Extraperitoneal Ventral Hernia Repair

Abstract

“Bridged-IPOM” of Leblanc has been introduced in the 1990s [1]. IPOM is still the mainstay of the repair of ventral hernia, but it has not been without limitation. Adhesive bowel obstruction, mesh erosion, enterocutaneous fistula, and chronic pain are due to tight mesh fixations [2]. Extraperitoneal mesh placement offer advantages: the retromuscular positioning of the mesh permits the integration of both sides, providing the repair with superior tensile strength and costly coated mesh is unnecessary. Nevertheless, the laparoscopic extraperitoneal approach continues to pose limitation in available degree of freedom and significant ergonomic challenge to the operating surgeons.

Introduction

“Bridged-IPOM” of Leblanc has been introduced in the 1990s [1]. IPOM is still the mainstay of the repair of ventral hernia, but it has not been without limitation. Adhesive bowel obstruction, mesh erosion, enterocutaneous fistula, and chronic pain are due to tight mesh fixations [2]. Extraperitoneal mesh placement offer advantages: the retromuscular positioning of the mesh permits the integration of both sides, providing the repair with superior tensile strength and costly coated mesh is unnecessary. Nevertheless, the laparoscopic extraperitoneal approach continues to pose limitation in available degree of freedom and significant ergonomic challenge to the operating surgeons.

To overcome these technical difficulties, two approaches were developed, the enhanced-view totally extraperitoneal (eTEP) technique and the mini or less open sublay (MILOS) repair. eTEP has initial approach for the inguinal hernia repair [3], but combined with other retromuscular and preperitoneal repair of ventral hernia repairs such as Rives-Stoppa or Transversus Abdominis Release (TAR), it enables us to put the mesh preperitoneal space and restore the midline defect [4]. MILOS permits insertion of a large mesh in the retromuscular or preperitoneal space and anatomical reconstruction of the abdominal wall via a small transhernial incision [5].

Indications

• Ventral hernias (primary, incisional, and also complex ventral hernias—multiple sites hernias)

Contraindications

• Mesh infection and/or fistula

• Loss of domain

• Dystrophic or ulcerated skin (relative)

• Incarcerated (relative)

• Previous retromuscular ventral hernia repair (relative)

• Previous incision from xiphoid process to the pubic bone (relative)

Preoperative Assessment

• Detailed history (review of prior medical and surgical records of previous interventions, anatomy, and the presence of any mesh or fixation devices)

• Physical examination

• Biochemical studies to assess their baseline health

• Defect location and size: up-to-date computed tomography (CT) study of abdomen and pelvis is recommended (Fig. 1)

• Prior or current wound complication

• Presence of ostomy

• Excess skin

• Screening colonoscopy for patients over the age of 50 years (optional)

Fig. 1

3D reconstructed CT images are useful to know the relationship between the location of the hernia orifice and anatomy of the abdominal muscle wall

Enhanced-View Totally Extraperitoneal (eTEP) Technique

OT Setup and Patient’s Position

• Supine position with arms tacked by the side; the table is flexed, putting the patient in hyperextension

• After induction of general anesthesia and intubation, a Foley catheter is routinely placed

• Instrumentation required: 0 or 30° telescope 10 mm

• 30° telescope 5 mm

• Atraumatic Graspers [2] 5 mm

• Curved Scissors [1] 5 mm

• Suction/irrigation device

• Needle driver

• Hook electrocautery

• Energy device (optional)

• Trocars size and position (see below)

Surgical Technique

• 1. Development of the retrorectus space and port placement

  • General rule for the port placement: Trocars to be placed at the opposite part of the abdomen from the location of the hernia defect (Fig. 2).

    • Lower midline defects: cranial approach (Fig. 2 top left).

    • Upper midline defects: caudal approach (Fig. 2 top right).

    • Lateral defects: contralateral lateral approach (Fig. 2 bottom).

  • Dissecting the retrorectus space using a balloon trocar or an optic trocar (Fig. 3).

  Caution: To avoid pneumoperitoneum, trocar should be held horizontally along the anterior layer of the posterior sheath. Figure 4 indicates the tip of the optic trocar mistakenly breaks the posterior sheath.

