of increased
other laparoscopic operations, except for certain adjuncts intra-abdominal pressure upon intracranial and cerebral
that may be useful specifically for the pediatric hernia perfusion pressure before and after volume expansion.
J Trauma 1996; 40: 936.
patient. Premedication is a matter of routine surgical care.
7 Tobias JD, Holcomb GW, Brock JW, et al. General anesthesia by
Atropine is useful to prevent some of the possible deleteri- mask with spontaneous ventilation during brief laparoscopic
ous cardiorespiratory events that may occur, such as the inspection of the peritoneum in children. J Laparoendosc Surg
vasovagal reflex. Intraoperatively, general endotracheal 1994; 3: 379.
35
Diaphragmatic herniation
History 257 Surgical technique: Morgagni hernia 258

Patient selection 257 Results 259
Surgical technique: Bochdalek hernia 257 References 259
HISTORY hypertension, and who are on either oxygen by nasal can-

nula or minimal conventional ventilator settings. Older
children who present either incidentally or with minimal
In 1848, the anatomist Vincent Bochdalek described symptoms are also suitable candidates.2
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. SURGICAL TECHNIQUE: BOCHDALEK
Thereafter, there was a steady increase in the success of HERNIA
repair of diaphragmatic hernias up to the 1970s, when
survival reached a plateau and the physiological effects
Posterolateral Bochdalek hernias may be approached
of persistent pulmonary hypertension and bilateral pul-
through either the chest or the abdomen, depending on
monary hypoplasia were better appreciated. Since then,
the preference of the surgeon. Supporters of the thoraco-
there has been slower progress in the surgical approach to
scopic route state that the herniated viscera are reduced
this disease. The greatest advance has been with the appli-
easily with carbon dioxide insufflation.3,4 Those who
cation of extracorporeal membrane oxygenation (ECMO).
support the laparoscopic approach state that the instru-
The most significant change in the postnatal management
ments are manipulated more easily and that the reduced
of diaphragmatic hernias since ECMO has been the advent
viscera can be inspected easily for possible injury.5
of minimally invasive techniques of repair. In 1995, van
For thoracoscopic repair, at least three ports are nec-
der Zee and Bax described the laparoscopic repair of a
essary: two 3-mm working ports and a 5-mm port for
posterolateral diaphragmatic hernia in a six-month old
the camera (Figure 35.1). Carbon dioxide insufflation,
infant.1 Since then, anterior Morgagni and posterolateral
as stated above, helps to reduce the herniated viscera. A
Bochdalek defects have been treated with minimally inva-
hernia sac, if present, is resected as the defect is sutured
sive techniques by experienced laparoscopists in stable, less
(Figure 35.2).2 If a hypoplastic lung is present, as is often
critically ill infants.
the case, then visualization is actually easier. Following
completion of the repair, a pleural catheter is placed
through the 5-mm port site.
PATIENT SELECTION For laparoscopic repair, three to five ports are needed.
An umbilical port is used to pass a 5-mm, 30-degree
The minimally invasive approach to diaphragmatic her- telescope. Two working ports (one 3 mm, one 5 mm)
nias should be considered only in infants who are hemo- are essential. Additionally, a port for a liver retractor and
dynamically stable, who are without signs of pulmonary 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

Figure 35.3 Port placement for Morgagni hernia repair.
Bochdalek hernia.
Figure 35.4 Laparoscopic view of a Morgagni hernia repair

using nitinol clips and a porcine submucosal patch.
Figure 35.2 Endoscopic view of a thoracoscopic Bochdalek
hernia repair.
pentalogy of Cantrell. These defects are often asympto-
matic. They may not be diagnosed until well after the
The viscera are reduced into the abdominal cavity, and
neonatal period, either as an incidental finding on chest
the sac, if present, is resected first. We close the defect
radiography or during the work-up of respiratory symp-
with 2-0 Ethibond (Ethicon, Inc.) sutures placed in an
toms in an older child.
interrupted fashion. The viscera are inspected for injury
Morgagni hernias are repaired through the abdomen.
at the completion of the repair.
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
SURGICAL TECHNIQUE: MORGAGNI
for instruments (Figure 35.3). The hernia contents are then
HERNIA
reduced. The sac is resected, and the hernia defect is closed
using 2-0 Ethibond sutures placed in an interrupted fash-
Morgagni hernias occur as anterior retrosternal or ion. More recently, we have repaired a Morgagni hernia
parasternal defects. Embryologically, they occur where laparoscopically using an alternative closure device. In this
the septum transversum joins the chest wall in the area case, we used clips of nitinol, a shape-memory metal
where the mammary vessels pass from the chest to the (U-CLIP, Coalescent), to secure a prosthetic patch over the
abdomen. These defects are rare, accounting for only one defect (Figure 35.4). Alternatively, a running suture of
to two per cent of congenital diaphragmatic defects. barbed Prolene (Ethicon, Inc.) is used by some surgeons to
Associated anomalies can occur, particularly heart complete the repair in order to prevent slippage of the
defects, as this type of hernia is one component of the suture.4
Diaphragmatic herniation 259
Morgagni hernias, as well as Bochdalek hernias that are patients who are asymptomatic before the discovery of the
large, may require the insertion of a prosthetic patch, as defect. Often, feeding can be initiated in the immediate
stated above, for adequate closure. Expanded polytetraflu- postoperative period, and the patient can be discharged
oroethylene (ePTFE) (Gore-Tex™, W. L. Gore & Associates, 24–48 hours following operation.
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 REFERENCES
the collagen of the Surgisis, which may enhance the
strength and longevity of the closure.
1 Van der Zee DC, Bax NM. Laparoscopic repair of congenital
diaphragmatic hernia in a 6-month old child. Surg Endosc 1995;
60: 448–50.
RESULTS 2 Ferro MM. Video-assisted repair of diaphragmatic defects. In: Lobe
TE, ed. Pediatric Laparoscopy. Georgetown, TX: Landes Bioscience,
2002, in press.
The results of Bochdalek and Morgagni herniorrhaphy are 3 Farmer DL, Sydorak R, Harrison MR, et al. Thoracoscopic repair of
similar. The postoperative course of the patient is highly neonatal congenital diaphragmatic hernia. Pediatr Endosurg Innov
dependent on the preoperative condition of the patient.2 Tech 2000; 4: 98.
4 Berchi FJ, Allal H, Cano I, et al. Diaphragmatic conditions in infants
In patients who do not require mechanical ventilation or
and children: endosurgery repair perspectives. Pediatr Endosurg
are weaned from it preoperatively, the postoperative Innov Tech 2001; 4: 65.
course is usually straightforward. Postoperative pain is 5 Smith J, Ghani AJ. Morgagni hernia: incidental repair during
minimal, and the recovery is often rapid, particularly in laparoscopic cholecystectomy. Laparoendosc Surg 1995; 5: 123–5.
36
Anesthetic complications 261 Hydrocele and testicular atrophy 262

Surgical complications 261 References 262
Recurrence 262
ANESTHETIC COMPLICATIONS Chen and colleagues reviewed the surgical complica-

tions that occurred in all patients undergoing laparoscopy
or thoracoscopy over a five-year period.3 Thoracoscopy
Anesthetic complications include deleterious cardio- was performed in 62 children, with a 13 per cent rate
vascular and respiratory effects, such as decreased cardiac of conversion to thoracotomy, and laparoscopy was
output, hypercapnea, shunting and atelectasis due to peri- performed in 574 children, with a 2.6 per cent rate of
toneal insufflation, and the extremes of patient position- conversion to laparotomy. The reasons for conversion to
ing.1 Premedication, which includes the use of atropine, laparotomy included hemorrhage, esophagotomy during
may alleviate these effects. The choice of anesthetic agent fundoplication, and malpositioned fundoplication. A case
may differ in laparoscopic hernia surgery. For instance, of a gastric volvulus after fundoplication and gastrostomy
nitrous oxide is avoided due to the increased incidence of required a laparotomy in the postoperative period and
bowel distention, which will obscure the view during was the result of a malpositioned gastrostomy tube. Other
laparoscopy. A balanced anesthetic technique using con- complications in the postoperative period included two
trolled ventilation with inhalation agents (sevoflurane, children who developed hernias at the umbilical trocar
desflurane or isoflurane), intravenous opioids, and non- sites used for contralateral groin exploration. Trocar-
depolarizing muscle relaxants is preferred.2 Patient selec- site cellulitis developed in three patients after laparo-
tion is important, and those patients at greater risk than scopic gastrostomy in which the tube was brought out
usual for the above complications, such as premature through the left upper quadrant port site. Other compli-
infants or children with cardiopulmonary disease, should cations following laparoscopy included five instances of
not be considered for laparoscopic herniorrhaphy. pelvic abscess after appendectomy, small-bowel obstruc-
tion after jejunostomy as well as after combined
appendectomy/cholecystectomy, one case of enterocolitis
SURGICAL COMPLICATIONS
after pull-through for Hirschsprung’s disease, and one case
of pneumonia after splenectomy. There were no deaths,
Adherence to meticulous technique is the best way to and complications were noted to decline with increased
prevent surgical complications. The laparoscopist should experience.
consider their experience and level of comfort before Thus far, we, and others who perform laparoscopic
embarking on or continuing difficult operations. One herniorrhaphy, have experienced very few surgical com-
should attempt more complex operations only after sim- plications. In their series of 450 patients undergoing
pler operations are mastered. Also, one should always laparoscopic herniorrhaphy, Lee and Liang had no oper-
consider the option to open when difficulty is encoun- ative complications.4 Schier and coworkers reported a
tered. Of course, this possibility should always be pre- series of 933 laparoscopic herniorrhaphies in boys and
sented to the patient and family preoperatively. girls in whom no intraoperative complications occurred
other than minor bleeding from peritoneal vessels in ipsilateral hernia, to be a relative contraindication for
three patients.5 We have had one conversion to open laparoscopic hernia repair in infants and children. Others,
herniorrhaphy following pre-peritoneal insufflation. however, repair these defects laparoscopically. Postopera-
This resulted in distortion of the pre-peritoneal plane tive hydrocele as a complication of laparoscopic hernior-
through which the ligature and passer must be directed. rhaphy is a different entity. We have not yet seen any
The subsequent open procedure was completed unevent- postoperative hydroceles in our series of patients. In their
fully. There have been no cases of hemorrhage or visceral large series, Schier and colleagues reported a 0.4 per cent
injury in our series of patients. incidence of postoperative hydroceles.5 Testicular atro-
phy, presumably from damage to the spermatic vessels or
a high-riding testis (iatrogenic cryptorchidism), are also
RECURRENCE 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 high-
The reported recurrence rate after traditional open
riding testis postoperatively.5 It is difficult to predict
inguinal herniorrhaphy is 0.9 per cent. In their multicen-
which patients will develop either of these complications
ter experience, Schier and colleagues had a recurrence rate
postoperatively. Again, meticulous technique is likely to
of 3.4 per cent, higher than that for open repair.5 Their
be the best measure for preventing these rare but real
technique of closure with either a purse-string suture or a
complications.
Z-suture potentially left a gap in the herniorrhaphy medi-
ally, because they noted that all recurrences occurred at
the medial margin between the suture and the epigastric
REFERENCES
vessels. Other reported series with smaller numbers of
patients have had recurrence rates between zero and 4.4
per cent.6–9 Lee and Liang used a circumferential closure 1 Pennant JH. Anesthesia for laparoscopy in the pediatric patient.
Anesthesiol Clin North Am 2001; 19: 69–88.
as their herniorrhaphy technique, and their recurrence
2 Tobias JD. Anesthetic considerations for laparoscopy in children.
rate in 450 cases was only 0.88 per cent.4 In our experi- Semin Laparosc Surg 1998; 5: 60.
ence in approximately 50 patients with a follow-up of ten 3 Chen MK, Schropp KP, Lobe TE. Complications of minimal access
to 15 months, there have been no recurrences. We also use surgery in children. J Pediatr Surg 1996; 31: 1161–5.
a circumferential ligature placed at the neck of the hernia 4 Lee Y, Liang J. Experience with 450 cases of micro-laparoscopic
herniotomy in infants and children. Pediatr Endosurg Innov Tech
sac, which leaves no gap. This may be a more effective
2002; 6: 25–8.
means of closure of the hernia defect. 5 Schier F, Montupet P, Esposito C. Laparoscopic inguinal
Perlstein and Du Bois used diagnostic laparoscopy in herniorrhaphy in children: a three center experience with 933
19 patients with recurrent inguinal hernias.10 Seventeen repairs. J Pediatr Surg 2002; 37: 395–7.
indirect hernias and one femoral hernia were repaired at 6 El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls.
Pediatr Endosurg Innov Tech 1997; 1: 185–8.
the original procedure. One child had no hernia identi-
7 Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;
fied during the primary procedure. Overall, 11 recur- 33: 1495–7.
rences were indirect hernias, four were direct hernias, 8 Montupet P, Esposito C. Laparoscopic treatment of congenital
and four were found to be femoral hernias. Forty-four inguinal hernia in children. J Pediatr Surg 1999; 34: 420–23.
per cent of these patients had unsuspected findings at 9 Schier F. Laparoscopic surgery of inguinal hernias in
children – initial experience. J Pediatr Surg 2000; 35: 1331–5.
diagnostic laparoscopy (contralateral indirect, direct or
10 Perlstein J, Du Bois JJ. The role of laparoscopy in the management
femoral hernias). Recurrent hernias themselves can be of suspected recurrent pediatric hernias. J Pediatr Surg 2000; 35:
managed effectively with laparoscopy and laparoscopic 1205–8.
repair.11 Direct hernias can be detected at the time of 11 Schier F. Direct inguinal hernias in children: laparoscopic aspects.
repair of recurrences, suggesting that they might have Pediatr Surg Int 2000; 16: 562–4.
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
PART
6
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 265 Conclusion 272

