Hernia (2009) 13:281–286 DOI 10.1007/s10029-009-0478-1
O R I G I N A L A R T I CL E
Laparoscopic incisional lumbar hernia repair N. Yavuz · Y. E. Ersoy · O. Demirkesen · O. B. Tortum · S. Erguney
Received: 21 July 2008 / Accepted: 16 January 2009 / Published online: 26 February 2009 © Springer-Verlag 2009
Abstract Purpose Incisional lumbar hernia is an uncommon hernia type. Open surgical procedures have signiWcant postoperative morbidity and patient dissatisfaction, therefore, for the repair of seven incisional lumbar hernias, we attempted using an intraperitoneal laparoscopic technique that was described to have good short-term results and decreased morbidity. Methods We applied a laparoscopic technique using polypropylene meshes in Wve patients and composite meshes in two patients to cover the defect, then placed prolene sutures and hernia staples to secure the mesh intraperitoneally. Result The technique was successful in all patients, and they tolerated the procedure well. All did well after surgery, ambulating and eating a regular diet on postoperative day 1. No postoperative complications developed. At a mean follow-up of 34.1 months (range 17–43 months) none of them had pain, mass, or evidence of recurrence, and furthermore, cosmesis was excellent.
N. Yavuz · O. B. Tortum · S. Erguney General Surgery Department, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey Y. E. Ersoy II. General Surgery Clinic, Vakif Gureba Research and Training Hospital, Istanbul, Turkey O. Demirkesen Urology Department, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey Y. E. Ersoy (&) Estonsehir, 1. Mahalle, KV 28/1 Bahcesehir Yani, Kucukcekmece/Istanbul, Turkey e-mail:
[email protected]
Conclusions We believe that the laparoscopic approach is feasible, safe, and the least invasive choice for repairing diYcult hernias such as incisional lumbar hernias. Keywords Incisional lumbar hernia · Laparoscopic repair · Intraperitoneal · Minimally invasive · Cosmesis
Introduction Lumbar hernias are defects that occur infrequently in the posterolateral abdominal wall, and in general they are classiWed into two groups by etiology: congenital or acquired [1, 2]. Acquired lumbar hernias are further classiWed as either primary or secondary hernias. Primary hernias can appear in two forms based on their locations: inferior or Petit type, and superior or Grynfeltt type (Wrst described by Grynfeltt in 1866). The secondary lumbar hernias are attributed to trauma to lumbar region, infection, or previous surgery (lumbotomy incision for nefrectomy, aortic aneurysm repair incisions or resection of abdominal wall tumors, bone resection on the iliac crest, and latissimus dorsi myocutaneous Xap) [2–8]. Patients typically have a bulge in the suprailiac area posteriorly that may be associated with pain [3]. Repairing these hernias is often diYcult, and it has remained a signiWcant surgical challenge for over three centuries [9]. Many techniques have been described for surgical repair of lumbar hernias, with an incision from the 12th rib to the iliac crest, including primary repair, local tissue Xaps, onlay fascial Xaps, and conventional prosthetic mesh repair [1, 3]. Despite the various methods, no repair has been adopted as the most favored surgical approach. The reasons for this include the relative rarity of lumbar hernias, the diYculty in deWning the external edges of the fascial defect because of
123
282
the location, the lack of adequate fascia and the inherent weakness of the surrounding tissue, the bony structure of the boundaries, concomitant paralysis of the muscles, and the lack of collective experience of any one surgeon or group of surgeons to allow modiWcation and improvement in the operative technique [1, 6, 10]. In recent years, laparoendoscopic techniques have been reported that achieved success in repairing these diYcult hernias using a variety of synthetic meshes [9]. We have applied the laparoscopic intraperitoneal repair technique to seven incisional lumbar hernias and described our experience with this approach using polypropylene and composite meshes as an alternative to the open surgical approach. We reviewed the literature and discussed the technical advantages.
Methods Patients From May 2003 to August 2005, seven patients with lumbar incisional hernias underwent laparoscopic intraperitoneal repair. Five of them were female (71.4%) and two were male (28.6%). Mean patient age was 48.7 years (range 31–81 years). The diagnosis was clinical. Abdominal computerized tomography revealed colon and left kidney in the hernia sac (Fig. 1) in one patient and omental herniation in the others. Six of the patients had previously been operated on for renal-stone disease (four of them had nefrectomy and two had their renal stones extracted). One of the patients who had chronic renal failure also had nefrectomy. Herniation was on the left in Wve patients and on the right in two. All of them had laparoscopic intraperitoneal incisional hernia repair with prolene or composite meshes.
