Open umbilical hernia repair with intraperitoneal mesh (Ventralex™ patch)

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Surgical anatomy of the anterior abdominal wall

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    1. Anterior abdominal muscles

    Rectus abdominis: Long abdominal strap muscle encased by the rectus sheath, crossed by 3 – 4 tendinous intersections intimately adherent to the anterior lamina of the sheath.

    Pyramidalis: Originates at the superior pubic ramus and inserts in the linea alba; it is anterior to the rectus abdominis muscle and is enclosed in its own sheath within the anterior lamina of the rectus sheath.

    2. Layered structure of the anterior abdominal wall

    Rectus sheath: Covers the rectus abdominis; superior to the midpoint between the umbilicus and symphysis there is a distinct anterior and posterior lamina; the inferior margin of the posterior lamina ends in a tendinous raphe, the arcuate line; above this line, the external oblique muscle inserts in the anterior layer of the rectus sheath, while the internal oblique inserts in both the anterior and posterior laminae, and the transversus abdominis in the posterior lamina.

    Linea semilunaris: Transition zone between the aponeuroses of the muscles of the lateral abdominal wall and the lateral margin of the rectus sheath.

    Linea alba: About 1 cm wide tendinous raphe between the left and right rectus sheath from the xiphoid process to the symphysis.

    Transversalis fascia: Cephalad to the arcuate line it covers the inside of the posterior lamina of the rectus sheath and caudad it is in intimate contact with the rectus abdominis.

    3. Internal aspect of the abdominal wall

    Median umbilical fold: Median peritoneal plication extending from the umbilicus to the bladder and comprising the median umbilical ligament (strand of connective tissue = remains of the urachus).

    Medial umbilical fold: Bilateral peritoneal plication comprising the medial umbilical ligament = obliterated remains of the bilateral umbilical artery.

    Lateral umbilical fold: Bilateral peritoneal plication superior to both inferior epigastric arteries, each with two comitant veins.

    4. Vessels and nerves

    a) Arteries

    Superior epigastric: Branch of the internal thoracic artery, anastomosed with the inferior epigastric artery at the level of the umbilicus.

    Inferior epigastric: Branch of the external iliac artery, coursing like the latter along the posterior surface of the rectus abdominis in the rectus sheath.

    Superficial epigastric: Branch of the femoral artery; after crossing the inguinal ligament it fans out in the subcutaneous tissue of the anterior abdominal wall.

    Posterior intercostals VI – XI and subcostal artery: Derived from the thoracic aorta; their final course takes them inferiorly and obliquely between the internal oblique and transverse abdominal muscles, reaching the rectus sheath laterally, where they anastomose with the inferior and superior epigastric arteries.

    b) Veins

    Superior epigastric: They accompany the eponymic artery, anastomose with branches of the inferior epigastric vein, and drain into the internal thoracic veins.

    Inferior epigastric: Fans out into comitant veins of the inferior epigastric artery and drains into the external iliac vein.

    Superficial epigastric: Parallels the eponymic artery (see above).

    c) Lymphatic vessels

    Superficial lymphatic vessels: Cephalad to the umbilicus they course to the axillary lymph nodes and caudad to the inguinal lymph nodes.

    Deep lymphatic vessels: Usually, they parallel the blood vessels and course to the parasternal, lumbar, and external iliac lymph nodes.

    d) Nerves

    Intercostals VI – XII: Anterior branches of the thoracic nerves VI – XII; posterior to the costal cartilages they course to the abdominal wall between the internal oblique and transversus abdominis; motor branches supply the anterior and lateral muscles of the abdominal wall and sensory branches the abdominal skin.

    Iliohypogastric, ilioinguinal, and genitofemoral: Contribute to the motor and sensory innervation of the genital and lower abdominal region.