Da Vinci and Zeus tele-robotic systems 268 References 272
Tele-robotic laparoscopic ventral and
incisional hernia repair 270
Over the past several years, there has been an ever-increas- refine the skills needed to perform more challenging cases
ing presence of robotics in the operating room. These with the use of robotics.
devices have been designed to help the surgeon overcome
the limitations of conventional open surgery and laparo-
AESOP ROBOTIC ARM
scopic surgery. These limitations range from the decreas-
ing availability of qualified surgical assistants, through the
limited dexterity offered by conventional laparoscopic The AESOP robotic arm uses proprietary speech-
instruments, to the lack of a three-dimensional operating recognition technology as the interface between the sur-
field.1 The potential advantages of such systems set the geon and the robotic arm. Simple voice commands are
stage for the next major change in the field of surgery. As used to direct the field of view of the laparoscope. The
availability increases and costs decline, proficiency with advantages of this technology include 24-hour availabil-
such devices will be required by all future generations of ity, thereby eliminating the need for an assistant to hold
surgeons. Additionally, the demands of patients for a the camera for a wide variety of laparoscopic operations,
robotic operation are expected to increase as more media including inguinal hernia procedures. Additionally, the
attention is placed on this technology. field of view is controlled by the surgeon and is com-
Currently there are three Food and Drug Administra- pletely free of tremor and straying.
tion (FDA)-approved devices on the market that facilitate
surgery: the AESOP robotic arm (Computer Motion, AESOP solo-surgeon laparoscopic
Inc.), the da Vinci tele-robotic system (Intuitive Surgical), hernia repair
and the Zeus tele-robotic system (Computer Motion
Inc.). The use of these devices has a definite learning Since 1995, over 500 laparoscopic totally extraperitoneal
curve that often deters busy surgeons from investing the (TEP) and transabdominal pre-peritoneal (TAPP) patch
time required to become proficient in this technology.2 hernia repairs have been performed at our institution
This chapter aims to serve as an introduction to the use using the AESOP robotic arm. The majority of these have
of robotic devices in laparoscopic hernia surgery by out- been TEP repairs performed by a single practitioner as a
lining the potential advantages of the technology. The solo surgeon operation.3
aforementioned devices have been used in inguinal, ven- Because AESOP uses voice recognition as the inter-
tral and diaphragmatic hernias. The frequency with which face between surgeon and the robotic arm, before using
these cases are encountered by the general surgeon makes AESOP for the first time each surgeon must create a voice
hernia surgery an ideal platform on which to develop and card that recognizes his or her individual voice. Frequent
266 Future considerations
use at our institution allows AESOP to be set up in less by the use of an ‘S’-retractor. This maneuver exposes the
than ten minutes. posterior rectus sheath. Using blunt finger dissection, the
space between the rectus muscle anteriorly and the poste-
Technique rior rectus sheath is developed. A stay suture is placed,
which encompasses the anterior rectus sheath laterally
After bilateral pneumatic compression boots are placed on and the midline fascia.
the patient, general anesthesia is induced and a Foley The patient is dropped into a Trendelenburg position
catheter is placed to decompress the bladder. A single dose (Figure 37.2). An Origin Medsystems balloon dissector is
of preoperative antibiotics is given approximately one hour then inserted into the space between the rectus muscle and
before incision. The surgeon puts on the voice-control the posterior rectus sheath. It is passed down gently paral-
headset before scrubbing and performs the operation from lel to the midline until the tip reaches the pubic bone. Care
the side opposite to the hernia. Laparoscopic monitors are is taken during this step to keep a slightly upward slant to
placed at the foot of the bed (Figure 37.1). The AESOP the balloon dissector tip, so as to avoid inadvertent entry
robotic arm is mounted on the table before prepping the into the peritoneal space and possible bowel injury. A
patient. The central articulated arm of AESOP is posi- 10-mm, zero-degree telescope is inserted through the
tioned over the patient’s umbilicus. Once the patient is trocar, and the balloon is inflated according to the man-
draped, a sterile plastic sleeve is placed over the robotic arm ufacturer’s specifications under direct visualization. The
and the arm is positioned manually over the operative field. balloon is kept inflated for approximately five minutes to
A 1-cm vertical para-umbilical incision is made on the allow for hemostasis. Next, the balloon is withdrawn and
ipsilateral side of the hernia. The incision is made approx- the pre-peritoneal space is insufflated to a pressure of
imately 0.75 cm lateral to the umbilicus. The incision is 12 mmHg. Once the pre-peritoneal space is insufflated, a
carried down through the fat until the anterior rectus 5-mm trocar is placed in the suprapubic position and
sheath is identified clearly. A 0.75-cm vertical incision is another 5-mm trocar is placed in the midline between
then made through the anterior rectus sheath, exposing the umbilical port and the suprapubic port.
the underlying rectus fibers. The medial edge of the rectus At this point, the laparoscope is changed to a 45-degree,
muscle is identified and the fibers are then pushed laterally 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 pre-
mounted 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 37.1 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 Figure 37.2 Position of the patient and the surgeon for solo-
(not draped in this photograph) or by the surgeon via voice. surgeon robot-assisted laparoscopic hernia repair. The patient is
An array of flat-screened digital and analog monitors are in a mild Trendelenburg position. A three-trocar technique is
distributed around the feet of the patient. This ensures that used: one port for the video-telescope and two ports for the
the surgeon can view the laparoscopic video image in an surgeon’s right and left hands. A voice-controlled robot, AESOP,
ergonomically comfortable position throughout the operation. holds the video-telescope.
Robotics and hernia surgery 267
preset angles as it is directed to move the camera anywhere Moreover, the need to connect and disconnect sophis-
in the operative field. It has been our consistent experience ticated equipment for each operation leads to equipment
that the camera does not have to be removed or manipu- malfunction. Electronic integration of operating rooms
lated until the placement of the mesh. The constant need facilitates advanced laparoscopic operations, improves
to remove the camera for cleaning is reduced considerably turnover times, and provides a more pleasant working
with AESOP compared with the use of surgical assistants. environment. Computer Motion first introduced voice
Additionally, the surgeon’s anatomical orientation is control for AESOP and then extended it to other laparo-
maintained much better when using an angled camera in scopic electronic equipment with HERMES. Storz
a confined space with the use of AESOP. Lastly, the opera- Endoscopy has recently introduced a similar system –
tive surgeon retains control over the now tremor-free field SESEM – that uses both touch-control panels and voice
of view.4 The simple voice commands available to the sur- control (Figure 37.1). These integrated control systems
geon with AESOP include ‘move in’, ‘move out’, ‘move left’, facilitate advanced laparoscopic operations by permitting
‘move right’, ‘move up’, and ‘move down’. the surgeon to control most aspects of the operating room.
In the TEP method, the hernia sac is bluntly dissected AESOP decreases the ‘footprint’ of the camera holder.
free from the surrounding fat and cord structures. Once In many laparoscopic operations, the camera holder inter-
this is done, the camera is disconnected from the robotic feres with the excursion arcs of the surgeon’s arms. The
arm and removed. A large piece of Prolene mesh is passed surgeon and the camera holder often stand in uncom-
through the umbilical port and into the pre-peritoneal fortable positions. In contrast, AESOP permits the sur-
space. The camera is reinserted, and the mesh is positioned geon to stand erect in an ergonomically comfortable
to cover the direct, indirect and femoral spaces. A minimal position (Figure 37.3). There is no crossing of arms with
number of spiral tacks is used to secure the mesh in place.5 the camera holder. AESOP decreases the fatigue of the
The pre-peritoneal space is deflated and the ports are surgeon in these solo operations.
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.
Advantages
The advantages of using the AESOP robotic arm in this
setting are clear. The use of the arm facilitates a solo-sur-
geon operation, provides a stable camera platform, further
integrates the surgeon’s control of the operating room,
and promotes an ergonomically advantageous posture.
Solo-surgeon operations have been also reported for
laparoscopic cholecystectomy, laparoscopic Nissen fundo-
plication, and laparoscopic colectomy.4,6 In our hospital,
the number of surgical residents available to assist in oper-
ations 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 assistant’s
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 surgeon’s 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, Figure 37.3 The surgeon wears a microphone through which
and the number of times the telescope requires cleaning he or she controls the robotic camera-holder and laparoscopic
is decreased.6 equipment. The voice-controlled robotic camera holder works
Advanced laparoscopic operations increase the com- unobtrusively, without interfering with the stance or arm
plexity of the operating-room environment. The need to movements of the surgeon. The overhead surgical light supports
roll various electronic towers and auxiliary equipment a video camera in its center for telecasting outside views of the
into the operating room slows turnover of operations. operation.
The use of AESOP for laparoscopic hernia operations Da Vinci

allows for the steady flow of the operation without
breaking the momentum with distractions such as cam- The da Vinci tele-robotic surgical system was designed
era cleaning or a moving operative field. Additionally, the from scratch to perform tele-robotic operations within a
consistency of the dissection required in laparoscopic virtual operative field. Da Vinci telecasts a true three-
hernia repairs aids in the learning curve of the robot. dimensional field of view. This is accomplished with a
After more than 500 laparoscopic hernia repairs by a special 12-mm laparoscope that has two smaller 5-mm
single surgeon at our institution, operative times are telescopes within it. The video images from the two 5-mm
now typically 45 minutes for a unilateral hernia repair telescopes remain separate and are projected on to two
and 60 minutes for a bilateral repair. separate monitors within the surgeon’s console. The sur-
geon sees the left console with their left eye and the right
DA VINCI AND ZEUS TELE-ROBOTIC monitor with their right eye, much like using field binocu-
SYSTEMS lars (Figure 37.4). This telecast system purposely isolates
the surgeon’s field of view. The surgeon gets the sense of
immersion within a virtual three-dimensional operative
The FDA has approved two tele-robotic surgical systems field. This helps the surgeon to maintain their orientation
for use in general surgical operations within the USA: the within the operative field despite their remote location.
da Vinci (Intuitive Surgical) and the Zeus (Computer The surgeon controls the robotic instruments by plac-
Motion, Inc.). The two tele-robots differ in certain features ing their hands within the masters (Figure 37.4 insert).
(see below). In tele-robotic surgery, the surgeon sits at a A foot pedal determines whether the masters are control-
computer console remote from the patient (Figure 37.4). ling the camera or two robotic surgical instruments. The
The computer controls robotic surgical instruments that da Vinci robotic instruments offer hand-like motions.
perform the operation. The computer translates the The robotic instruments move with seven degrees of free-
motions of the surgeon’s hands into motions of the robotic dom, like the human wrist. These hand-like motions
instruments and refines the motion by eliminating tremor overcome the limitations of traditional straight laparo-
and allowing for motion scaling. The FDA currently scopic instruments. Da Vinci also offers motion scaling.
requires the surgeon who performs the operation to be in The computer translates coarse movements of the sur-
the same operating room as the patient; however, the tech- geon’s hands into finer motions of the robotic instru-
nology permits the surgeon to sit thousands of miles away ments. Buttons on the surgeon’s console set the motion
from the patient. Marescaux performed a tele-robotic scaling to one-, three- or five-to-one scales. The computer
laparoscopic cholecystectomy on a patient in Strasbourg, also performs a fast Fourier transform (FFT) on the
France while sitting at a Zeus surgeon’s console in New hand motions. This allows identification and filtering
York City.7 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 37.4 Surgeon’s console and hand masters for da Vinci

tele-robotic surgery. The surgeon views a virtual three- Figure 37.5 The da Vinci electronics tower and four robotic arms.
dimensional operative field through binoculars in the surgeon’s The electronics tower holds the video and electronics equipment
console. The surgeon places his or her hands into the masters, for the stereoscopic telescope. In this prototype, the robotic tower
which translate the motions of the surgeon’s hands into motions holds four robotic arms. One arm holds the camera and the other
of the robotic instruments (insert). three hold robotic laparoscopic surgical instruments.
from the trocars whenever the surgical table is reposi- The three modified AESOP arms attach directly to the
tioned. The FDA has recently approved use of a fourth surgical table (Figure 37.7). The surgical instruments are
arm with the da Vinci system, which became available inserted into the abdomen through standard laparo-
commercially in 2003. scopic trocars. Movements of the surgical table do not
require repositioning of the AESOP arms. This is advan-
Zeus tageous in advanced laparoscopic procedures, such as
colectomy, in which the patient is repositioned several
Zeus evolved from AESOP. Zeus consists of a surgeon’s times during the course of the operation.
console and three modified AESOPs that attach directly We believe that these tele-robotic surgical systems
to the surgical table. The surgeon sits at a computer con- offer specific technologic solutions to specific limitations
sole with an open architecture (Figure 37.6). The sur- of traditional laparoscopic surgery. Both Zeus and da
geon maintains direct visual contact with the patient and Vinci project three-dimensional operative fields. This
the operative field. The surgeon controls movements of helps the surgeon to maintain their orientation and
the camera with voice commands and controls the also helps to avoid complications generated by past
robotic instruments with the two hand interfaces (Figure pointing. The hand-like motions of the robotic instru-
37.6 insert). This permits simultaneous control of all ments replace the extreme limitations of straight laparo-
three robotic arms. The voice-control system, Hermes, scopic instruments. Motion-scaling and tremor-filtration
can also control other electronics equipment in the oper- increase significantly the precision of laparoscopic tasks
ating room. such as suturing. The surgeon sits in an ergonomically
Zeus offers a three-dimensional image but with a comfortable position at the computer console.
technology that is different to that of da Vinci. In the Surgeons face a learning curve before mastering
Zeus system, alternating images from the left and right tele-robotic surgery. Before the use of these devices,
video cameras are projected on to the main monitor. surgeons and operating-room staff must attend an
Polarizing filters permit the surgeon’s right eye to see FDA-approved training course. After completion of this
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 surgeon’s console and hand device. The

surgeon sits at a computer console with an open architecture. Figure 37.7 Zeus robotic arms. The three robotic arms attach
The surgeon sees the operative field in a three-dimensional video directly to the surgical table. The camera holder is a modified
projection from the main monitor. Other flat-screen monitors AESOP that is voice-controlled by the surgeon. The two other
display controls for the surgical instruments. The insert shows arms are AESOPs that have been modified to hold robotic
the Zeus hand interface. surgical instruments.
course, individual hospitals may have specific require- placed on the anterior axillary line above and below the
ments for granting privileges towards the use of this camera port (Figure 37.8).
emerging technology.8 In our hospital, we require that This operation begins by using a solo-surgeon tech-
surgeons practice tele-robotic operations in live animal nique. The scrub technician changes the instruments as
models, act as a first assistant in five to ten operations, needed. The first assistant, although scrubbed, is used only
and are then observed by a proctor for an additional when a fourth port is placed or for emergency laparotomy.
five to ten operations. This process for granting clinical At the end of the procedure, the assistant surgeon is
privileges has successfully introduced tele-robotic surgery required to help pass the fixation sutures through the
safely into clinical practice at our hospital. 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 opera-
TELE-ROBOTIC LAPAROSCOPIC VENTRAL
tive field. Foot pedals are used to control the camera
AND INCISIONAL HERNIA REPAIR
movements, and ergonomically positioned fingertip con-
trols are used to manipulate the surgical instruments in
We obtained two da Vinci systems in November 2000. We real time within the patient.
initiated our clinical experience with da Vinci by perform-
ing a series of tele-robotic laparoscopic cholecystectomies.9
After demonstrating that we could perform cholecystec-
tomies 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.10–14 We have found that the da Vinci
tele-robotic surgery system facilitates the performance of a
laparoscopic Stoppa ventral hernia repair.
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)