  Caution: When using a balloon dissector, it is critical to avoid overinflation which may rupture the linea semilunaris and consequently injure the neuromuscular bundles passing through posterior sheath to the rectus muscle.

  • The retromuscular space is insufflated with CO₂ to a pressure of 10–15 mmHg (Fig. 5).

• 2. Crossover of the midline

  • “Crossover” refers to the surgical dissection that joins one retrorectus space to its contralateral counterpart without violating the intra-abdominal cavity.

  • Accomplished by remaining superficial to the falciform or umbilical ligaments—depending on where the crossing-over of linea alba is performed (Fig. 6).

  • Crossover should ideally be performed at a level of the midline which has not been previously violated.

• 3. Connection of both retrorectus spaces, left and right

  • Both retrorectus spaces are linked by the preperitoneal bridge represented by the falciform ligament and/or umbilical ligament (Fig. 7).

  • The retrorectus dissection is limited laterally by the semilunaris lines, where neurovascular bundles pass through the posterior sheath to the rectus muscles.

• 4. TAR (when needed)

  • Indication of TAR: additional TAR may be necessary if maximal defect width closely approximates or exceeds 2× rectus width (Dr. Alfredo Carbonell-ninth Annual AWR Summit, Montana, Feb 2018), tension on the posterior layer, narrow unilateral retrorectus space(<5 cm), poor compliant abdominal wall.

  • Incision of the posterior lamella of the internal oblique fascia 1 cm medially to the semilunaris line to protect the neurovascular bundles (the last 6 pairs of intercostal nerves).

  • “Bottom to top” or “top to bottom” depending on comfort of the surgeon.

  • Transection of transversus abdominis muscle (TA) and posterior component separation should be done as laterally as possible, to the psoas muscle, and as cranial (behind the diaphragm) as it is needed, depending on hernia location.

• 5. Closure of the posterior fascial layer defect

  • Closure of the posterior layer is necessary to keep a barrier between the mesh and viscera.

  • This posterior layer is not a layer of resistance, so it is recommended to preserve the peritoneum (the falciform ligament) as a bridge between the rectus sheaths.

  • It is strongly recommended to avoid any tension in the suture line on the posterior layer. To reduce tension between the posterior sheath, hemi-TAR (unilateral) or TAR could be necessary (Fig. 8).

  Compared with the anterior hernia orifice, the gap between the posterior layers became larger. In this case, right hemi-TAR was useful to close the posterior layer without tension.

• 6. Closure of the anterior fascia (Restoration of linea alba)

  • Restoration of the linea alba is done by suturing the anterior rectus sheaths on the midline. Nonabsorbable barbed 0 (zero) sutures in running fashion (Fig. 9)

  • When we pull the stitch, reduce the pressure of insufflation to 5–6 mmHg

• 7. Mesh placement

  • Appropriate mesh size selection: entire dissected area should be covered

  • Medium weight macroporous mesh (polypropylene or polyester) (Fig. 10)

  • Deployed through 12 mm trocar

  • Mesh fixation is not necessary, except in the situation of suprapubic defect.

• 8. Drain placement (optional)

• 9. Exsufflation

  • Slow exsufflation under direct vision to ensure the mesh remains in the correct position.

Fig. 2

Ports placement and patient’s position in three different situations. Upper left: Cranial approach. Upper right: Caudal approach for an epigastric hernia, inferior epigastric arteries were marked by using preoperative ultrasound. Bottom: Lateral approach for an incisional hernia located just cephalic of the right iliac crest

Fig. 3

Dissecting the retrorectus space using an optic trocar

Fig. 4

Tip of the optic trocar entered the extraperitoneal fat

Fig. 5

Retrorectus dissection

Fig. 6

Crossing the midline anteriorly to the falciform ligament

Fig. 7

Connecting the both retrorectus spaces

Fig. 8

Hemi-TAR

Fig. 9

Closure of anterior sheath by nonabsorbable suture

Fig. 10

Mesh placement

Mini or less Open Sublay (MILOS) Repair

MILOS is a minimally invasive transhernial approach. It is an open procedure, using endoscopic dissection instruments. eMILOS is an endoscopic MILOS variation and divided into single-port and multiple port.