Fig. 1 Computerized tomography appearance of a patient with left lumbar incisional hernia
123
Hernia (2009) 13:281–286
Surgical technique With the patient in a full lateral decubitus position (Fig. 2) under general anesthesia, and a lumbar roll in place— opening the space between the rib cage and the iliac crest to optimize the exposure—the kidney rest was elevated and the bed was Xexed. Positioning the patient side up facilitated the operation by allowing gravity to retract the viscera to fall away from the operative Weld. Then a 12mm incision was made in the midclavicular line halfway between the 12th rib and the iliac crest. Carbon dioxide (CO2) pneumoperitoneum was established to a pressure of 12 mmHg using a Veress needle placed subcostally in the midclavicular line at the lateral edge of the abdominal rectus musculature. A 10-mm trochar was then inserted. The remaining ports (generally two 5-mm ports) were placed under visual 30° laparoscopic guidance based on the location and the size of the hernia. After the abdominal cavity was entered, omental adhesions from the previous surgeries were dissected free, exposing the hernia defect. The contents of the hernia were carefully extracted from the sac, and adhesions of these contents to the sac were divided as needed. Next, the edges of the hernia defects were deWned, and the sizes of the defects were determined. Five polypropylene meshes and two composite meshes were used to repair the defects. Typically, the meshes were cut so that they overlapped the entire fascial edges of the hernias with at least a 4-cm margin in all directions. Mesh sizes were 10–15 and 10–20 cm to extend beyond the edges of the fascial defects. The meshes were secured to the fascia around the hernia defect with a combination of tacking and suturing (full thickness, transabdominal sutures of 2/0 polypropylene) techniques. Distinct marks were placed on the mesh and on the external abdominal surface to assist intra-abdominal orientation.
Fig. 2 Position of the patient and port localizations (for left lumbar incisional hernia)
1 3 90 Tacker 10 £ 15 Prolene 6 £ 10 Left colon HT Hypertension, MNG multinodular goiter, DM diabetes mellitus
Left Nefrectomy Renal-stone disease M 31
Pain, swelling
2
2 7
11 90
120 Tacker
Tacker 10 £ 20
10 £ 15 Prolene
Composite 6 £ 10
4£6 Omentum
Omentum Left
Right Nefrectomy
Nefrectomy Renal-stone disease
Renal-stone disease Pain 45
Pain, swelling F
F
46
2
1 7 90 Tacker 10 £ 15 Composite 4£6 Omentum Left Renal-stone extraction Renal-stone disease F 48
Pain, swelling
6
13 150
75 Tacker
Tacker 10 £ 20
10 £ 15 Prolene
Prolene 8 £ 10
4£6 Omentum
Omentum Right
Left Nefrectomy
Nefrectomy Chronic renal failure
Renal-stone disease Pain, swelling
81
Pain
M
F
39
10 120 Anchor 10 £ 15 Prolene 6£8 Colon Left Renal-stone extraction Pain F
Renal-stone disease, HT, MNG, DM
Hernia localization Previous operation Coexistent medical conditions
51
Incisional lumbar hernias following surgeries with Xank and lumbar approaches are rare, including small neck hernias and large protrusions on the posterolateral aspect of the
Sex Complaints
Discussion
Age (years)
Laparoscopic repair of lumbar incisional hernia was successful in all patients, and the patients tolerated the procedure well. Using polypropylene and composite meshes enabled complete coverage of the hernia beyond the boundaries of the defects. We had no intraoperative complications such as bleeding or injury to the viscera, ureters, or nerves located close to the hernia defect, and blood loss was minimal. Mean operative time was 105 min (range 75– 150 min). The patients did well after surgery, ambulating and eating a regular diet on postoperative day 1. No postoperative complications such as infection, hematoma, or seroma developed. The patients were discharged after a mean time of 8.14 days (range 3–13 days). The patients returned to normal activities in about 1.57 weeks (range 1–2 weeks). At a mean follow-up of 34.1 months (range 17–43 months) after undergoing laparoscopic incisional lumbar herniorrhaphy, none of them had pain, mass, or evidence of recurrence, and cosmesis was excellent. Table 1 lists the characteristics of the patients and operative data.