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 orogas-
tric 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
8mm
three robotic arms (two arms for the surgeon’s right and
left hands, one arm for the laparoscope). 12mm
Trocar placement varies somewhat with the location of 8mm
the incisional hernia. The trocars are inserted as far away
as possible from the defect. We select the side of the patient
(b)
away from the previous operation for trocar insertion. If
the patient had previously undergone sigmoid colectomy, Figure 37.8 (a) Trocar placement for a tele-robotic Stoppa
for example, we would insert our trocars on the patient’s repair of an incisional ventral hernia. (b) A three-trocar
right side. For a midline hernia, three incisions are used: technique is used. The 12-mm stereoscopic telescope is inserted
the camera port is placed at the level of the umbilicus in through the 12-mm trocar. The two robotic surgical instruments
the mid-axillary line and the remaining two ports are are inserted through the 8-mm trocars.
The first part of the operation involves reducing the A Storz suture-passer is inserted through the abdominal
hernia and lysis of any adhesions to the anterior abdom- wall at each of the stab incisions and used to retrieve the
inal wall. A 30-degree telescope is used. Angulation of the ends of the Gore-Tex sutures (Figure 37.10). Once all of
telescope upwards improves visualization of the anterior the suture ends are retrieved, they are tied. The edge of the
abdominal wall. The hernia can usually be reduced with mesh is inspected. The mesh needs to sit firmly against
the use of two graspers and a hand-over-hand technique the anterior abdominal wall. Pleats between the sutures are
with gentle downward pressure to avoid tearing or injur- flattened out with 5-mm surgical tacks (Autosuture).
ing the hernia contents. Once this is done, any adhesions The abdomen is deflated and the trocars are removed.
to the anterior abdominal wall can be lysed easily, using The fascial defect of the 12-mm trocar is closed with an
the electrocautery hook, harmonic scalpel scissors, or absorbable suture. The skin edges of the three trocar sites
surgical scissors (Figure 37.9). Working on the underside are closed with absorbable subcutaneous sutures. All
of the abdominal wall is facilitated greatly by the wounds are covered with impermeable dressings.
dexterous instruments.
After adequate lysis of adhesions, the fascial defect is Advantages
usually evident. The limits of the defect are marked on the
abdominal wall and measured. We like to overlap the mesh We have found that the da Vinci facilitates laparoscopic
at least 2.2 cm beyond the perimeter of the hernia defect. repair of ventral and incisional hernias. The da Vinci pro-
DualMesh Plus (W. L. Gore & Associates) is fashioned so vides a stable camera platform, permits a solo-surgeon
that a degree of overlap is achieved. We place Gore-Tex approach to the lysis of adhesions, helps to maintain the
sutures every two inches around the perimeter of the surgeon’s orientation within the operative field, promotes
mesh. The sutures are tied with two throws to the mesh dissection on the anterior abdominal wall, and simplifies
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 pneumoperi-
toneum 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 inci-
sions are made in the skin at the positions of the sutures.
(a)
(b)
Figure 37.10 Passing sutures through the abdominal wall to fix

Figure 37.9 Robotic scissors and atraumatic Cadierre grasper. the dual-sided mesh in place. The da Vinci’s stereoscopic view
The adhesions are divided with robotic instruments. The Cadiere facilitates passing the sutures. A suture-passer drags the sutures
grasper retracts the bowel, and the adhesions to the abdominal through the abdominal wall (a). Two robotic graspers are used to
wall are divided with scissors. hand the sutures to and from the suture-passer (b).
the passage of the fixation sutures through the abdominal Tele-robotic surgery remains in a period of rapid evo-
wall. The da Vinci holds the video camera. The robot does lution. Newer generations of both da Vinci and Zeus con-
not tire and does not wander from the operative field. tinue to be developed rapidly. Whether tele-robotics will
This stable camera platform avoids the eye fatigue gener- become the standard of care in the near future remains
ated by a constantly moving, human-held video camera. uncertain. Nonetheless, even at this early juncture, tele-
Although all laparoscopic surgeons have been trained robotic surgical systems address some of the specific limi-
to operate from a two-dimensional monitor, the true tations of standard laparoscopic surgery. Tele-robotic
three-dimensional virtual operative field provides imme- surgical systems maintain a stable camera platform,
diate advantages and rapidly became our preferred field immerse the surgeon in a three-dimensional virtual oper-
of view. The surgeon comprehends more easily the three- ative field, move the surgical instruments with six or seven
dimensional virtual operative field. Our impression is degrees of freedom, and further improve the ergonomics
that this makes it easier for us to maintain our orientation for the surgeon. Tele-robotics also have the potential usage
and helps to avoid past pointing injuries. in very remote settings, such as the battlefield and outer
Straight laparoscopic instruments often fail to reach space.
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 REFERENCES
anterior abdominal wall. This maneuver is awkward at
best with conventional straight laparoscopic instruments 1 Ballantyne GH. The pitfalls of laparoscopic surgery: challenges for
because of their anterior position. Straight laparoscopic robotics and telerobotic surgery. Surg Laparosc Endosc Percutan
instruments are often limited from reaching the anterior Tech 2002; 12: 1–5.
abdominal wall by the point of fixation of the trocar at 2 Talamini MA. Surgery in the 21 century [editorial]. Ann Surg 2001;
234: 8–9.
the abdominal wall. The angulated movements of the 3 Fan P. Surgical grand rounds presentation: laparoscopic hernia
robotic instrument tips permit the attack of the adhe- repair. Hackensack University Medical Center, April 3, 2001.
sions from a wide variety of angles. 4 Merola S, Weber P, Wasielewski A, Ballantyne GH. Comparison of
Three-dimensional imaging also assists in the passage laparoscopic colectomy with and without the aid of a robotic
of the fixation stitches through the abdominal wall. camera holder. Surg Laparosc Endosc Percutan Tech 2002; 12:
46–51.
Although this process can be accomplished with two- 5 Felix EL. Laparoscopic extraperitoneal hernia repair. In: Eubanks
dimensional video cameras, novice laparoscopic surgeons SW, ed. Mastery of Endoscopic and Laparoscopic Surgery.
accomplish this task more quickly in a three-dimensional Philadelphia: Lippincott Williams & Wilkins, 2000: 443–55.
operative field. 6 Geis WP, Kim HC, Brennan EJ, Jr, et al. Robotic arm enhancement
to accommodate improved efficiency and decreased resource
utilization in complex minimally invasive surgery procedures.
Stud Health Technol Inform 1996; 29: 471–81.
7 Marescaux J, Leroy J, Gagner M, et al. Transatlantic robot-assisted
CONCLUSION telesurgery. Nature 2001; 413: 379–80.
8 Ballantyne GH, Kelley WE, Jr. Granting clinical privileges for
telerobotic surgery. Surg Laparosc Endosc Percutan Tech 2002;
Many surgeons perform advanced laparoscopic opera-
12: 17–25.
tions with standard twentieth-century technologies. 9 Hourmont K, Pereira S, Wasielewski A, et al. Robotic versus
Nonetheless, standard laparoscopy presents certain telerobotic laparoscopic cholecystectomy: duration of surgery and
limitations that impede the learning of advanced skills outcomes. Surg Clin North Am 2003; in press.
and prevent many surgeons from performing advanced 10 Cadiere GB, Himpens J, Vertruyen M, Favretti F. The world’s first
obesity surgery performed by a surgeon at a distance. Obes Surg
laparoscopic operations. Robotics offers technological
1999; 9: 206–9.
solutions to some of these shortcomings. We have found 11 Cadiere GB, Himpens J, Vertruyen M, et al. Evaluation of
that AESOP provides a stable camera platform, maintains telesurgical (robotic) Nissen fundoplication. Surg Endosc 2001;
a stable relationship with the horizon, adequately replaces 15: 918–23.
a human camera-holder, and lets the surgeon stand in an 12 Gould JC, Melvin WS. Computer-assisted robotic antireflux
surgery. Surg Laparosc Endosc Percutan Tech 2002; 12: 26–9.
ergonomically comfortable position. Voice-control sys-
13 Shah J, Rockall T, Darzi A. Robot-assisted laparoscopic Heller’s
tems help to integrate the operating room and to keep the cardiomyotomy. Surg Laparosc Endosc Percutan Tech 2002; 12:
surgeon in control of an ever more complicated operating 30–32.
environment. In our hospital, robot-assisted laparoscopic 14 Horgan S, Vanuno D, Benedetti E. Early experience with robotically
pre-peritoneal inguinal hernia repair in an integrated assisted laparoscopic donor nephrectomy. Surg Laparosc Endosc
Percutan Tech 2002; 12: 64–70.
operating room is our standard of care. We believe that
15 Ballantyne GH, Hourmont K, Wasielewski A. Telerobotic
this technique permits the surgeon the best opportunity laparoscopic repair of incisional ventral hernias using intra-
to replicate the operation in a high-volume mode with peritoneal prosthetic mesh (Stoppa technique): report of two
excellent clinical outcomes. 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 274 Economics of laparoscopic surgery 278

