Laparoscopic Flank Hernia Repair

Laparoscopic Flank Hernia Repair Archana Ramaswamy, MD, and Bruce Ramshaw, MD

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lank hernias occur between the costal margin and the iliac crest. Primary acquired hernias tend to form in the inferior lumbar triangle (of Petit) and superior lumbar triangle (of Grynfeltt). The superior lumbar triangle is bounded by the 12th rib, paraspinal muscles, and internal oblique muscle whereas the inferior lumbar triangle is bounded by the iliac crest, latissimus dorsi muscle, and external oblique muscle. Unnamed hernias can also occur in the flank anywhere through muscular and fascial defects. Flank hernias are uncommon defects without any wellreported incidence. The acquired defect can be primary or secondary to trauma, infection, or surgery. Primary defects comprise 50% of flank hernias with secondary and congenital comprising the rest. Post surgical hernias can follow flank incisions primarily for kidney or adrenal surgery and less frequently after iliac bone graft harvesting, retroperitoneal vascular procedures or abscess drainage. The incidence of hernia after flank incision for urologic surgery has recently been reported as high as 31%. The risk of hernia formation has been associated with age greater than 50, wound infection, abdominal wall hematoma, and hypoproteinemia. Over 80% of these hernias were detected within 1 year of surgery.1 Flank hernias usually present as a posterior bulge that may be asymptomatic, or may be associated with mild or severe discomfort from nerve compression. Acute incarceration, though infrequent, is more commonly seen with a primary acquired defect. The diagnosis can be difficult and often imaging studies are helpful to distinguish a hernia from a soft tissue lesion, hematoma, abscess, renal lesion or muscular laxity. Imaging studies (commonly CT or MRI) are also helpful in identifying the anatomical boundaries of the hernia. Department of Surgery, University of Missouri, Columbia, MO. Address reprint requests to Bruce Ramshaw, Department of Surgery, University of Missouri, 1 Hospital Dr. MC 414, Columbia, MO, 65212.Email: [email protected]

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1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2006.04.009

This is useful for surgical planning because healthy tissue needs to be identified for mesh fixation. With intraabdominal pressure and presumed muscle atrophy, the natural history of flank hernias tends to be an increase in size. Because repair of large flank hernias can become very complex with increasing size, consideration should be given to early repair in individuals who do not have medical contraindications to surgery. Techniques for open repair of flank hernias have ranged from layered closure with muscular and fascial flaps to the use of prosthetic material. Laparoscopic flank hernia repair is based on the principles of laparoscopic repair for ventral hernias: adequate overlap of mesh with healthy tissue and appropriate fixation. These two requisites for a durable repair are often challenging in the flank. Posteriorly, the mesh is usually fixed to the paraspinal muscles (sacrospinus, serratus posterior inferior, latissimus dorsi) with attention being paid, in large hernias, to the position of the inferior vena cava. Superiorly, fixation can often be applied just below the costal margin with a flap of mesh extending up to the diaphragm. As our experience has increased with these hernias, we have found that with defects that extend right to the costal margin tack fixation can be performed at the level of a superior rib, being careful to avoid the diaphragm and thus the mediastinal organs. Inferior fixation can also be difficult with hernial defects extending to the iliac crest. In these situations, fixation can be accomplished through the iliac crest by using Mitek anchors or simply by drilling through the bone. We have chosen to leave power tools to our orthopedic colleagues and perform a dissection similar to that for an inguinal hernia, identifying Cooper’s ligament and the iliopubic tract and obtaining solid fixation at Cooper’s ligament, draping a leaf of mesh into the pelvis. Prosthetic material should be appropriate for intraperitoneal use: e-PTFE or composite lightweight polypropylene or polyester.

Laparoscopic flank hernia repair

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Operative Technique

Figure 1 After intubation, antibiotic administration (usually first generation cephalosporin) and thromboembolic precautions, bladder catherization is performed. Patient positioning is then undertaken with diligence. We position the patient in full lateral decubitus, using a bean bag if necessary, being careful to allow easy access to the area of the paraspinal muscles. The kidney rest can be used to open up the space between the costal margin and the iliac crest. The ipsilateral arm needs to be suspended in a similar manner as that used for positioning for adrenalectomy. The surgeon and assistant are positioned on the same side with the tower and monitor being placed just opposite. A monitor on the other side can be useful during suture fixation at the posteromedial border through the paraspinal muscles. The skin is then prepped widely and an adhesive skin barrier is used to keep the drapes in place.

Figure 2 Initial access is usually gained at the infraumbilical position using an open approach to place a 10 mm port. Two 5 mm ports are then usually placed in the midline above and below the camera port. A fourth trocar is sometimes placed through the paraspinal muscles and will be discussed later.

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A. Ramaswamy and B. Ramshaw

Figure 3 Initial view of the right flank hernia may demonstrate incarcerated contents including small and large bowel. Also important to note is that the initial view may not provide a realistic estimate of the hernia size because a large portion of the defect is masked by the overlying colon.

Figure 4 After reduction of any incarcerated contents, the colon then needs to be mobilized. With significant incarcerated contents, the peritoneum is often stripped down allowing access into the retroperitoneal space as the contents are reduced. If there aren’t any incarcerated contents, the white line of Toldt can be incised to begin mobilizing the colon. The kidney may also have to be mobilized lateral to medial if the hernia defect extends posteriorly. Adequate dissection has been performed when there is at least 4 cm of exposed abdominal wall circumferentially around the hernial defect. Energy sources are usually avoided during the initial dissection to avoid the risk of transmitted injury to the bowel.