  • Special anatomy of the umbilical region

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    Umbilical region: (1) Umbilical ring, (2) Layer of collagen fibers, (3) Round ligament of liver, (4) Umbilical scar, (5) Linea alba, (6) Tendinous intersections of rectus abdominis, (7) Rectus abdominis (shining through), (8) Anterior cutaneous branches.

    The navel or umbilicus is the relic of the insertion of the umbilical cord and remains post partum at the level of the center of the body.

    The umbilicus comprises three layers:

    • Anterior superficial layer of skin and subcutaneous tissue,
    • Aponeurotic layer in the middle, and
    • Deep posterior layer of preperitoneal connective tissue and peritoneum.

    1. Superficial layer

    In adults, the rather delicate umbilical skin may only displaced cepahalad against the umbilical ring; in all other places it securely inserts in a firm connective plate underneath. Within the umbilical ring the subcutaneous tissue is rather delicate, traversed by just a few vessels and nerves.

    2. Middle layer

    The aponeurotic layer in the middle comprises a firm matrix of connective tissue traversed by the obliterated vestiges of the embryonic vessels and the remaining strand of the urachus; the matrix also closes off the umbilical orifice. At the edges of the umbilical orifice, the plate of connective tissue fuses with the umbilical ring which also accepts tendinous strands from the rectus sheath. The rugged plate of connective tissue obturates the umbilical orifice by the end of the second year of life.

    3. Deep posterior layer

    Usually, the deep posterior layer of the umbilical plate comprises a palm-sized pad of fatty tissue traversed by radial strands of connective tissue and a total of five peritoneal plications, the so called plicae umbilicales coursing from inferolaterally cepahald toward the umbilicus:

    • The sole median umbilical fold comprises the obliterated urachus,
    • Two medial umbilical folds comprising the obliterated umbilical arteries, and
    • Two lateral umbilical folds comprising the inferior epigastric vessels.

    The transversalis fascia and its adherent peritoneum seal off the abdominal cavity from the umbilical region. In the umbilical region the peritoneum is strengthened by the umbilical fascia which is made up of firm connective tissue. The fascia extends posterior to the umbilical vein, is anchored laterally to the posterior lamina of the rectus sheath and terminates caudad at the level of the center of the umbilical ring. Cephalad it extends beyond the umbilicus for about 5 cm; its fibers course toward the line alba where they conjoin.

    Between the transversalis fascia and linea alba runs a canal loosely filled with connective tissue (umbilical canal) which may pave the way for umbilical hernias.

  • Chirurgische Praxis

    Dr. Karl Heinz Moser

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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 Management

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date of publication: 26.04.2009
  • Chirurgische Praxis

    Dr. Karl Heinz Moser

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  • Skin incision

    64-5

    Semicircular skin inferior to the umbilicus (“smiling incision”).

  • Dissecting the hernia sac

    64-6

    Divide the subcutaneous tissue and dissect along the hernia sac down to the fascia.

  • Fully exposing the hernia sac

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    Free the hernia sac from the umbilicus fully exposing the sac, and incise the latter at its base

  • Excising the hernia sac

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    After full exposure of the edges of the fascia, excise the hernia sac at the level of the hernia orifice. This umbilical hernia has a diameter of about 3.5 cm.

  • Mesh insertion

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    Insert the Ventralex™ patch (6,4 cm x 6.4 cm) and check if the memory ring has sprung open and lies flat along the abdominal wall.

  • Fixating the positioning straps

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    The positioning straps are anchored with interrupted non-absorbable sutures and then trimmed.

  • Closing the fascia

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    Close the hernia orifice transversely with full bites of interrupted non-absorbable sutures

  • Reattaching the umbilicus

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    Reattach the umbilicus to the fascia.

  • Skin suture

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    Close the skin incision with an intracutaneous running suture or interrupted sutures

  • Chirurgische Praxis

    Dr. Karl Heinz Moser

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  • Intraoperative complications

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  • Postoperative complications

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  • Klinikum Ingolstadt

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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