Economics of day-case surgery 275 Payment changes 280
Incentives and day-case hernioplasty 276 Conclusion 281
Return to normal activity and work 276 References 281
Economic evaluations of new and existing healthcare Economic Cooperation and Development (OECD) coun-
interventions are an essential input into decision-making. tries, and the USA.3
Healthcare systems around the world face steady increases It is no longer sufficient to consider the clinical or
in expenditure as a result of demographic change and therapeutic effects of healthcare interventions: purchasing
improvements in medical technology. Increasingly, payers choices will be predicated on studies that identify, measure
must choose which interventions will be provided and and value what is given up when an intervention is used
which will not be reimbursed from limited public or pri- (the cost) and what is gained (improved patient health
vate funds. This creates difficult choices, as systems are no outcomes). This requires explicit economic evaluation of
longer limited by what is technically possible to improve healthcare interventions. Purchasers have a fixed budget
the health of patients but by what is practically possible and are aware of the opportunity costs of interventions.
given resource constraints. In a situation where resources Increasingly, they are likely to require evidence of effec-
are scarce, all choices about who will be treated have an tiveness and cost-effectiveness, and they may develop
opportunity cost – the value of the benefit foregone. Health contracts and enforce protocols to ensure this.
economics and the techniques of economic evaluation aim Economic evaluation values both inputs (costs) and
to maximize the amount of health that is produced within outcomes (consequences) of an intervention, comparing
the scarce resources available. In the UK, the National more than one alternative. This builds upon clinical eval-
Institute for Clinical Excellence (NICE) synthesizes evi- uations that assess efficacy (can an intervention work in
dence and reaches a judgment as to whether on balance the experimental circumstances?) and effectiveness (does it
intervention can be recommended as a cost-effective use of work in normal clinical practice?) to assess efficiency
National Health Service (NHS) resources.1 In 2000, NICE (does it provide the greatest benefit at least cost?). The
published recommendations for the use of laparoscopic type of economic evaluation depends upon the outcome
hernia surgery. It recommended its use outside centers of measure chosen:
expertise only in cases of bilateral inguinal hernia or recur-
rent inguinal hernia. In the UK in 1996, approximately ten • Cost-minimization analysis is appropriate only when
per cent of hernia repairs were carried out laparoscopi- the outcomes of two or more interventions have
cally.2 Since the publication of the NICE guidelines, this fig- been demonstrated to be equivalent, in which case
ure has decreased dramatically and supports the concept the least costly alternative is the most efficient, and
that the application of clinical pathways can reduce costs. only cost analysis is required.
Such measures are important in the UK, where the num- • Cost-effectiveness analysis includes both costs and
bers of medical staff and the annual NHS budget are well outcomes using a single outcome measure, usually a
below those in other European countries, Organization for natural unit. This allows comparisons between
treatments in a particular therapeutic area where should technological innovations such as laparoscopic
effectiveness is unequal, but not between therapeutic surgery be introduced? All such pioneering innovations
areas where natural outcome measures differ. should be evaluated in well-designed trials. There are
• Cost-utility analysis combines multiple outcomes difficulties in implementing randomized controlled trials
into a single measure of utility (e.g. a quality- of surgical techniques due to the difficulties of blinding,
adjusted life year, QALY). This allows comparisons but a carefully designed trial can mitigate these prob-
between alternatives in different therapeutic lems. Clinical trials protect the safety of patients and
categories with different natural outcomes. ensure that new technologies produce effective healthcare.
• Cost-benefit analysis links costs and outcomes by Economic evaluations ensure that such health gains are
expressing both in monetary units, forcing an purchased at least cost. The guidelines applied to phar-
explicit decision about whether an intervention is maceutical products, intended to protect society’s health
worth its cost. Various techniques have been used to and scarce resources, should also be applied to surgical
attach monetary values to health outcomes, but the innovations, but this is a difficult task to institute.
technique remains rare in health economics. The principle of evaluating innovative surgical inter-
ventions was accepted by the Department of Health in the
Considerations in cost-effectiveness are particularly UK in a press release in 1995, which announced that major
relevant at a time when healthcare costs are escalating innovations were to be ‘scrutinised, evaluated and then, if
disproportionately in relation to gross national product approved, fast tracked throughout the health service’.6 A
in many westernized countries.4 The value of any indi- major advance should, under a new system, be subjected to
cated treatment is directly proportional to treatment clinical trials, and a central register would give information
outcome and inversely proportional to treatment cost. on approved operations. Purchasers could then consult the
Evaluation of both the numerator (outcome quality) and register as a measure of the effectiveness of various opera-
the denominator (cost) of the equation are subject to tions and procedures. This register, the Safety and Efficacy
many methodological limitations. The value depends on Register of New Interventional Procedures (SERNIP), is
whether it is viewed from the perspective of the patient, managed by the Academy of Medical Royal Colleges and
surgeon, hospital, employer, payer or industry. Moreover, funded by the Department of Health. Doctors are asked
cost does not equate with charge. In hernia surgery, the to register new techniques that they intend to pilot, and
total cost includes pretreatment (diagnostics), treatment, to check the register to discover the current status of new
post-treatment medical care including complications invasive procedures.7 An advisory committee convened by
and recurrence, and societal and employer costs, which SERNIP will then assess all known data and assign the
include insurance, worker’s disability compensation, procedure to one of four categories:
worker replacement costs, and loss of productivity. Each
1 Safety and efficacy unsatisfactory – procedure must
sector of the treatment process has variable fixed and
not be used.
semi-fixed costs. The trends to eliminate general anes-
2 Safety and efficacy established – procedure can be used.
thesia and to perform conventional herniorrhaphy in an
3 The procedure is sufficiently similar to one of
ambulatory setting have been cost-beneficial. Ideally, cost
established safety and efficacy to raise no reasonable
containment could be achieved by performing all elective
doubts and can be used.
inguinal hernia repairs at ambulatory surgical centers for
4 Safety and efficacy are not established – controlled
a standardized charge.
evaluation is needed.
Technological innovation in surgery and in other areas
(e.g. diagnostic innovation) is not regulated in the same The proposed system is voluntary and controlled clin-
way as innovative pharmaceutical therapies. A new phar- ically. In time, economic evaluation of innovative invasive
maceutical product is subjected to rigorous clinical trials procedures will be required, as is the case for pharmaceu-
to identify evidence of safety and efficacy, before licensing tical products. In the majority of other countries, includ-
for public use. Increasingly, new and existing pharmaceu- ing the USA, such a system does not exist at any level.
tical 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
ECONOMICS OF HERNIA REPAIR
that ‘the economic evaluation of pharmaceuticals should
become part of taking decisions about treatment’, and
set out clear guidelines regarding how a high-quality Hernia repair is an established and effective procedure.
economic evaluation should be carried out.5 Its relatively fixed cost and high volume among surgical
The careful procedures that control the introduction procedures mean that economic evaluation of the proce-
of innovative pharmaceutical products are essential for dure itself has become a priority. Hernias create pain and
innovative surgical and diagnostic therapies. How, then, discomfort for patients and limit their ability to work or
Socioeconomic issues 275
carry out other productive activities. While the increased on as outpatients. Additionally, because of the increasing
risk of surgical procedures in elderly people means that trend of incisional herniorrhaphy by the laparoscopic
repair of some small direct hernias may not be manda- method, many incisional and ventral hernias are per-
tory, there would seem to be clear clinical and economic formed with a length of stay of 23 hours or less.15,16
arguments in favor of carrying out hernia repairs among Economic appraisal is unlike surgical decision-
the majority of the working population.8 making. Economists analyze the results of their inter-
J.W. Hurst, a health economist, has compared the ben- ventions by comparing them within different scenarios:
efits and costs of hernia repair with the benefits and costs as the scenarios change – employment prospects, labor
of home dialysis for renal failure, and with the benefits relations, etc. – the economics change too. Surgeons are
and costs of a successful renal transplant.9 Drawing on a used to evaluating their outcomes over time with the sce-
measure of health status that measures two dimensions of nario held constant. For instance, with day-case surgery
health (disability and distress), and using Department of and a constant surgeon-related scenario, one impact of
Health and Social Security (DHSS) cost data, Hurst calcu- shortening the patients’ stay will be empty beds, which
lated the health status yield per pound sterling for the the surgeon will perceive as the currency of an ‘efficiency
three selected treatments. Using this cost-benefit equa- saving’. The economist would not call this a saving; the
tion, uncomplicated hernia repair comes out better than concept of opportunity cost means that no benefit has
a successful renal transplant, and a renal transplant is bet- accrued until the empty beds (resources) are put to some
ter value than continuous home hemodialysis. Memories alternative use. Benefit is thus not necessarily the same to
of Cecil Wakeley’s aphorism crowd in to confirm that the surgeon as to the economist.
refined clinical judgment may well be as valuable in Any economic appraisal of day-case surgery must,
evaluating the benefits of clinical care as the statistical therefore, first address the crucial issue of the term
gymnastics of contemporary health economists.10 ‘benefit’. Are the benefits to be:
Innovations in the procedure of hernia repair and the
management of patients should, however, be subject to
• more surgery, using the freed resources to undertake
a greater volume of surgery or more complex
economic evaluation, ideally based upon a randomized innovative surgery?
controlled trial. The recent developments in hernia repair,
such as the expansion of day-case surgery in Europe,
• a redeployment of the freed resources towards a
different client group, e.g. elderly or mentally ill
require a clinical and economic base. However, the expe- people?
rience from the Shouldice clinic in Canada and the results
from the USA support the use of limited hospitalization
• a reduction in overall health service expenditure by
the amount saved?
for the repair of hernias. Laparoscopic inguinal hernia
surgery has not been proven to represent an economic A day-case surgery policy will need to be appraised in
benefit for the unilateral primary hernia. There may be the short run and in the long run. Short-run benefits may
some benefit for the patient with bilateral and/or recur- be very difficult to gain; for instance, a reduction in surgi-
rent herniation. Other laparoscopic hernia surgeries, such cal bed requirements by 15 may confer no benefit since
as hiatal and incisional hernia repair, have reduced the one cannot eliminate half a 30-bed ward and reduce staff
length of hospitalization significantly. costs by 50 per cent overnight. While there may be no
short-term gains, the long-term gains could be substan-
tial and allow explicit alterations to existing surgical and
nursing practice. Consequently, new hospital provision
ECONOMICS OF DAY-CASE SURGERY could include fewer traditional inpatient surgical wards
and instead have dedicated day-case units. In the USA,
Reductions in length of stay for many surgical and other there are, in fact, many centers that are free-standing and
inpatient procedures result from improvements in surgical dedicated to day-case surgery or short-stay procedures.
procedures reducing recovery time, changing preferences Stepping through the looking-glass, more day-case
of patients, and financial and political pressures on hospi- surgery will need less capital expenditure on surgical
tals to reduce costs. Day-case surgery is often preferred inpatient facilities, and fewer nursing staff will need to be
by patients, and it may encourage early mobilization and employed for the same volume of work in the long term.
reduce the risk of hospital-acquired infection.11 Day-case The quantification of savings accruing from a day-case
treatment for hernia repair may result in good outcomes policy is difficult; four approaches have been advanced:
for lower costs than other organizational forms of care.12,13 • Comparing the bills paid by patients in private
The Royal College of Surgeons recommends that at least practice.17
30 per cent of elective hernioplasties should be performed • The analytical device of holding the level of service
on a day-case basis.14 In the USA, however, all but the most constant and estimating the benefits that could be
ill or infirm individuals with inguinal hernias are operated bought with the now unused resources.18
• The technique of comparing average per diem greater demand will initially be met and the queue
inpatient and outpatient costs.19 Farquharson reduced. If there is no queue and no excess demand, then
produced the seminal paper advocating this type of reducing costs should allow premises to be closed and
economic evaluation.20 staff made redundant, with considerable reduction in
• Comparing and computing the one-year costs of a fixed and variable costs. The cost of doing an extra case
day-care facility with the one-year costs of a after hours in a day-case unit, when staff must be paid
traditional in-patient unit.21 overtime, is a very high marginal price – a fact to be
remembered when case-scheduling is considered.
Bailey, an economist from the Audit Commission in
If day-case surgery is used to cut unit costs and increase
the UK, has proposed an alternative strategy to deter-
the overall volume of surgery, then this extra burden of ris-
mine the resources that might be released as a result of
ing productivity will fall on the surgeons and nurses. There
a change from inpatient to day-case while treating an
are reports of the proportion of day cases rising to close
equivalent patient.22 He states that the costs of day sur-
to 40 per cent in some units, with consequent increases
gery are substantially less than inpatient care, but it is
in surgical throughputs. Ultimately, the increased output
misleading to interpret such measures as savings. The
may demand an alteration on the supply side of the equa-
resource implications of more day surgery should be
tion, and more doctors and nurses may then need to be
estimated directly by looking at precisely what changes
employed to cope with increased demand.24 While the
are planned to take place.
relationship between demand and output of a surgical
In conclusion, there is evidence that the unit costs of
service is elastic in the short term, in the longer term supply
day-case surgery are much lower than inpatient care:
inevitably must be increased to allow greater output. This is
of the order of 40–75 per cent per treatment episode,
particularly evident in many areas in the USA, where there
however calculated. These lower unit costs will free up
are nursing and anesthesia staff shortages.
resources to carry out more surgery or for alternative uses.
It must be apparent that there is no economic incen-
Day-case surgery has been found to be superior to in-
tive for surgeons and other hospital employees to expand
patient surgery in terms of wound infection and return to
day-case surgery. Substantial savings can be achieved
work, although this finding is not statistically significant.23
only by maintaining constant the quantity of surgery
Day-case surgery is also becoming increasingly acceptable
carried out, by not allowing day cases to increase the out-
to patients. A dedicated five-day care unit allows more
put, and by closing premises and dismissing redundant
resources to be saved compared with day cases in a tradi-
staff. The development of free-standing centers, however,
tional theater suite and ward, where all the resources can-
will transfer these cases to these centers and allow more
not be redeployed easily, particularly in the short run. This
efficient use of the hospital staff and/or relocate these
is consistent with the conclusions of a US review of cost-
employees.
effectiveness of management of hernia by Millikan and
Deziel.4 These authors concluded that the most cost-
effective approach to hernia repair would use an ambula-
tory surgical center with open-mesh repair for primary RETURN TO NORMAL ACTIVITY AND WORK
inguinal hernia and failed primary suture repair.
There is enormous variation in reported times for return
to normal activity and work. For instance, in a socialized
INCENTIVES AND DAY-CASE HERNIOPLASTY
system of healthcare where patients’ expectations and
the insurance system still favor hospitalization, length
To date, resource savings from day-case surgery in the of hospital stay after hernia surgery may be in excess of
NHS have been used largely to expand surgical services eight days.25 Even in the USA, where ambulatory surgery
either quantitatively or qualitatively. Every hospital units are quite commonplace, the length of stay may be
experienced this phenomenon in the 1970s. It has been several days in institutions where reimbursement is not
quantified and shown that as resources are liberated by controlled as strictly as the private sector, although this is
day-case work, they are used up in other surgical endeav- rapidly becoming uncommon. Customers of the Metro-
ors. This extra work sucks in further resources, and the politan Life Insurance Company surveyed by a nationwide
overall surgical budget becomes larger. claims questionnaire revealed a length of stay that aver-
Increasing the proportion of day cases in the surgical aged 2.9 days.26 In the US army, average hospital stay for
unit mix will lead to a fall in the average cost of each hernia surgery is 4.6 days.27 In reality, housing conditions,
patient treated. This may enable more cases to be oper- the distance from home to hospital, and the availability
ated upon; even though the marginal costs of doing each of home nursing care (spouse, relative, friend) are the
extra case within normal working hours are low, the major factors affecting early discharge after hernia repair.28
aggregated cost to the hospital will be higher, although These societal issues are more frequently problematic with
other larger procedures. Payers, however, seldom provide appears to be the most important factor affecting clinical
consideration for these important matters that involve outcome and return to activities. Callesen and coworkers
patient care. have demonstrated that well-defined recommendations
The technique adopted has little predictive value for and improved pain management can shorten convales-
early postoperative pain and analgesic consumption. cence.32 One hundred patients having elective hernior-
Kawji and colleagues, in a study of 240 patients who had rhaphy under local anesthesia and managed analgesia
been treated with Lichtenstein under general anesthesia, were recommended to have one day of convalescence for
Lichtenstein under local anesthesia, laparoscopic trans- light/moderate work and three weeks of abstinence from
abdominal pre-peritoneal (TAPP), Shouldice operation, strenuous physical activity. The overall median absence
or pre-peritoneal Wantz procedure, found that the only from work was six days; unemployed patients returned
technical factor significantly reducing analgesic require- to activities in just one day, those in light/moderate work
ment during the first three perioperative days was the use returned in six days, and those in heavy jobs returned by
of intraoperative local anesthesia.29 Lau and Lee studied 25 days. A more detailed prospective study of return to
postoperative pain by linear analogue scores in 239 patients work after inguinal hernia repair has been undertaken by
having inguinal herniorrhaphy with a variety of tech- Jones and colleagues.33 Data were collected by personal
niques.30 With multiple regression analysis, older patient interviews, written surveys, and medical record reviews
age was the only independent factor of pain, a finding in in 235 patients, the main outcome measures being actual
keeping with anecdotal experience of surgeons used to and expected return to work. Age, educational level,
operating on patients under local anesthesia. income level, occupation, symptoms of depression, and
The French Association for Surgical Research investi- the expected day of return to work (ten days) accounted
gated the feasibility of discharge within 48 hours of for 61 per cent of the variation in actual (12 days) return
inguinal hernia repair in 500 consecutive men with uni- to work.
lateral, uncomplicated non-recurrent inguinal hernias. Advice given in the UK on driving after groin-hernia
Of 411 patients suitable for early discharge, 107 (26 per surgery varies widely because there is no evidence-based
cent) eventually stayed for more than 48 hours, early information.34 In a postal questionnaire sent to 200 sur-
discharge was declined by 84, and early discharge was geons, the advice ranged from it being acceptable to drive
contraindicated in 42 (these patients had local or general on the same day of surgery (three per cent of respon-
complications), which finally resulted in one-day surgery dents) to suggesting that patients wait six to eight weeks
being performed in only 51 (ten per cent) of the patients. before driving (nine per cent of respondents); the most
These results emphasize the need for careful preoperative common response was that patients should wait two
evaluation, which includes not only the hernia and the weeks (37 per cent of respondents). Amid has stated that
patient’s general medical condition, but also any social the recovery period is dependent solely on the amount of
conditions, such as isolation, flights of stairs, or lack of a postoperative discomfort, which should be minimal and
telephone, that may limit the ability to discharge a patient should not usually require narcotic analgesia.35 Amid
soon after surgery. recommends that patients can resume driving as early
Advice concerning return to normal activity has been as one week or less after surgery, depending on their
managed poorly by surgeons. Recent studies indicate comfort and whether they are using narcotic analgesics.
that factors limiting a patient’s return to activity and Those who drive different types of vehicles need different
work are governed principally by the perceived amount advice. An additional consideration should be the com-
of postoperative pain. Socioeconomic factors strongly plexity of the operative procedure. Intra-abdominal pro-
influence this perception over and above the actual procedures will require longer periods of convalescence than
cedure performed or the anatomy involved.31 In a case- inguinal hernia repair.
controlled comparison of patients receiving workers’ It must be apparent that there is no economic incen-
compensation compared with patients having commer- tive for surgeons and other hospital employees to expand
cial insurance, seven surgeons from a single clinic com- day-case surgery. Substantial savings can be achieved
pared 22 consecutive workers’ compensation patients only by maintaining constant the quantity of surgery
with 22 commercial insurance patients. All patients had carried out, by not allowing day cases to increase the out-
received open hernioplasty, and the duration of post- put, and by closing premises and dismissing redundant
operative pain and the days off work were compared. The staff. Such a policy is unlikely to make surgeons who take
differences between the two groups were striking: the up day-case surgery popular. However, the experience in
median duration of postoperative pain in the workers’ the USA, where day surgery is quite commonplace, has
compensation group was 27 days, with 36.5 days off proven that the patients and their surgeons are quite sat-
work. In the commercial insurance patients, the duration isfied with these economics. In fact, many patients are
of postoperative pain was 7.5 days and they went back to dismayed when they are told that their medical condition
work after only 8.5 days. Personal motivation, therefore, dictates a hospital stay of even one night.
therapies rather than open surgery. It is important to