Table 1 Patient characteristics and surgical data on laparoscopic incisional lumbar hernia repair
Results
Hernia content
Hernia size (cm)
Mesh type
Mesh size (cm)
Mesh Wxation
Operating time (min)
Hospital stay (days)
Return to normal activity (weeks)
After sutures (2/0 prolene) were placed at four corners of the mesh, it was wrapped around a laparoscopic grasper and inserted through the 10-mm trocar. Once the mesh was unfurled and oriented correctly, four to six small skin incisions were made at the mesh corners, with a number 11 scalpel blade, and a suture passer was passed through the full thickness of the posterolateral abdominal wall. Then the preplaced sutures were pulled through the abdominal wall at slightly diVerent angles with the suture passer at predetermined locations so that the suture passer would penetrate the muscular fascia and mesh at least 1 cm away from the Wrst pass. With both ends of the suture outside the abdomen, the suture was tied to itself within the subcutaneous layer. The same suturing technique was used for the other mesh corners to secure the mesh. In six of the patients, a 5-mm spiral tissue tacker (ProTack; United States Surgical, Norwalk, CT) was used, and in one of the patients, an endo-anchor (Ethicon) was used to Wx the mesh to the peritoneum in the gaps between sutures each at least 1 cm apart. The small skin incisions were reapproximated using 4/0 polypropylene mattress sutures.
1
283
2
Hernia (2009) 13:281–286
123
284
abdominal wall [8]. They complicate 7% of retroperitoneal approaches [5]. A 25% risk of incarceration and 8% risk of strangulation have been reported [3]. Although lumbar incisional hernias are uncommon in healthy individuals, several factors may contribute to their development including advanced patient age, chronic debilitation, nutritional depletion, obesity, pulmonary conditions with cough, previous wound infection, and postoperative sepsis [8, 11]. The most common symptom is a posterior, small or large regional protruding bulge in the lumbar region and at the site of a previous operation, which usually disappears easily under pressure [1–3, 8]. It may be asymptomatic, associated with a vague sense of local and abdominal discomfort, or the cause of notable localized tenderness. Depending on the hernia contents, the patient may experience pain that can travel down along the sciatic nerve or be referred to the anterior abdomen due to panniculitis or incarceration of the viscera. Signs of intestinal obstruction or strangulation may also be present [2, 3, 6]. The diagnosis may be made clinically in the majority of cases. Sometimes, however, when the defect is associated with vague and ill-deWned symptoms, or presents after trauma or injury, it is diYcult to detect it on physical examination, and it can be easily missed by even the most careful diagnostician. Even when lumbar hernias are eventually identiWed, large defects can be diYcult to repair. Thanks to the more widespread use of imaging modalities such as CT and MRI, the diagnosis of lumbar hernia is more easily made [9]. Those who are suspected of having incisional lumbar hernias should undergo an imaging study before surgical repair to determine the cause of the symptoms and to enable detection of small or additional hernias and deWne the boundaries of the defect before planned surgery [8, 10]. A diagnosis is often easily obtained with the use of a CT scan [1, 3, 5]. In addition to making the diagnosis of hernia, CT typically allows clear assessment of the size of the defect and the diVerent muscle layers, identiWes the anatomical relationships in this region well, visualizes the contents of the hernia if present, deWnes the hernia boundaries and any concomitant intra-abdominal pathologies, and provides needed information if the mass, in actuality, is a tumor [1, 3, 5]. Ultrasonography is also an imaging modality that can be used to make the diagnosis of a hernia in the posterior abdominal wall. It is less costly, safe, quick, eVective, and often easily accessible in the physician’s oYce [3]. The diVerential diagnosis of a Xank bulge with or without pain may include a lipoma, rhabdomyoma, abscess, hematoma, or various renal tumors or sarcomas, in addition to a posterior abdominal wall hernia [3]. Furthermore, lumbar incisional hernias have to be distinguished from abdominal wall musculature denervation atrophy, which is a result of an injury to the subcostal nerve during Xank incisions or due to herpes zoster and manifests as laxity and, in severe
123
Hernia (2009) 13:281–286
