Perioperative management - Spigelian hernia, laparoscopic

Spigelian hernia (SpH) is a rare form of ventral hernia, which is mostly acquired. SpH is defined as the protrusion of local preperitoneal fat tissue or a hernia sac through a defect in the Spigelian aponeurosis. The Spigelian aponeurosis refers to the fascia of the transversus abdominis muscle, laterally bounded by the semilunar line (extending from the 9th rib to the symphysis) and medially by the lateral edge of the rectus muscle. SpH is an interstitial herniation with disruption of the aponeurosis of the transversus abdominis and the internal oblique abdominis muscles, while the superficial fascia of the external oblique abdominis muscle usually remains intact. The predilection site of this hernia is the intersection between the semilunar line and the arcuate line. When located below the arcuate line, it is referred to as a "low Spigelian hernia," a subtype of SpH, which is situated caudally to the inferior epigastric artery within Hesselbach's triangle. In the axial plane, the hernia sac tends to extend laterally into the interstitial layer between the internal and external oblique muscles, without penetrating the intact external oblique aponeurosis. The specific anatomical situation of SpH, with a rather small hernia orifice and the development of an interoblique hernia sac, complicates the diagnosis of this condition with a particular tendency towards incarceration. The most important epidemiological feature is the risk of incarceration requiring emergency intervention, affecting up to 17% of all SpH cases. Compared to other ventral hernias, SpH has a significantly increased risk of incarceration.

Due to the significant risk of incarceration, all SpH should be surgically treated.

Regardless of the technique used, mesh repair is recommended. Only for small hernias (< 2 cm) can a repair without mesh be a reasonable alternative.

The IPOM method is considered the easiest to learn and the safest to perform.

The advantage of the IPOM procedure or the TAPP method in "low Spigelian hernia" is the ability to explore the entire abdomen. Both methods can also be applied in emergency situations with incarcerated hernia content.

• bacterial peritonitis (foreign material/mesh not in case of inflammation)
• ileus due to the risk of bowel perforation
• decompensated cardiorespiratory insufficiency
• In cases of severe cardiac and pulmonary pre-existing conditions, the benefits and risks of laparoscopy must be weighed, but even in cases of higher-grade heart failure or respiratory limitation, laparoscopy under monitoring (blood pressure, pulse, ECG, oxygen saturation) is feasible.
• Severe coagulation disorders (Quick < 50%, PTT > 60 s, platelets < 50 /nl) and pronounced portal hypertension with caput medusae, in both cases mainly due to the risk of bleeding from abdominal wall vessels.

Patients most commonly suffer from intermittent pain and swelling in the lower abdomen.

A "low Spigelian hernia" can be mistaken for an inguinal hernia, and the definitive diagnosis is often made intraoperatively.

Differential diagnoses of a palpable hernia sac in the typical SpH region include lipomas, hematomas of the rectus abdominis muscle, or solid tumors in the abdomen.

The SpH remains a clinical diagnosis, which can be challenging.

Imaging techniques such as abdominal wall ultrasound or computed tomography are usually performed in cases of uncertain diagnosis. Several studies indicate that abdominal sonography in SpH is a significant imaging technique with a sensitivity of 83 - 90%. The advantage of CT imaging lies in the ability to identify not only the hernia defect but also the hernia contents.

For better characterization of the present hernia, the EHS classification should be used.

Classification of primary ventral hernias

Single-shot antibiotic i.v. perioperative (due to the use of foreign material/mesh) with possible continuation of therapy in case of intraoperative signs of inflammation or bacterial contamination.

General:

• Pneumonia
• Bleeding, Hematoma
• Wound infection/Wound healing disorder
• Thrombosis/Embolism
• Excessive scar formation

Specific:

• Implantation of synthetic material
• Nerve injury/chronic pain
• Seroma (usually present, mostly without therapeutic consequence)
• Infection of the implant with the consequence of needing to remove it.
• Recurrent hernia
• Trocar hernias
• Conversion to open procedure intraoperatively
• Bowel perforation
• Subsequent interventions
• Lethality

Intubation anesthesia in capnoperitoneum

Supine positioning on the operating table, hernia-side arm positioned outward.

The surgeon and assistant stand on the side of the patient, both facing the side to be operated on. The assisting nurse stands on the side to be operated on at the foot end.

Standard MIC Set:

• Two 5mm Trocars
• One 10mm Trocar, possibly 12mm Trocar for larger mesh
• Atraumatic 5mm Forceps
• 5mm Dissecting Scissors
• Bipolar Coagulation

Additional:

• Suture Catcher (for grasping the transcutaneous holding sutures)
• Measuring Tape
• Sterile Marker
• Hernia Stapler
• Monofilament Holding Sutures
• Plastic meshes suitable for intraperitoneal placement in hernia closure (IPOM meshes).

Postoperative Monitoring: on the general ward.
Analgesia: Peripheral analgesics are usually sufficient.
Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management).
Follow the link here to the current guideline: Management of acute perioperative and post-traumatic pain.

Thrombosis Prophylaxis: In the absence of contraindications, due to the moderate thromboembolic risk (surgical procedure >30min duration), in addition to physical measures, low molecular weight heparin should be administered prophylactically, possibly in weight- or disposition risk-adjusted dosage until full mobilization is achieved.
Note: Renal function, HIT II (history, platelet monitoring).
Follow the link here to the current guideline: Prophylaxis of venous thromboembolism (VTE).

Mobilization: As early as possible, preferably on the day of surgery, possibly with an abdominal support bandage.
Physical Therapy: Not required for healthy patients.
Diet Advancement: Occurs on the day of surgery.
Bowel Regulation: Generally not required, otherwise with mild laxatives.
Incapacity for Work: Full physical load three weeks after surgery, incapacity for work depending on the profession 10-21 days.