ECONOMICS OF LAPAROSCOPIC SURGERY remember that lengths of inpatient stay were falling for
many years, and the additional savings from laparoscopic
Since the pioneering laparoscopic removal of a gall surgery may be lower than anticipated. History, however,
bladder by French surgeon Phillippe Mouret in 1987, the has proven that many of these worries have not resulted
introduction and rapid diffusion of laparoscopic surgical in a decline in the use of laparoscopic surgery. In most
techniques was accepted with unbridled enthusiasm, and procedures, except for inguinal hernia repair, the trend is
often without question, by many surgeons, the media upward.
and the general public. The years that have passed since Complication rates are important determinants of the
then have allowed a more rational approach to many overall costs of any surgical procedure. Complications
of these procedures. The majority of laparoscopic adap- with laparoscopic surgery procedures, such as bile-duct
tations of the general surgical operations have proven to injuries with laparoscopic cholecystectomy, have been
be cost-effective due to the diminution in the length of well documented (see Table 1 in Soper et al.38). Most bile-
hospital stay. The great exception is laparoscopic repair duct injuries occur early in a surgeon’s experience, high-
of inguinal hernias, which is always more costly. lighting the need for careful training and accreditation of
Some economic arguments have been used to support surgeons, and clinical practice guidelines.39 The rate of
the rapid diffusion of laparoscopic surgery. Studies often conversions from laparoscopic operations to open opera-
quote reductions in the length of inpatient hospital stay tions ranges from 1.8 to 8.5 per cent, and tends to be high-
in comparison with standard surgical procedures and est early in a surgeon’s experience.38 The cost implications
imply that this will necessarily save hospitals money. This of complication rates include increased operating time,
is, however, not necessarily the case, and hospital man- increased length of inpatient stay, increased care burden
agers are increasingly questioning the appropriateness of on families or other caregivers, and increased time for the
procedures that involve purchase of sophisticated and patient to return to work or normal activities. The current
expensive capital equipment and considerably increased rates of complications, however, have now established the
operative time, resulting in lower patient throughput for laparoscopic cholecystectomy as the standard of care for
surgical procedures. Available time in the operating gallbladder disease because they are comparable, whether
theatre is a scarce resource, and although operating time open or laparoscopic.
in laparoscopic surgery declines as experience increases, A recent systematic review of the effectiveness and
Cuschieri estimated that on average it will continue to safety of laparoscopic cholecystectomy showed that effec-
take about one-third longer than the corresponding con- tiveness of this procedure is similar to that of open and
ventional operation, with the excess of time over open mini-cholecystectomy.40 Complete alleviation of symp-
surgery the higher the more complicated the basic oper- toms was achieved in 60–70 per cent of patients. However,
ation.36 Time, however, has proven that once past the safety profiles differ, with more technical support and
learning curve, many of these operations are only as long specialized surgical equipment required for the laparo-
as or are shorter than that of the open method. Many of scopic procedure. Differences in complication rates were
these comparisons may be flawed because there are ‘slow difficult to assess because of methodological problems
operators’ and ‘quick operators.’ Many of the operations and differences between studies. In particular, studies
discussed in this book are commonly performed with often do not have sufficient statistical power to identify
less operative time than their open counterparts in clinically important differences in outcomes, particularly
centers with surgeons skilled in these procedures. bile-duct injury, because the rate of adverse events is low.
The effect of length of inpatient stay on health service Sculpher argues that laparoscopic surgery has a differ-
resource use is an important issue in many studies. ent ‘production function’ to conventional surgical tech-
Cuschieri estimates that discharge may, on average, niques, i.e. it requires a different mix of inputs to the
be expected to be within less than 48 hours.36 This is production process, more inputs of theater and medical
thought to result in cost-savings from earlier discharge staff time, more sophisticated equipment, and fewer
and earlier return to normal activities, including work. inputs of inpatient bed days.37 The overall effect on
However, economists such as Sculpher note that this may hospital costs and on overall costs to society is unclear
not always be the case.37 First, a reduction in the demand and requires economic evaluation. Evaluation should be
for hospital beds may not result in cash-savings unless it long-term in order to include any effects of different
allows ward closures. At one time, this was felt to be re-admission rates, and should include not only hospital
unlikely as laparoscopic surgery represented a small pro- costs and effects but also the burden on community-
portion of all hospital procedures. Other arguments were based services, patients and carers, which may change
that laparoscopy did not release other resources used for due to earlier discharge.
surgical procedures, particularly theater time, and that The ‘production function’ description of surgery is
some laparoscopic procedures replaced non-invasive useful in considering other issues. The appropriate level
of individual and center specialization should be deter- be more expensive than the laparoscopic approach (open,
mined by evidence of economies of scale. If a center spe- US$1150; laparoscopic, US$1179).46 In many centers,
cializes in laparoscopic surgery, then this may influence however, this has been a stimulus for surgeons to abandon
costs per patient, as theater time may be reduced as famili- the procedure altogether (willingly or unwillingly). The
arity with the procedure increases. In addition, outcomes insurance industry has refused to reimburse hospitals and
may be improved, particularly by reduced complication surgeons for the procedure, leading to the rapid demise of
rates. However, the appropriate level of individual and the procedure. Medicare in the USA actually pays sur-
center specialization requires careful evaluation: could the geons less to perform these operations laparoscopically
alleged benefits of centralization be matched by careful than through the open technique (see below).
training and treatment protocols at local levels? Identifi- These realities have resulted in the trend of many cen-
cation of the conditions necessary for the production of ters to utilize this operation only in the bilateral situation
efficient laparoscopic procedures is absent but inhibits and for recurrent hernias. The success for this diagnosis is
neither unsubstantiated assertions by policymakers nor proven.47,48 The ongoing studies of the Medical Research
significant investments in new facilities. Council (MRC) Laparoscopic Groin Hernia Trial Group
The repair of inguinal hernias with the laparoscopic support the move to specialist surgeons to perform this
method continues to raise many questions, particularly operation.49 Based upon the experience in the USA, this
regarding economics. Whereas it is generally accepted appears to be the trend.
that this technique is effective for these hernias, the costs Data comparing open versus laparoscopic repair of
associated with this method causes many surgeons to inguinal hernias are now voluminous, and a detailed
question the usefulness of this technique. In 1996, the analysis of all the factors is beyond the scope of this chap-
benefits were unclear.41 In 2003, the clinical efficacy is not ter. Suffice to say that the vast majority of reports have
generally questioned. The cost issues have been resolved identified the same findings that are commonly known.
for the most part. It is more expensive to perform the That is, in general the laparoscopic operation is more
minimally invasive method except in a very few areas that expensive but postoperative pain is diminished and the
have managed to eliminate the use of disposable instru- return to work is notably shorter. The learning curve and
ments and tissue-expansion balloons. the payors of these operations will force this procedure
Evidenced-based studies have definitely revealed that into the hands of a few skilled surgeons with excellent
the levels of pain and subsequent convalescence after outcomes. Even in this case, this will be for bilateral and
laparoscopic repair are decreased when compared with recurrent hernias. Studies such as that by Lawrence and
open repair.42 This is particularly true with the compari- coworkers used a UK randomized controlled trial as the
son of pure tissue repairs, but it has also been found with basis of an economic evaluation of laparoscopic versus
open prosthetic repairs. However, some studies have open inguinal hernia repair, on data collected from 104
reported that while these patients experience less pain day-case patients.41 The mean total health service cost of
postoperatively, the return to work interval was not dif- laparoscopic repair was £1074, compared with £489 for
ferent after TAPP repair. The opinion of these authors open repair. Linking this additional cost with the addi-
was that the increase in costs did not justify the operation tional pain-free days in the laparoscopic group showed
unless the operative costs could be reduced.43 Another an additional cost per pain-free day of £109 (95 per cent
study found that laparoscopically repaired patients returned confidence interval, £41–393). The authors concluded
to their usual activities seven days earlier than those of that there were strong arguments against the intro-
the open group. The incremental cost for this time frame duction of laparoscopic hernia repair until evidence on
was £55 548 per QALY over the open method. This report long-term outcomes becomes available. Such studies,
showed that there might be specific situations in which although important, are few. Hekkinnen and colleagues
this laparoscopic repair may be a viable alternative, conversely proved that the overall societal costs are less
particularly when reusable rather than disposable instru- with the laparoscopic method.50 Regardless, the cost–
ments were used because these costs were decreased benefit structure of the insurance industry does not
significantly.44 appreciate the societal costs as do the individual patient
The operative costs that are increased with the laparo- and surgeon. Therefore, this limited use of the laparo-
scopic approach are the use of disposable instruments, scope to repair inguinal hernias will probably be perma-
balloon dissection devices, balloon trocars, additional nent in the USA. In other countries, such as those in
personnel, and the length of the operation. These costs Europe, a more critical look at these issues may be possi-
can be reduced to the extent that the cost of the operation ble because of the public nature of the healthcare system.
can approach that of the open procedure. Lorenz has This is needed.
shown that by the deliberate attempt to decrease costs, the Unlike those of laparoscopic inguinal herniorrhaphy,
laparoscopic approach can be less expensive to the hospi- the clinical and economic benefits are clearer with the
tal.45 Beets and Dirksen found that the open approach can laparoscopic repair of incisional and ventral hernias.
Many papers in the literature have demonstrated the evaluated the cost of the repair.16,54 In both papers, the
short period of hospitalization seen with this approach laparoscopic method was associated with less cost than
to this problem.15,16,51,52 It is generally believed by surgeons the open repair. This is based primarily upon the
proficient in this technique that this method lessens the decreased length of stay of laparoscopically repaired
length of hospitalization for the patients. Five publica- patients. This occurred even when the additional costs of
tions have compared open and laparoscopic repair of any re-admissions were included in the overall determi-
incisional and ventral hernias (Table 38.1).16,53–56 In all nation. Interestingly, the work by DeMarie and col-
of these series, laparoscopic repair was associated with leagues evaluated the costs based upon open repair using
fewer complications and fewer days of hospitalization a polypropylene product versus the laparoscopic repair
than those of open method. Only two of these papers using an expanded polytetrafluoroethylene (ePTFE)
patch.16 Therefore, based upon the limited study that has
been done on this operation, it appears that laparoscopic
Table 38.1 Results of comparative analysis of open and herniorrhaphy for incisional and ventral hernia is the
laparoscopic incisional and ventral herniorrhaphy economically preferred choice.
Laparoscopic
These issues are discussed more frequently with the
Open repair repair Ref. repair of inguinal and incisional hernias. The use of the
laparoscope to repair the other hernias discussed in this
Operative time, 45–259* 70–211* 54 textbook appears to compare favorably with open repair.
range (min) 27–148 45–170 55 Decreased length of stay, decreased morbidity, and a more
60–180 30–180 53
rapid return to normal activity have been shown.
25–220 18–225 56
N/A N/A 16
Operative time, 97.6* 128.5* 54
average (min) 78.5 95.4 55
PAYMENT CHANGES
111.5 87 53
82 58 56 Despite the points discussed above, the financial realities
N/A N/A 16 of governmental reimbursement in the USA have declined
Length of hospital N/A N/A 54
continuously. We selected the comparison of the payments
stay, range (days) 2–26* 1–17* 55
3–21* 1–15* 53
from Medicare in the USA since 1993 for four hernia oper-
N/A N/A 56 ations (Figure 38.1). Unless noted otherwise, all of these
0.5–14* 0.5–3* 16 are inguinal hernia repairs. It is readily apparent that these
Length of hospital 4.9 1.6 54 levels of payment have not changed significantly in nine
stay, average (days) 6.5* 3.4* 55 years. These payments do not reflect the inflationary
9.06* 2.23* 53 increases in office overheads and the enormous elevations
2.8 1.7 56 in the cost of medical liability insurance. Additionally, the
4.4* 0.8* 16 payment for the repair of bilateral inguinal hernias is 1.5
Complication rate 31 15 54 times the payment for the repair of a single hernia. Because
(%) 36.7* 17.9* 55 of this, some surgeons simply cannot afford to repair bilat-
? 53
eral hernias at the same time. Instead, these are repaired
36 10 56
N/A N/A 16
sequentially in two separate procedures. It is particularly
Recurrence rate 12.5 1 54 disturbing that payment for the repair of an incisional
(%) 34.7 11 55 hernia (US$636.69) is less than the repair of a recurrent
2 0 53 incarcerated inguinal hernia (US$644.07). The differences
20.7 2.5 56
0 4.8 16 800
Open
Cost, range (US$) 1987–12 611* 3555–5235* 54 700
Recurrent
N/A N/A 55 600
Recurrent
US dollars
N/A N/A 53 500 incarcerated