OT Setup and Patient’s Position

Supine position with arms tacked by the side or in lithotomy position

Instrumentation required

• Standard laparoscopic instruments

  • 30° telescope 10 mm

  • Atraumatic Graspers (2) 5 mm

  • Curved Scissors (1) 5 mm

• Rectangular retractors

• Light-armed laparoscopic instruments: EndoTorch ™ (Wolf TM, Knittlingen, Germany) (optional)

• Flexible single ports (optional)

• Suction/irrigation device

• Needle driver

• Hook electrocautery

Surgical Technique

• 1. Small incision directory above the center of the hernia defect (Fig. 11)

  • skin incision of 2–5 cm = mini-open, 6–12 cm = less-open

• 2. Hernia sac preparation (Fig. 12)

• 3. Small incision of the peritoneum for diagnostic laparoscopy (Fig. 13)

• 4. Resection of abundant peritoneum of the hernia sac (Fig. 14)

• 5. Complete and precise exposure of the fascial edge of the hernia orifice

• 6. Transhernial extraperitoneal dissection around the hernia gap

  • Rectangular retractors are used to lift the abdominal wall.

  • EndoTorch™ (laparoscopic instruments armed with a light tube) is a specially designed instrument for this dissection (optional).

  • It is important to clearly expose the posterior sheath to enable safe opening of the retromuscular space (Fig. 15).

  • With large ventral hernias, MILOS and eMILOS operation can be combined with TAR.

• 7. Closure of the abdominal cavity (Figs. 16 and 17)

• 8. Transhernial extraperitoneal mesh implantation

  • The mesh should posteriorly overlap the hernia defect by at least 5 cm (Fig. 18).

• 9. Mesh fixation (optional)

• 10. Hernia defect closure (Fig. 19)

Fig. 11

Skin incision (4 cm) over the hernia sack. (Courtesy of Dr. Taketo Matsubara at St. Luke’s International Hospital, Tokyo, Japan)

Fig. 12

Dissection of the hernia sac and clear exposition of the hernia ring. (Courtesy of Dr. Taketo Matsubara at St. Luke’s International Hospital, Tokyo, Japan)

Fig. 13

Dissection of the hernia sac and clear exposition of the hernia ring. (Courtesy of Dr. Taketo Matsubara at St. Luke’s International Hospital, Tokyo, Japan)

Fig. 14

Transhernial laparoscopy. (Courtesy of Dr. Taketo Matsubara at St. Luke’s International Hospital, Tokyo, Japan)

Fig. 15

Resection of abundant peritoneum of the hernia sac. (Courtesy of Dr. Taketo Matsubara at St. Luke’s International Hospital, Tokyo, Japan)

Fig. 16

Closure of peritoneum. (Courtesy of Dr. Taketo Matsubara at St. Luke’s International Hospital, Tokyo, Japan)

Fig. 17

Closure of posterior rectus sheath. (Courtesy of Dr. Taketo Matsubara at St. Luke’s International Hospital, Tokyo, Japan)

Fig. 18

Mesh with at least 5 cm overlap. (Courtesy of Dr. Taketo Matsubara at St. Luke’s International Hospital, Tokyo, Japan)

Fig. 19

Anterior rectus sheath closure. (Courtesy of Dr. Taketo Matsubara at St. Luke’s International Hospital, Tokyo, Japan)

Complications and Management

• Injury to the bowel

• Hematoma

• Recurrence

• Intraparietal hernia: Dehiscence of the posterior sheath closure results in an intraparietal hernia in which the viscera may become incarcerated between mesh anteriorly and the posterior sheath (Fig. 20). To avoid any tension on the suture line, change the direction of suturing to close the posterior fascia.

Fig. 20

Intraparietal hernia developed 19 days after the index operation. Treated by using IPOM

Postoperative Care

• Standard Analgesia

• Discharge the patient when the patient is able to ambulate

• Reduce sports activities and carrying heavy weight for 2 weeks