cases, protrusion of the abdominal contents through the Xank as a large hernia [3, 5, 11]. Given the inherent risks of complication, and because even those hernias that remain benign become more diYcult to repair as they enlarge, it is recommended that all lumbar hernias be repaired early if medically feasible [3]. Although several techniques have been described for the open repair of incisional lumbar hernia such as simple closure, placement of various rotational musculofascial pedicle Xap grafts with bony Wxation for secure coverage of the defect, free grafts, fascial strip repair, and applying various synthetic meshes, such as polypropylene mesh, with muscle Xaps in sandwich fashion [8, 9, 11, 12], it is diYcult to identify the best surgical approach, and no procedure has been shown to have a clear advantage over the others, especially in view of the relative rarity of these cases [5]. Open surgical repair of a Xank incisional hernia may be diYcult due to fascial attenuation and bony hernia boundaries including the iliac crest and/or 12th rib [1] and the lack of adequate tissue for coverage and the need for extensive dissection [11]. This approach requires a large incision and may result in signiWcant postoperative morbidity [8]. The use of prosthetic mesh to repair lumbar hernias usually requires a Xank incision over the hernia defect and suturing of the mesh around the hernia edges. But a large incision is usually required because palpation inadequately deWnes the external defect. The bony boundaries of these hernias also may make adequate Wxation of the synthetic material diYcult [1]. However, regardless of the technique, the open surgical approach is associated with signiWcant morbidity and long convalescence related to extensive surgical dissection. Thanks to the laparoendoscopic surgery, however, minimally invasive surgical techniques can be the solution to this challenging surgical problem. Recently, laparoscopic techniques that were developed and described to repair incisional ventral hernias have been applied successfully for the repair of incisional lumbar hernias with good short-term results and decreased morbidity (quick recovery, less pain, and decreased ileus) [3, 5, 6, 9–11, 13, 14]. Principles of laparoscopic repair include lateral decubitus positioning with table Xexed, adhesiolysis, and reduction of hernia contents, securing a prolene mesh with staples, and transfascial prolene sutures. Internal visualization of the hernia using the laparoscope under pneumoperitoneum aVords an excellent anatomic view of the whole of the lumbar area, hernia type and content, and the edges of the fascial defect so that unrecognized small preoperative defects can be included in repair at the deepest layer of the posterior abdominal wall without a large incision [1, 6, 8, 10]. In the study of Heniford et al. [3], a 3-cm superior defect that was not detected by CT was identiWed by laparoscopy and repaired simultaneously. The size of the hernia can be measured accurately, and the size of the mesh can be tailored as needed.
Hernia (2009) 13:281–286
In 1996, Burick and Parascandola [14] reported the initial case of a successful transperitoneal repair of a traumatic superior lumbar hernia via laparoscopy. A few months later in 1997, Bickel et al. [13] successfully repaired an acquired superior lumbar triangle hernia laparoscopically in a morbidly obese (110 kg) patient. In 1997, Heniford et al. [3] reviewed the laparoscopic approach to lumbar herniorrhaphy and described a transperitoneal, three-port, lateral position repair using a 4-cm overlapping PTFE patch secured intraperitoneally with transabdominal polypropylene sutures placed at 3-cm intervals. In 1998, Arca et al. [1] presented a series of seven laparoscopically repaired lumbar hernias using a mixture of mesh types, six of which showed no recurrences with a 1- to 15-month follow-up. In 1999, Woodward et al. [15] operated on a patient who had previously undergone an attempt at open mesh repair of a lumbar hernia that occurred following iliac crest bone harvesting, by laparoscopic retroperitoneal Wxation of the prosthetic material to the iliac crest using bone screws. In 2001, Shekarriz et al. [8] reported three cases of successful repair using a four-trocar, transperitoneal, polypropylene mesh technique with staple Wxation. Meinke [9] repaired a large inferior triangle lumbar hernia successfully in 2002, using laparoendoscopic surgical techniques and overlapping synthetic mesh technique while remaining entirely in an extraperitoneal plane. The following year, in 2003, Habib [4] repaired a primary GrynfelttLesshaft hernia using a retroperitoneoscopic tension-free method and suggested retroperitoneoscopic tension-free repair for primary and postoperative lumbar hernia and transabdominoretroperitoneal laparoscopic tension-free repair for traumatic lumbar hernia. Encouraged by all of these reports, we decided to approach the incisional lumbar hernias via laparoscopy. With the excellent visualization of both the incisional lumbar hernia defect and the surrounding abdominal wall anatomy, this approach resulted in a generous