N/A N/A 56 400 Incisional
6574–18 448 5323–11 223 16 300 Laparoscopic
Cost, average (US$) 7299* 4395* 54 200 inguinal
N/A N/A 55 100 Laparoscopic
N/A N/A 53 0 recurrent
inguinal
93
94
95
96
97
98
99
00
01
02
N/A N/A 56
19
19
19
19
19
19
19
20
20
20
12 461 8273 16
Figure 38.1 Medicare reimbursement in real dollar values
*Statistically significant difference. from 1993 to 2002.
in the complexity of the operations, potential morbidity, gaps about its clinical and economic attributes. The poten-
and length of postoperative care are obvious to every tial clinical and economic benefits of laparoscopic inguinal
surgeon. The financial realities of the practice of surgery hernia repair are particularly unclear given the need for
in the USA are subtly affecting the ethics of surgery. general anesthesia and the possibility of rare but serious
Laparoscopic repair of primary inguinal hernias is injuries to intra-abdominal organs. This procedure bene-
reimbursed less than that of the open repair. There is no fitted from large-scale clinical trials and economic evalua-
consideration given to the extra level of expertise and tions for inguinal hernia repair. The use of laparoscopy in
training that is required to perform that operation. One the repair of many of the other hernias of the abdominal
could postulate that the financial disincentive is placed to wall seems to have a strong economic benefit, however.
discourage the use of the procedure in these patients The future development of advanced techniques and
because of the extra cost associated with the operation. even the availability of even the simplest of hernia repairs
This is especially troubling, as this will inhibit its use in may become more difficult due to the negative financial
patients who might benefit from that method of repair. consequences of governmental payment schedules.
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 REFERENCES
governmental healthcare is being affected adversely. Many
people cannot find physicians who will accept these low 1 Sculpher M, Drummond M, O’Brien B. Effectiveness, efficiency and
levels of payment. Some surgeons no longer repair bilat- NICE. Br Med J 2001; 322: 943–4.
eral hernias simultaneously. Because of the costs of doing 2 O’Riordan DC, Kingsnorth AN. Audit of patient outcomes after
herniorrhaphy. Surg Clin North Am 1998; 78: 1129–39.
business, the ethics of medicine are being impacted. There
3 Editorial. Country profile: United Kingdom. Lancet 1997; 350:
does not appear to be hope of any meaningful relief in the 48–58.
near term. In fact, there may be less reimbursement by 4 Millikan KW, Deziel DJ. The management of hernia: considerations
Medicare to the surgeon to perform any operation laparo- in cost effectiveness. Surg Clin North Am 1996; 76: 105–16.
scopically rather than by the open technique. Further gov- 5 Department of Health. Press release no. 94/251. London:
Department of Health, 1994.
ernment intervention may avert this unfortunate event,
6 Department of Health. Press release no. 95/82. London: Department
but politics are part of the medical landscape in all coun- of Health, 1995.
tries. Unless changes are forthcoming, few surgeons will 7 Bower H. A safety net cast over new surgery. Hospital Doctor 1996;
adopt these newer techniques. 16 May.
8 Royal College of Surgeons of England. Clinical Guidelines for the
Management of Groin Hernias in Adults. London: Royal College of
Surgeons of England, 1993.
CONCLUSION 9 Hurst JW. Measuring the benefits and costs of medical care – the
contribution of health status measurement. Health Trends 1984;
16: 16–19.
It is no longer sufficient to consider only the clinical and 10 Wakeley CPG. Treatment of certain types of external herniae. Lancet
1940; 1: 822–6.
therapeutic effects of healthcare: purchasing choices
11 Ruckley CV. Day care and short stay surgery for hernia. Br J Surg
require explicit economic evaluation to identify, measure 1978; 65: 1–4.
and value costs and patient health outcomes. Surgical 12 Bridger P, Rees M. What a difference a day makes. Health Serv J
interventions are no exception to this business principle. 1995; 105: 22–3.
Hernia repair is an established and effective procedure 13 Ruckley CV, Cuthbertson C, Fenwick N, et al. Day care after
operations for hernia or varicose veins: a controlled trial. Br J Surg
for most patient groups, and its relatively low cost among
1978; 65: 456–9.
surgical procedures means that economic evaluation of 14 Royal College of Surgeons of England. Guidelines for Day
the procedure itself is not a priority. However, innova- Case Surgery. London: Royal College of Surgeons of England,
tions in the procedure of hernia repair and the manage- 1992.
ment of patients, such as day-case and laparoscopic repair 15 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
of the different hernias, should be subject to economic
2000; 180: 193–7.
evaluation. 16 DeMarie EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal
The unit costs of day-case surgery are lower than polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral
those of traditional in-hospital care. Any money saved hernia. Surg Endosc 2000; 14: 326–9.
will enable more operations to be carried out and more 17 Rockwell E. Out-patient repair of inguinal hernia. Am J Surg 1982;
143: 559–60.
patients to be treated. Alternatively, savings generated
18 Russell IT, Devlin HB, Fell M, et al. Day case surgery for hernias and
could be used to develop other services. haemorrhoids. Lancet 1977; 1: 844–7.
Laparoscopic surgery has spread rapidly through many 19 Burn JMB. Responsible use of resources: day surgery. Br Med J
surgical specialties, but there are still major knowledge 1983; 286: 492–3.
20 Farquharson EL. Early ambulation with special reference to 40 Downs SH, Black NA, Devlin HB, et al. Systematic review of the
herniorrhaphy as an out-patient procedure. Lancet 1955; ii: 517–19. effectiveness and safety of laparoscopic cholecystectomy. Ann R
21 Royal College of Surgeons of England. Guidelines for Day Case Coll Surg Engl 1996; 78: part II.
Surgery. London: Royal College of Surgeons of England, 1985. 41 Lawrence K, McWhinnie D, Goodwin A, et al. An economic
22 Bailey J. The economics of day surgery. In Royal College of Surgeons evaluation of laparoscopic vs open inguinal hernia repair. J Public
of England: Guidelines for Day Case Surgery. London: Royal College Health Med 1996; 18: 41–8.
of Surgeons of England, 1992. 42 EU Hernia Trialists Collaboration. Laparoscopic compared with open
23 Cheek C, Black NA, Devlin HB, et al. Systematic review on groin methods of groin hernia repair: systematic review of randomized
hernia surgery. Ann R Coll Surg Engl 1998; 80 (suppl): S1–80. controlled trials. Br J Surg 2000; 87: 860–67.
24 Devlin HB. The economics of day case surgery. In Royal College of 43 Pananini AM, Lezoche E, Carle F, et al. A randomized, controlled,
Surgeons of England: Guidelines for Day Case Surgery. London: clinical study of laparoscopic vs open tension-free inguinal hernia
Royal College of Surgeons of England, 1985. repair. Surg Endosc 1998; 12: 979–86.
25 Grotzinger U. Ambulante Herniechirurgie. Therapeutische Umschau 44 MRC Laparoscopic Groin Hernia Trial Group. Cost-utility analysis of
1992; 49: 478–81. open versus laparoscopic groin hernia repair: results from a
26 Rutkow IM, Robbins AW. Demographic, classificatory, and multicentre randomized clinical trial. Br J Surg 2001; 88: 653–61.
socioeconomic aspects of hernia repair in the United States. Surg 45 Lorenz D, Stark E, Oestreich K, Richter A. Laparoscopic hernioplasty
Clin North Am 1993; 73: 413–26. versus conventional hernioplasty (Shouldice): results of a
27 Haydorm WH, Velanovich V. A five year U.S. Army experience with prospective randomized trial. World J Surg 2000; 24: 739–45.
36,250 abdominal hernia repairs. Am Surg 1990; 56: 596. 46 Beets GL, Dirksen CD, Go PM, et al. Open or laparoscopic
28 Millat B, Fingerhut A, Gignoux M, et al. Factors associated with preperitoneal mesh repair for recurrent inguinal hernia: a
early discharge after inguinal hernia repair in 500 consecutive randomized controlled trial. Surg Endosc 1999; 13: 323–7.
unselected patients. Br J Surg 1993; 80: 1158–60. 47 Sarli L, Iusco DR, Sansebastiano G, Costi R. Simultaneous repair of
29 Kawji R, Feichter A, Fuchsjager N, Kux M. Postoperative pain and bilateral inguinal hernias. Surg Laparosc Endosc Percutan Tech
return to activity after five different types of inguinal 2001; 11: 262–7.
herniorrhaphy. Hernia 1999; 3: 31–5. 48 Schmedt C-G, Däubler P, Leibl BJ, et al. Simultaneous bilateral
30 Lau H, Lee F. Determinant factors of pain after ambulatory inguinal laparoscopic inguinal hernia repair. Surg Endosc 2002; 16:
herniorrhaphy: a multi-variate analysis. Hernia 2001; 5: 17–20. 240–44.
31 Saledo-Wasicek CM, Thirlby RC. Postoperative course after inguinal 49 MRC Laparoscopic Groin Hernia Trial Group. Laparoscopic versus
herniorrhaphy: a case controlled comparison of patients receiving open repair of groin hernia: a randomised comparison. Lancet 1999;
worker’s compensation vs patients with commercial insurance. Arch 354: 185–90.
Surg 1995; 130: 29–32. 50 Heikkinen TJ, Haukipuro K, Hulkko A. A cost and outcome
32 Callesen T, Klarskov B, Bech K, Kehlet H. Short convalescence after comparison between laparoscopic and Lichtenstein hernia
inguinal herniorrhaphy with standardized recommendations: operations in a day-case unit. Surg Endosc 1998; 12: 1199–8.
durations and reasons for delayed return to work. Eur J Surg 1999; 51 Costanza MJ, Heniford BT, Area MJ, et al. Laparoscopic repair of
165: 236–41. recurrent ventral hernias. Am Surg 1998; 64: 1121–7.
33 Jones KR, Burney RE, Peterson M, Christy B. Return to work after 52 Kochler RH, Voeller G. Recurrences in laparoscopic incisional hernia
inguinal hernia repair. Surgery 2001; 129: 128. repairs: a personal series and review of literature. J Soc
34 Ismail W, Taylor SJC, Beddow E. Advice on driving after groin hernia Laparoendosc Surg 1999; 3: 293–304.
surgery in the United Kingdom: questionnaire survey. Br Med J 53 Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic
2000; 321: 1056. treatment vs open surgery in the solution of major incisional
35 Amid PK. Driving after repair of groin hernia. Br Med J 2000; 321: and abdominal wall hernias with mesh. Surg Endosc 1999;
1033–4. 13: 250–52.
36 Cuschieri A. Minimal Access Surgery: Implications for the NHS. 54 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and
Edinburgh: HMSO, 1994. incisional hernioplasty. Surg Endosc 1997; 11: 32–5.
37 Sculpher M. Phase II medical laser technology assessment. HERG 55 Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia
Research Report No. 15, Brunel University, 1993. repair: a comparison study. Surgery 1998; 124: 816–22.
38 Soper NJ, Brunt LM, Kerbl K. Laparoscopic general surgery. N Engl J 56 Ramshaw BJ, Escartia P, Schwab J, et al. Comparison of
Med 1994; 330: 409–19. laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65:
39 See WA, Cooper CS, Fisher RJ. Predictors of laparoscopic 827–32.
complications after formal training in laparoscopic surgery. J Am
Med Assoc 1993; 270: 2689–92.
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 anatomy 255 vascular injury 91