Laparoscopic flank hernia repair

Figure 5 The hernia defect is then sized using spinal needles if needed. The mesh is chosen to provide at least 4 to 5 cm overlap with healthy tissue. This overlap with healthy tissue can be limited depending on the extent of the defect; hernias which extend to the costal margin or the iliac crest will be addressed later. With large posterior extension of the defect, it is imperative to assure that there is adequate tissue lateral to the spine for fixation. If this is lacking, there is a high expected risk of recurrence since the mesh will pull away from the defect edge. Preoperative CT scan is of value to identify these situations and to appropriately select patients for surgical management. Once the appropriate size mesh is chosen, four nonabsorbable sutures are placed, knots tied, and the tails left long. Sites for pulling through the transfascial sutures are marked on the skin, and the mesh is then marked for orientation, inserted into the abdominal cavity and unrolled. The sutures are then grasped with a suture passer and pulled through the abdominal wall. These are not tied down until all four sutures have been pulled through to allow adequate visualization of the entry of the suture passer and of the suture tails. We begin with the posteromedial suture because there can often be no modifications made to the site of suture pull through because of limitations in this area secondary to the spine.

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Figure 6 The next suture pulled through the abdominal wall can be the inferior or superior one. After fixation with the first two sutures, tension should be placed on these to pull the mesh up to the abdominal wall. The mesh should then be pulled taut at the unfixed superior or inferior end to see if the site marked externally for suture pull through needs to be modified. This maneuver is similarly performed for the anteromedial suture. The mesh should be stretched taut so that once the pneumoperitoneum is deflated the mesh will configure to the natural curve of the abdominal wall.

Figure 7 Tacks are then placed circumferentially at 1 cm intervals. Additional transfascial sutures should be placed when a large mesh is being used, at 4 to 5 cm intervals around the mesh.

Laparoscopic flank hernia repair

Figure 8 (A,B) For large defects, a trocar may need to be placed through the paraspinal muscles to obtain an angle to apply fixation for the anteromedial edge of the mesh. Depending on the posteromedial extent of the mesh fixation, this 5-mm trocar may be medial to the mesh or come through the mesh.

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Figure 9 A hernia defect that extends to the level of the iliac crest will require either fixation through the bone, or fixation down in the pelvis. We choose to identify Cooper’s ligament and place tacks at this level, leaving a skirt of mesh draped into the pelvis. The inferior edge of the mesh is also fixed just anterior to the iliopubic tract, both with tacks and sutures. Similar to an inguinal hernia repair, no fixation should be placed below the iliopubic tract to avoid nerve and vascular injury.

Laparoscopic flank hernia repair

Figure 10 For fixation, with the defect edge bordering on or in close proximity to the costal margin, the mesh is sized and positioned to provide a 5 cm flap above the costal margin. Transfascial fixation is then performed just subcostally and tack fixation is performed at the level of a rib. Intercostal vessel injury is a theoretical risk, though unlikely since the tacks are only 3.8 mm long and need to first go through at least a 1 mm mesh. Of importance here is to avoid placing any tacks in the diaphragm to minimize risk of cardiac or lung injury.

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Figure 11 Appearance after the final fixation has been completed, applicable in a patient with a small hernia.

Figure 13 Appearance after the final fixation has been completed, applicable for a large hernia when fixation is required both at the level of Cooper’s ligament and up to the diaphragm.

Figure 12 Appearance after the final fixation has been completed, applicable for a large hernia when fixation is required both at the level of Cooper’s ligament and up to the diaphragm.

Figure 14 CT scan image of right flank hernia following repair.

Laparoscopic flank hernia repair Postoperative care is similar to that for laparoscopic ventral hernia repair. Early ambulation is encouraged. The bladder catheter is removed in the immediate postoperative period for simple cases or on ambulation for large repairs. Adequate analgesia can be achieved with regular administration of nonsteroidal anti-inflammatory agents in addition to narcotics with a PCA if needed. Epidural analgesia is currently being evaluated for efficacy in patients undergoing laparoscopic ventral hernia repair. Oral intake is allowed on the day of surgery and advanced as tolerated by the patient. Venous thromboembolic prophylaxis should be undertaken until there is adequate ambulation. Postoperative seromas are frequent and usually resolve spontaneously over 4 to 6 weeks. Abdominal binders may be used for patient comfort. We do not routinely drain seromas, and will only consider it after a prolonged period in a severely symptomatic patient since the risk of introduction of bacteria into a sterile collection exists. Short term outcomes have been good in our initial experi-

61 ence. Of our first 10 cases, nine were incisional hernias, and one was posttrauma. Median hernia diameter was 222 cm2 (25-780 cm2) and median size of mesh was 600 cm2 (962368 cm2). Median operative time was 137 minutes (81-322 minutes). There were no intraoperative or postoperative complications and median hospital stay was 2.5 days (0-6 days). There were no complications or recurrences at 1 month follow up. In conclusion, laparoscopic repair is well suited for flank hernias because there is clear visualization, and wide coverage and secure fixation can be achieved. Good knowledge of groin and retroperitoneal anatomy is required and patient positioning is key to accessing this difficult region.

Reference 1. Delgado MS, Urena MAG, Garcia MV, Marquez GP: La Eventracion Lumbar Como Complicacion de la Lumbotomia Por el Flanco: Revisio de Nuestra Serie. Actas Urol Esp 26:345-350, 2002