Laparoscopic spigelian herniorraphy

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Surgical anatomy of the anterior abdominal wall

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    1. Layer by layer anatomy

    The large region comprising the anterior abdominal wall from the xiphoid process and costal margins to the pelvis is characterized by its layered structure: The skin and subcutaneous fatty tissue are followed by superficial fascias, muscles and their investing fascias, then the extraperitoneal fascia and finally the parietal peritoneum.

    Particularly in the infra-umbilical anterior abdominal wall the otherwise characteristic superficial single fascia layer becomes a double-layered structure comprising a superficial fatty layer (panniculus adiposus telae subcutaneae abdominis or Camper fascia) and a deeper membranous layer (stratum membranosum telae subcutaneae abdominis or Scarpa fascia). The 5 abdominal muscles comprise:

    3 oblique muscles (1. external oblique, 2. internal oblique and 3. transversus abdominis) and

    2 strap muscles (4. rectus abdominis and the inconsistent 5. pyramidalis)

    a) Anterior muscle

    Immediately posterior to the superficial fascia it courses mediocaudad to the great aponeurosis, with both sides fusing in the midline to the white line (linea alba). Its inferior margin comprises the inguinal ligament traversing from the anterior superior iliac spine to the pubic tubercle, with the medial aspect of the inguinal ligament giving rise to the lacunar and pectineal ligaments (Gimbernat and Cooper respectively).

    b) Middle muscle

    Its fibers course cephalomedially and fuse with fibers from 1. to form the linea alba.

    c) Most posterior muscle

    Its transverse coursing fibers also conjoin with the linea alba.

    Each of the three oblique abdominal muscles has its own thin anterior and posterior fascia, while the posterior aspect of the transverse abdominal muscle is covered by the firm transversalis fascia. The latter lines the abdominal cavity; cephalad it fuses with the diaphragmatic fascia and posteriorly with the thoracolumbar fascia. Caudad it inserts in the iliac crest and fuses with the endopelvic fascia.

    The bilateral rectus abdominis muscle is a long straight muscle crossed by 3 – 4 tendinous intersections (“six-pack”).

    The pyramidalis muscle is an inconsistent triangular muscle originating at the superior pubic ramus and inserting in the linea alba. It rests anterior to the rectus abdominis and is invested by its own sheath in the anterior lamina of the rectus sheath.

    2. Fascias and peritoneum

    The rectus abdominis and pyramidalis muscles are invested by the rectus sheath formed by the 3 oblique abdominal muscles. While the rectus sheath completely invests the upper 3/4 of the rectus abdominis, below the arcuate line it covers the inferior 1/4 only anteriorly; here, the posterior aspect of the rectus abdominis is covered solely by the transversalis fascia and the peritoneum. Above the midpoint between the umbilicus and the symphysis pubis, the rectus muscle has a well-defined investment, formed in front by the aponeurosis of the external oblique and the anterior lamina of the aponeurosis of the internal oblique, and behind by the aponeurosis of the transversus abdominis and the posterior lamina of the aponeurosis of the internal oblique.

    Depending on its location, the extraperitoneal space between the transversalis fascia and the peritoneum may be well or ill defined. The retroperitoneal abdominal organs are located in the retroperitoneum. At the anterior abdominal wall, this narrow space (e.g., at the deep inguinal ring) often is termed spatium praeperitoneale (preperitoneal space).

    The peritoneum (parietal serosa) forms the completely closed (except for the fallopian tubes in women) peritoneal cavity, with the visceral peritoneum covering the intraperitoneal organs. Inferior to the umbilicus it retains three folds:

    Single median umbilical fold (obliterated urachus/embryological urinary tract),

    Left and right medial umbilical fold (former umbilical artery),

    Left and right lateral umbilical fold (inferior epigastric vessels).

    3. Innervation and blood supply

    The anterior abdominal wall is innervated by the anterior branches of spinal nerves Th7 to Th11, Th12 (subcostal nerve) and L1 (iliohypogastric and ilioinguinal nerves).

    The internal thoracic artery supplies the superior region of the superficial blood supply (→ musculophrenic artery), while the inferior region is supplied by the superficial epigastric and superficial circumflex iliac arteries (both being branches of the femoral artery). The superior epigastric artery supplies the superior region of the deep blood supply (← internal thoracic artery), while the lateral region is supplied by the intercostal arteries and the inferior region by the inferior epigastric and deep circumflex iliac arteries (both being branches of the external iliac artery). Venous drainage is via the corresponding veins.

  • Anatomy of spigelian hernia

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    Spigelian hernias are hernias of the linea semilunaris and mostly located where the latter crosses the semicircular line of Douglas (also known as the arcuate line) (point of least resistance).

    The arcuate line is the lateral commissure of the rectus sheath and extends from the costal cartilage of the 9th rib down to the symphysis pubis. Where it fuses mediad with the tails of the aponeurosis of the external oblique to form the anterior rectus sheath, it is termed spigelian fascia. Usually, these hernias are located at the level of the inferior margin of the posterior rectus sheath.