218, 243–4 complications in 261–2 visceral injury 92–3
abdominal wall, anterior anatomy see diaphragmatic hernia repair laparoscopic assisted ventral hernia
anterior abdominal wall anatomy history 257 repair 163–4
achalasia 198–9 patient selection 257 para-esophageal hernia repair 206–7
adhesiolysis, and bowel injury 163 surgical technique with prosthetic biomaterials 17–21
adhesives 11–12 Bochdalek hernia 257–8 and recurrent gastroesophageal reflux
AESOP robotic arm 266–8 Morgagni hernia 258–9 disease 217–22
alkaline reflux gastritis 218 history of laparoscopy in 251–4 and return to work 276–7
Allison’s procedure 174–5 physiology 255–6 with transfascial sutures 134–5
Alloderm prosthetic material 22–4 cigarette smoking, and hernia ventral/incisional hernioplasty
Anatomical Mesh 21 formation 36 bowel injury 161–3
anatomy clinical studies, ventral/incisional comparative studies 157–9
anterior abdominal wall see anterior hernioplasty gastrointestinal complications 166
abdominal wall anatomy comparative studies 157–9 postoperative pain 166
in children 255 series comparisons 155–7 prosthetic mesh fixation 107–8
diaphragm 179–83 collagen defects 46 prosthetic mesh infection 164–5
inguinal/femoral region see Collis gastroplasty 198 recurrence rates 166–8
inguinal/femoral anatomy colostomy, parastomal hernias see series comparisons 156t, 157
peritoneal cavity 41–2 parastomal hernias seroma 165–6
pre-peritoneal space 42–3 compartmented stomach, after see also recurrence rates
and total extraperitoneal (TEP) patch fundoplication 219–20 Composix prosthetic biomaterials 21–2
technique 66–7, 68f complication rates congenital hernias 257–9
anesthetic complications 89 laparoscopic method comparisons 83–4 connective tissue damage
in children 261 laparoscopic vs open methods 84–6 and hernia formation 36
Angimesh prosthetic material 17–18 complications and pathophysiology 46
anterior abdominal wall anatomy 104–5 in children 255–6, 261–2 convalescence after surgery 276–7
and cosmetic results 109 diaphragmatic hernia repair 235–7 Cooper’s ligament 42–3
and functional outcomes 109–10 economic evaluation 278 cosmetic outcomes, ventral/incisional
and hernia formation 105–6 fundoplication hernioplasty 109
and hernia repair methods 106–7 intraoperative 239–40 crural disruption, after fundoplication 219
and prosthetic biomaterial fixation 107–8 bougie perforation 240–1 cyanoacrylate fixation 12
and scar healing 108–9 esophageal perforation 240
arcuate line 42f, 44 gastric injury 243 da Vinci tele-robotic system 268–9
hemorrhage 241–2 ventral/incisional hernioplasty 270–2
balloon trocars 9 large hernia 243 day-case surgery, economic evaluation
barium swallow 188, 190 pneumothorax 241 275–6
Bassini, E 34 short esophagus 242–3 denervation hernias
bilateral hernia 62 postoperative anatomy 151, 152f
in children 251–2 dysphagia 246 formation of 105–6
bioadhesives 11–12 gastrointestinal symptoms 243–4 surgical repair
biochemical changes, and hernia ileus 246 indications/contraindications 152
formation 36 para-esophageal hernia 244 operative technique 152–3
biological prosthetic materials 22–4 recurrent reflux 247 outcomes 153
Biomesh prosthetic materials 17–18 slipped Nissen 244–5 diaphragm
bladder injury 92 symptom assessment 243 anatomy 179–83
Bochdalek hernia 257–8 vagal nerve injury 245–6 and hernia surgery 184–5
bone complications 93 inguinal/femoral hernioplasty physiology 183–4
bowel injury 161–3 anesthesia 89 diaphragmatic hernia
bowel obstruction 92–3 hydrocele 90 in children 257
laparoscopic repair 111–13 laparoscopic access 89–90 fundoplication see fundoplication
nerve injury 91–2 history of surgery for
calcitonin gene-related peptide organ complications 90 Allison, P 174–5
(CGRP) 45–6 prosthetic mesh problems 93 in children 257
Cheatle, GL 34 recurrence rates 93–4 early surgery 173
children seroma 90–1 laparoscopic approach 175–6
284 Index
diaphragmatic hernia (Contd) fascia transversalis 42–4 symptom assessment 187–8

Nissen fundoplication 175 pathophysiology 46 recurrent disease 217
short esophagus 174 femoral canal 45 clinical presentation 217–18
outcomes of surgery 235–7 femoral hernioplasty evaluation after failed surgery 190–1
para-esophageal hernias see history 76 incorrect diagnosis 221–2
para-esophageal hernias incidence of femoral hernias 75–6 incorrect surgery 221
from traumatic injury 209–10 postoperative management 77 mechanisms of failure 219–21
acute herniation 210–12 surgical technique 76–7 surgery for
chronic herniation 212–14 femoral nerve 45 indications 222–4
types of hiatal hernia 235 femoral sheath 45 patient selection 230
see also gastroesophageal reflux fibrin adhesive agents 11–12 preoperative evaluation 227–30
disease (GERD) fixation devices 11–12 surgical technique 230–4
diarrhea, after fundoplication 218 EndoAnchor device 27–8 surgical treatment
diffuse esophageal spasm 198–9 helical coil devices 27 individualization of therapy 199–200
disposable instruments 7–8 Salute device 27, 28f operative technique
dissecting instruments 8 staple devices 25–7 Collis gastroplasty 197–8
double-crown technique Fortagen prosthetic material 22–4 crural closure 195–6
indications/contraindications 133–4 Fortaperm prosthetic material 22–4 esophagomytomy 198–9
instrumentation 135–6 fundoplication 194 mobilization 194–5
operating room set-up 137 anatomical considerations 184–5 modified Toupet 196–7
outcomes 141 complications Nissen fundoplication 196
postoperative management 141 intraoperative 239–40 pyloroplasty 199
preoperative management 135–6 bougie perforation 240–1 patient preparation 194
prosthetic biomaterials 136–7 esophageal perforation 240 see also diaphragmatic hernia
surgical technique 137–41 gastric injury 243 gastrointestinal complications
transfascial suture comparison 134–5 hemorrhage 241–2 after fundoplication 243–4
driving, after surgery 277 large hernia 243 after ventral/incisional hernioplasty 166
DualMesh prosthetic biomaterials 18–21 pneumothorax 241 recurrent gastroesophageal disease
in ventral/incisional hernioplasty postoperative 217–19
double-crown technique 136–7 dysphagia 246 genitofemoral nerve 45
parastomal hernias 146–7 gastrointestinal symptoms 243–4 injury to 91–2
series comparisons 156t, 157 ileus 246 giant prosthetic reinforcement of the
transfascial suture technique 117–18 para-esophageal hernia 244 visceral sac (GPRVS), history 36
Dulex prosthetic biomaterial 18–21 recurrent reflux 247 Glucamesh prosthetic biomaterial 21–2
dysphagia, after fundoplication slipped Nissen 244–5 Glucatex 3D prosthetic biomaterial 21–2
217–18, 246 symptom assessment 243 grasping instruments 8
vagal nerve injury 245–6
economic evaluation 273–4 short esophagus 242–3 hand-assisted laparoscopy (HAL) 12–13
day-case surgery 275–6 failure of Hasson trocar 8–9
hernia repair 274–5 clinical presentation 217–18 health economics
laparoscopic surgery 278–80 mechanisms of failure 219–21 day-case surgery 275–6
payment methods 280–1 history 175–6 economic evaluation 273–4
return to work 276–7 Nissen fundoplication see Nissen hernia repair surgery 274–5
electrosurgery 10 fundoplication laparoscopic surgery 278–80
employment, return to after surgery 276–7 operative technique payment methods 280–1
EMS stapler 25–6 Collis gastroplasty 197–8 and return to work 276–7
EndoAnchor fixation device 27–8 crural closure 195–6 helical coil fixation devices 11, 27
Endopath EMS stapler 26 esophagomytomy 198–9 hemorrhage
endoscopy 188, 190, 227–8 mobilization 194–5 with fundoplication 241–2
endosopic gastroplasty 194 modified Toupet 196–7 with inguinal/femoral hernioplasty 91
enterotomy 161–3 pyloroplasty 199 Henry, AK 34
epigastric hernia 106 outcomes of surgery 235–6 hepatocyte growth factor/scatter factor
ergonomics 13 preoperative evaluation (HGF/SF) 45–6
esophageal hiatus 181–3 esophageal manometry 188–9 Hermesh prosthetic biomaterials 17–18
esophageal manometry 188–9, 190, 228f, pH monitoring 189–90 Hertra prosthetic biomaterials 17–18
229 symptom assessment 187–91 Hesselbach’s triangle 43
esophageal perforation, with fundoplication for recurrent disease Hessert’s triangle 46
240–1 patient selection 230 hiatal hernia see diaphragmatic hernia
esophagography 228–9 preoperative evaluation 227–30 hiatal stenosis 220
esophagomytomy 198–9 surgical technique 230–4 history
expanded polytetrafluoroethylene (ePTFE) diaphragmatic hernia in children 257
products gastric blood vessel injury 241–2 diaphragmatic hernia surgery
composite products 21–2 gastric emptying studies 230 Allison, P 174–5
flat, single-component products 18–21 gastric injury 243 early surgery 173
in ventral/incisional hernioplasty 126 gastroesophageal reflux disease (GERD) laparoscopic approach 175–6
double-crown technique 136–7 diaphragmatic anatomy 179–83 Nissen fundoplication 175
fixation 108 and surgical repair 184–5 early surgery 33
obstructed/incarcerated bowel 112–13 diaphragmatic physiology 183–4 femoral hernioplasty 76
parastomal hernias 146–7 fundoplication see fundoplication fixation devices 25–8
and scar healing 108–9 non-surgical treatment 193–4 intraperitoneal onlay of mesh (IPOM)
series comparisons 156t, 157 preoperative evaluation procedure 47–8
transfascial suture technique 117–18 esophageal manometry 188–9 laparoscopic general surgery 3–5
external oblique muscle 44, 104 pH monitoring 189–90 laparoscopic hernia repair 37–9
Index 285
nonoperative management 33 obturator hernioplasty see obturator Marcy, HO 33–4

obturator hernioplasty 76 hernioplasty Marlex prosthetic biomaterial 17–18
open hernia repair 33–6 outcomes history 34–5
ventral/incisional hernioplasty 99–100 laparoscopic method comparisons Mersilene prosthetic biomaterial 18
hydrocele 90 83–4 mesh prosthetics see prosthetic biomaterials
in children 262 laparoscopic vs open methods 83–6 modified Toupet fundoplication 196–7
hypertensive lower-esophageal perineal hernia 79–80 Morgagni hernia 258–9
sphincter 198–9 prevascular hernia 80 muscular denervation see denervation
sciatic hernia 77–9 hernias
ileostomy, parastomal hernias see supravesical hernia 79 Mycromesh prosthetic biomaterials
parastomal hernias total extraperitoneal (TEP) patch 18–21
ileus 246 technique see total extraperitoneal myopectineal orifice 35, 36f, 44–5
ilio-hypogastric nerve 45 (TEP) patch technique
ilio-inguinal nerve 45 transabdominal pre-peritoneal (TAPP) Nanticoke Hernia Stapler 26
iliopubic tract 42–3 patch technique see transabdominal National Institute for Clinical Excellence
imaging systems 12 pre-peritoneal (TAPP) patch (NICE) 273
see also robotic devices technique needle drivers 11
incarcerated bowel repair 111–13 injuries neoplasia, and recurrent gastroesophageal
incarcerated inguinal hernia 63 from laparoscopic access 89–90 reflux disease 220, 221–2
incisional hernias traumatic diaphragmatic injuries see nerves
diagnosis 125 traumatic diaphragmatic injuries anatomy 45
incidence 125 from trocars 8–10 injury to 91–2
pre-peritoneal hernioplasty see see also complications with prosthetic biomaterial
pre-peritoneal hernioplasty instrumentation fixation 108
repair methods 125–7, 129–30 disposable 7–8 and recurrent gastroesophageal
risk factors 125 dissecting and grasping instruments 8 reflux disease 221, 245–6
see also ventral/incisional hernioplasty energy sources 10–11 Nissen fundoplication
infants see children ergonomics 13 anatomical considerations 184–5
infection, with prosthetic biomaterials 93, fixation devices 11–12, 25–8 complications 220, 244–5
113, 164–5 hand-assisted laparoscopy 12–13 history 175
inferior epigastric vessels 41 robotic devices see robotic devices preoperative evaluation 187–91
injury to 91 trocars 8–10 surgical technique 196
infertility, and prosthetic mesh 93 videoendoscopy systems 12 non-cutting trocar 10
inguinal canal 44 internal inguinal ring 41–2 nutcracker esophagus 198–9
inguinal/femoral anatomy internal oblique muscle 44, 104 Nyhus, LM 34
femoral canal 45 intestinal complications 92–3, 161–3
femoral sheath 45 intestinal stomas, parastomal hernias oblique muscles 44
inguinal canal 44 see parastomal hernias obstructed bowel repair 111–13
myopectineal orifice 44–5 Intramesh prosthetic biomaterials 17–18 obturator artery, injury to 91
nerves 45 intraperitoneal onlay of mesh (IPOM) obturator hernioplasty
oblique muscles 44 procedure history 76
peritoneal cavity 41–2 advantages and disadvantages 51 incidence of obturator hernias 76
pre-peritoneal space 42–3 history 37, 47–8 postoperative management 77
spermatic cord 44 operating room set-up 48–9 surgical technique 76–7
transversalis fascia 43–4 patient selection 48 Omni-Tack 26–7
inguinal/femoral hernioplasty postoperative management 51 open hernia repair
complications surgical technique 49–51 and anterior abdominal wall
anesthesia 89 irreducible inguinal hernia 63 anatomy 106–7
hydrocele 90 ischemic orchitis 90 history 33–6
laparoscopic access 89–90 for incisional hernias 126–7
nerve injury 91–2 laparoscopic assisted ventral hernia laparoscopic method comparison
organ complications 90 repair 163–4 economic evaluation 279–80
prosthetic mesh problems 93 laparoscopic hernia repair outcomes of surgery 84–6
recurrence rates 93–4 history 37–9 for ventral/incisional hernias 129–30,
seroma 90–1 open method comparison 84–6 157–9
vascular injury 91 laparoscopic surgery for para-esophageal hernias 202
visceral injury 92–3 economic evaluation 278–80 optical view trocar 9
economic evaluation 279 history 3–5 Origin tacker 27
femoral hernioplasty lateral cutaneous nerve of thigh 45 outcome of surgery
history 76 Lichtenstein repair inguinal/femoral hernioplasty
incidence of femoral hernias 75–6 history 35–6 laparoscopic method
postoperative management 77 laparoscopic method comparison comparisons 83–4
surgical technique 76–7 84–5 laparoscopic vs open methods 84–6
history lipomas 80–1 ventral/incisional hernioplasty
in children 252–4 liver injuries 241 comparative studies 157–9
early surgery 33 low Spigelian hernia 81 cosmetic results 109
nonoperative management 33 lower-esophageal sphincter 183–4 denervation hernias 153
open hernia repair 33–6 lumbar hernias double-crown technique 141
intraperitoneal onlay of mesh (IPOM) anatomy 151, 152f functional outcomes 109–10
procedure see intraperitoneal onlay surgical repair lumbar hernias 153
of mesh (IPOM) procedure indications/contraindications 152 parastomal hernias 148–9
lipomas 80–1 operative technique 152–3 pre-peritoneal hernioplasty 129–30
low Spigelian hernia 81 outcomes 153 series comparisons 155–7
286 Index
pain composite products 21–2 AESOP robotic arm 266–8