operating space to easily complete the repair using a transabdominal-wall suture technique with staple reinforcement. Laparoscopy, a minimally invasive approach, is technically feasible and some of its advantages are reduced postoperative pain and analgesic requirements, decreased hospital stay, better functional and cosmetic results, minimal lifestyle intrusion, and a quick resumption of normal activities [1, 3, 6, 8, 10]. Postoperative lifting restrictions are similar to those after routine open surgery [8]. The use of laparoscopic techniques to repair large incisional lumbar hernias seems to have aVorded us several advantages while eVecting a complete reconstruction of the area. The mesh was placed to cover the defect, allowing intra-abdominal pressure and the staples to hold it in position; we were able to use familiar techniques (the same as those used for laparoscopic ventral herniorrhaphy) to Wx the
285
unusual problem; and the technique notably limited the size of the incision and probably the associated patient discomfort [3]. Therefore, this approach is preferable to open surgery since it requires less tissue dissection [8]. The intraperitoneal approach may also be advantageous over the usual open-Xank approach via the previous incision, which requires dissection through a previous operative Weld in scarred tissue [8]. Lumbar incisional hernia must be diVerentiated from muscle atrophy with no fascial defect, and the laparoscopic approach also provides an attractive option for this often challenging problem [5]. In conclusion, although the laparoscopic procedure requires skill, it enables the surgeon to obtain an exact localization of the anatomic defect from inside the hernia site, avoiding the need for wide exploration and dissection of the lumbar region through large incision. It provides an excellent anatomic view, thus avoiding injury to structures (such as the ureter or nerves) or viscera in proximity to the hernia during repair. Furthermore, it possesses all the wellknown advantages of the laparoscopic approach (minimal morbidity, less postoperative pain and wound infection, a shorter hospital stay, and quick postoperative recovery) [2, 13]. It is feasible, safe, and the least invasive choice for surgical therapy; thus, it contributes to a better quality of life for the patient. Although long-term follow-up is necessary for assessing the ultimate eYcacy of this procedure, we believe that as experience with laparoscopic ventral herniorrhaphy grows and the long-term results continue to emerge, the laparoscopic approach using the same methods can be the treatment of choice for repairing these diYcult lumbar incisional hernias and that the laparoscopic repair may be of better durability than the previously suggested open surgical techniques [3, 8]. Acknowledgments This study was presented as a poster abstract at SAGES 2008 meeting, April 9–12, in Philadelphia, PA, USA.
References 1. Arca MJ, Heniford BT, Pokorny R et al (1998) Laparoscopic repair of lumbar hernias. J Am Coll Surg 187:147 2. Maeda K, Kanehira E, Shinno H et al (2003) Laparoscopic tension-free hernioplasty for lumbar hernia. Surg Endosc 17(9):1497 3. Heniford BT, Iannitti DA, Gagner M (1997) Laparoscopic inferior and superior lumbar hernia repair. Arch Surg 132:1141 4. Habib E (2003) Retroperitoneoscopic tension-free repair of lumbar hernia. Hernia 7:150–152 5. Salameh JR, Salloum EJ (2004) Lumbar incisional hernias: diagnostic and management dilemma. JSLS 8(4):4–391 6. Madan AK, Ternovits CA, Speck KE et al (2006) Laparoscopic lumbar hernia repair. Am Surg 72(4):21–318 7. Moreno-Egea A, Baena EG, Calle MC et al (2007) Controversies in the current management of lumbar hernias. Arch Surg 142(1):8–82 8. Shekarriz B, Graziottin TM, Gholami S et al (2001) Transperitoneal preperitoneal laparoscopic lumbar incisional herniorrhaphy. J Urol 166(4):9–1267
123
286 9. Meinke AK (2003) Totally extraperitoneal laparoendoscopic repair of lumbar hernia. Surg Endosc 17(5):7–734 10. Moreno-Egea A, Torralba-Martinez JA, Morales G et al (2005) Open vs laparoscopic repair of secondary lumbar hernias. A prospective nonrandomized study. Surg Endosc 19:184–187 11. Sutherland RS, Gerow RR (1995) Hernia after dorsal incision into lumbar region: a case report and review of pathogenesis and treatment. J Urol 153:382 12. Bolkier M, Moskovitz B, Ginesin Y et al (1991) An operation for incisional lumbar hernia. Eur Urol 20:52
123
Hernia (2009) 13:281–286 13. Bickel A, Haj M, Eitan A (1997) Laparoscopic management of lumbar hernia. Surg Endosc 11:1129 14. Burick AJ, Parascandola SA (1996) Laparoscopic repair of a traumatic lumbar hernia: a case report. J Laparoendosc Surg 6:259 15. Woodward AM, Flint LM, Ferrara JJ (1999) Laparoscopic retroperitoneal repair of recurrent postoperative lumbar hernia. J Laparoendosc Adv Surg Tech A 9(2):6–181