    Clinically, spigelian hernias present as a protrusion in the lateral lower quadrant, at about the projection of McBurney’s point. The hernia sac may include intestine, omentum, ovary etc.

    Spigelian hernias are always acquired and become manifest between the fourth and seventh decade, with no gender predominance. Incarceration is rare.

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative Behandlung

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date of publication: 26.04.2009

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  • Positioning, skin incision, pneumoperitoneum

    56-5

    Position patient supine on OR Table, skin prep and drape (sterile!): Entire abdomen from costal arches to symphysis pubis. Incise skin on opposite side of hernia and enter abdomen in open fashion. Bluntly insert the 10 mm trocar and accomplish the pneumoperitoneum with an intra-abdominal pressure of about 12-15 mmHg.

    Note:

    It is up to the surgeon how he/she gains access to the abdomen. Open access is preferred. Because of numerous unnoticed injuries with at times lethal outcome, medical experts in legal proceedings have become more and more wary of the Verres needle.

  • Inserting the laparoscope and working trocars

    56-6

    Insert the laparoscope with the camera and inspect for possible injury and bleeding: In particular, carefully check for any adhesions in the immediate vicinity. Laparoscopic overview: Inspect all organs and look out for any pathologies. Insert the first 5 mm trocar. Always do this under visual camera control to minimize any risk of injury. The surgeon will determine the exact location based on his/her experience and preference. The second 5 mm working trocar will be inserted later on.

  • Inspecting the hernia orifice

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    Inspect the hernia orifice Typically, this will be located between the aponeurosis of the transversus abdominis or internal oblique muscle (lateral margin) and the rectus sheath (medial margin) at the level of the arcuate line. The lateral margin is called linea semilunaris or Spieghelius line.

  • Determining the size and position of the hernia orifice

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    Mark the center of the hernia orifice with a percutaneous needle. The exact location of the center of the hernia orifice must be known because otherwise it is impossible to determine the required size of the mesh. First, gently free any omentum or intestine incarcerated in the hernia. Carefully measure the exact diameter of the hernia orifice. Determine the precise edges of the hernia with the needle and mark them on the skin.

  • Choosing the best mesh size

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    Position the second 5 mm trocar under visual camera control.  After having marked the precise edges of the hernia orifice on the skin, determine the best size of the mesh. The mesh should overlap the outer edge of the hernia orifice by at least 5 cm on all sides. Mark the mesh diameter and the puncture sites for the stay sutures on the skin. This ensures that the stay sutures arming the mesh will exit at exactly as planned and that the mesh will best cover the hernia orifice.

  • Mesh positioning

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    Arm four corners of the mesh with four monofilament stay sutures. These stay sutures help to extend the mesh later on and temporarily anchor it across the hernia orifice. Furl up the mesh and introduce it through the 10 mm trocar. Depending on the size of the mesh, this may present some problems. When furling up the mesh, the stay sutures must remain on the inside and should not protrude. If the trocar is too small, replace it with a 12 mm trocar or try to insert the mesh percutaneously without the trocar in site.

    Unfurl the mesh with the graspers and roughly position it across the hernia orifice. Now adjust its position with the graspers such that its center matches the center of the hernia orifice.

  • Mesh fixation

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    Through stab incisions at the previously marked skin locations recover the stay sutures at the four corners of the mesh. Catch the stay sutures with the suture catcher, pull them through the abdominal wall and clamp them.

    Once the stay sutures have been tightened, contour the mesh precisely to the abdominal wall with graspers.

    Lower the intra-abdominal pressure to about 8 mmHg and tighten the mesh. This step reduces the concavity of the abdominal wall, caused by the intra-abdominal pressure, and ensures that the mesh will not crease later on.

    Fixate the mesh in circular fashion with helical hernia tacks: Placing the helical tacks at about 1-2 cm intervals prevents any intestinal loop or omentum becoming incarcerated between the mesh and the abdominal wall. At the same time the tacks ensure solid mesh fixation. Optionally, a second spiral of helical tacks can be stapled directly to the edge of the hernia orifice.

  • Trimming the stay sutures, removing the trocars, bleeding off the pneumoperitoneum

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    Trim the stay suture such that they will rest subcutaneously. The stay sutures hardly increase the strength of fixation and may cause significant postoperative pain at times.

    Bleeding off the peritoneum: This is done under visual camera control to check the position of the implant. Before this step, remove the 5 mm trocars under visual camera control to check for any possible bleeding. Let the pneumoperitoneum escape completely, since any gas remaining in the abdominal cavity causesd postoperative pain.

  • Fascia sutures, skin sutures, dressing

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    Close the fascia at the site of the 10 mm trocar. In order to prevent any incisional hernias, trocar access sites > 5 mm should be closed with slowly absorbable sutures. Extreme care must be taken not to injure any intestine or include it in the sutures.

    Skin sutures and sterile dressing. The skin is closed with absorbable intracutaneous sutures. However, all other standard types of suture are also possible.

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  • Intraoperative complications

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  • Postoperative complications

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Literature search

    Literature search under: http://www.pubmed.com