after fundoplication 218 flat, single-component products tele-robotic systems 268
after ventral/incisional hernioplasty 166 17–18 da Vinci system 268–9
management in children 256 history 34–5 in ventral/incisional hernioplasty
and return to work 277 preformed products 21 270–2
para-esophageal hernias in ventral/incisional hernioplasty Zeus system 269–70
after fundoplication 244 108, 126 round ligament, lipoma 80–1
outcomes of surgery 236–7 double-crown technique 136–7
surgical repair obstructed/incarcerated bowel Safety and Efficacy Register of New
anatomical considerations 202 112–13 Interventional Procedures
indications/contraindications 201–2 and scar healing 108–10 (SERNIP) 274
laparoscopic vs open methods 202 postoperative complications see Salute fixation device 11, 27, 28f
operating room set-up 203 complications scar healing 108–9
operative technique 203–7 pre-peritoneal hernioplasty sciatic hernioplasty 77–9
postoperative management 207–8 comparison with other techniques scrotal hernioplasty 63
preoperative evaluation 202–3 129–30 Sepramesh prosthetic biomaterial 21–2
types of 201 indications 127 seroma 90–1, 165–6
parastomal hernias laparoscopic vs open methods 129–30 shielded trocar 9–10
assessment 144 operating room set-up 127 short esophagus
outcomes 148–9 outcomes 129 Collis gastroplasty 197–8
postoperative management 147–8 patient preparation 127 and fundoplication 242–3
surgical repair postoperative management 129 history of surgery for 173–4
indications/contraindications 144–5 surgical technique 127–9 and recurrent gastroesophageal reflux
methods 144 tele-robotic systems 270–2 disease 219
preoperative preparation 145 see also total extraperitoneal (TEP) Shouldice technique 84–5
surgical technique 145–7 patch technique skin
types of 143–4 pre-peritoneal space, anatomy 42–3 complications 93
Parietene prosthetic biomaterial 17–18 prevascular hernioplasty 80 cosmetic outcomes 109
Paritex prosthetic biomaterials 18, 21–2 processus vaginalis smoking, and hernia formation 36
partitioned stomach, after anatomy 44 socioeconomic issues
fundoplication 219–20 pathophysiology 45–6 day-case surgery 275–6
pathophysiology 36, 45–6 Prolene prosthetic biomaterials 17–18 economic evaluation 273–4
pectineal ligament 42–3 Prolite prosthetic biomaterial 17–18 hernia repair 274–5
pediatric hernia prosthetic biomaterials laparoscopic surgery 278–80
anatomical considerations 255 history 34–5, 37–9 and payment methods 280–1
complications infection 93, 164–5 and return to work 276–7
anesthesia 261 non-synthetic materials 22–4 Soft Tissue Patch prosthetic
hydrocele 262 and outcome of surgery, laparoscopic vs biomaterial 18–21
recurrence rates 262 open methods 85–6 spastic disorders of esophagus 198–9
surgical complications 261–2 synthetic materials spermatic blood vessels, injury to 91
testicular complications 262 composite products 21–2 spermatic cord
diaphragmatic hernia repair flat, single-component products 17–21 anatomy 44
history 257 preformed products 21 lipoma 80–1
patient selection 257 see also individual surgical procedures Spigelian hernia 81
surgical technique Protack device 27 spiral tack fixation devices 11, 27
Bochdalek hernia 257–8 protease/antiprotease imbalance, and splenic injury 242
Morgagni hernia 258–9 hernia formation 36 staple fixation devices 11, 25–7
pathophysiology 44, 45–6 pyloroplasty 199 stomach complications, after
physiological considerations 255–6 fundoplication 219–20
pediatric laparoscopy, history 251–4 radially expanding trocar 10 Stoppa procedure 36
pelvic anatomy Reconix prosthetic biomaterial 18–21 strangulated bowel repair 113
anterior abdominal wall see anterior rectus abdominus muscle 104 Stretta Procedure 193–4
abdominal wall anatomy recurrence rates supravesical hernioplasty 78
inguinal/femoral region see gastroesophageal reflux disease (GERD) surgical ergonomics 13
inguinal/femoral anatomy see gastroesophageal reflux disease Surgipro prosthetic materials 17–18
pelvic hernia repair see femoral hernioplasty; (GERD), recurrent disease Surgisis prosthetic materials 22–4
obturator hernioplasty hiatal hernia repair 235–7 suture passers 11
perineal hernioplasty 79–80 inguinal/femoral hernioplasty 93–4 synthetic biomaterials
peritoneal cavity, anatomy 41–2 laparoscopic vs open methods 84–6 composite products 21–2
pH monitoring 189–90, 190–1, 229–30 pediatric hernia 262 flat, single-component products 17–21
phreno-esophageal ligament 181 total extraperitoneal (TEP) patch preformed products 21
physiology technique 84 see also prosthetic biomaterials
in children 255–6 transabdominal pre-peritoneal (TAPP)
diaphragm 183–4 patch repair 62–3, 84 tack fixation devices 11, 27
inguinal region 45–6 ventral/incisional hernioplasty 166–8 TAPP technique see transabdominal
plug-and-patch technique, history 37 comparative studies 158t, 159 pre-peritoneal (TAPP) patch
pneumothorax 206, 241 series comparisons 156t, 157 technique
polyester biomaterials reflux esophagitis see gastroesophageal tele-robotic systems 268
composite products 21–2 reflux disease (GERD) da Vinci system 268–9
flat, single-component products 18, 19f respiration ventral/incisional hernioplasty 270–2
preformed products 21 and incisional hernias 106 Zeus system 269–70
in ventral/incisional hernioplasty 126 and laparoscopy in children 256 TEP technique see total extraperitoneal
polypropylene mesh (PPM) products robotic devices 13 (TEP) patch technique
Index 287
testicular complications operating room set-up 55, 56f ventral/incisional hernioplasty

in children 262 postoperative management 63 anterior abdominal wall anatomy 104–5
inguinal/femoral hernioplasty 90 preoperative evaluation 54–5 and hernia formation 105–6
thermal energy sources 10 recurrence rates 93–4 and repair methods 106–7
3D Max prosthetic biomaterial 21 for recurrent hernia 62–3 complications
total extraperitoneal (TEP) patch technique for scrotal hernia 63 bowel injury 161–3
AESOP robotic arm 266–8 surgical technique 56–61 gastrointestinal complications 166
anatomical considerations 66–7, 68f transfascial suture technique postoperative pain 166
complications adhesiolysis 120–1 prosthetic mesh infection 164–5
anesthesia 89 advantages/disadvantages 134–5 seroma 165–6
hydrocele 90 indications/contraindications 115–16 denervation hernias see denervation
laparoscopic access 89–90 instrumentation 118–19 hernias
nerve injury 91–2 patient preparation 118 double-crown technique see
organ complications 90 postoperative management 123–4 double-crown technique
with prosthetic mesh 93 preoperative evaluation 116–17 economic evaluation 279–80
seroma 90–1 prosthetic biomaterials 117–18 history 99–100
vascular injury 91 insertion/fixation 122–3 laparoscopic assisted hernia
visceral injury 92–3 surgical technique 120 repair 163–4
history 38 trocar placement 119–20 lumbar hernias see lumbar hernias
indications/contraindications 65–6 trocar selection 119 obstructed/incarcerated bowel 111–13
instrumentation 68 transversalis fascia 42–4 outcomes
open method comparison 84–5 transversus abdominus muscle 104–5 comparative studies 157–9
postoperative management 73 traumatic diaphragmatic injuries 209–10 cosmetic 109
preoperative evaluation 68 acute herniation 210–12 functional 109–10
recurrence rates 93–4 chronic herniation 212–14 series comparisons 155–7
surgical technique 69–73 Trelex prosthetic biomaterial 17–18 parastomal hernias see parastomal
transabdominal pre-peritoneal (TAPP) trocars hernias
comparison 83–4 design of 8–10 pre-peritoneal hernioplasty see
transabdominal pre-peritoneal (TAPP) injury from 89–90 pre-peritoneal hernioplasty
patch technique tumors, and recurrent gastroesophageal prosthetic biomaterial fixation 107–8
AESOP robotic arm 266–8 reflux disease 220 recurrence rates 166–8
for bilateral hernia 62 twisted fundoplication 220 scar healing 108–9
complications transfascial suture technique see
anesthesia 89 ultrasonic dissection 10–11 transfascial suture technique
hydrocele 90 ultrasonically activated trocar 10 Zeus tele-robotic system 268–9, 270–2
laparoscopic access 89–90 umbilical hernia 106 videoendoscopy systems 12
nerve injury 91–2 urinary bladder injury 92 da Vinci tele-robotic system 268–9
organ complications 90 US Surgical Corporation stapler 26 ventral/incisional hernioplasty 270–2
prosthetic mesh 93 Usher, FC 34–5 visceral injury 89–90, 92–3, 243
seroma 90–1 with fundoplication 241–2
vascular injury 91 vagal nerve injury 221, 245–6 with para-esophageal hernia repair 206
visceral injury 92–3 vas deferens complications 90, 93 and trocar design 8–10
history 37–8 vascular injury 89–90, 91
indications/contraindications 53–4 with fundoplication 241–2 work, return to after surgery 276–7
instrumentation 55 with prosthetic biomaterial fixation 107–8
open method comparison 54, 84–5 and trocar design 8–10 Zeus tele-robotic system 269–70

Laparoscopic Hernia Surgery

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Laparoscopic Hernia Surgery

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Laparoscopic hernia

Karl A. LeBlanc MD MBA FACS

A member of the Hodder Headline Group

Distributed in the United States of America by

British Library Cataloguing in Publication Data

Library of Congress Cataloging-in-Publication Data

ISBN 0 340 80940 X

Commissioning Editor: Joanna Koster

Typeset in 10/12 Minion by Charon Tec Pvt Ltd., Chennai, India

1 Laparoscopic general surgery 3

2 Technological and instrumentation aspects of laparoscopic hernia surgery 7

3 Prosthetic biomaterials for hernioplasty 17

4 Fixation devices for laparoscopic hernioplasty 25

PART 2 LAPAROSCOPIC INGUINAL/FEMORAL HERNIOPLASTY 31

6 Anatomy and physiology 41

7 Intraperitoneal onlay mesh approach 47

8 Transabdominal pre-peritoneal approach 53

9 Totally extraperitoneal approach 65

10 Femoral and pelvic herniorrhaphy 75

11 Results of laparoscopic inguinal/femoral hernia repair 83

12 Complications and their management 89

PART 3 LAPAROSCOPIC INCISIONAL AND VENTRAL HERNIOPLASTY 97

PART 4 LAPAROSCOPIC TREATMENT OF DIAPHRAGMATIC HERNIATION 171

32 Complications and their management 239

PART 5 LAPAROSCOPY IN THE PEDIATRIC HERNIA PATIENT 249

34 Anatomy and physiology 255

35 Diaphragmatic herniation 257

36 Complications and their management 261

PART 6 FUTURE CONSIDERATIONS 263

37 Robotics and hernia surgery 265

38 Socioeconomic issues 273

Gina L. Adrales MD Ed Felix MD

Stephen M. Kavic MD Marco G. Patti MD

CGRP calcitonin gene-related peptide

Angiologica, S. Martino Sicc., Italy

1 Laparoscopic general surgery 3 3 Prosthetic biomaterials for hernioplasty 17

ROGER K.J. SIMMERMACHER

GINA L. ADRALES AND ADRIAN E. PARK

(a) (b) (c) (d)

In an effort to secure the prosthetic material and to facil-

of the surgeon’s hand via an upper midline incision with

The feasibility of robotic-assisted surgery has been

Synthetic prosthetic biomaterials: ﬂat, single-component Non-synthetic prosthetic biomaterials 22

(a) (b) (c)

Table 3.3 ePTFE biomaterials and manufacturers

There is a distinctive difference between DualMesh

Figure 3.3 ePTFE biomaterials: (a) DualMesh, (b) DualMesh Plus,

Figure 3.6 Anatomical Mesh.

Table 3.4 Composite biomaterials and manufacturers

SYNTHETIC PROSTHETIC BIOMATERIALS:

Figure 3.8 Sepramesh.

PPM similar to the other two products above. The

Table 3.5 Biological prosthetic biomaterials and manufacturers

Figure 3.9 Alloderm.

Figure 3.11 (a) Fortagen and (b) Fortaperm.

Figure 3.10 (a) Surgisis ES and (b) Surgisis Gold.

Figure 3.12 Permacol.

At the time of writing, all of these biomaterials are rel- REFERENCES

Early devices 25 Conclusion 28

Figure 4.8 Origin Tacker.