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 ¤  Abstract
 ¤ Introduction
 ¤ Case Report
 ¤ Discussion
 ¤ Conclusion
 ¤  References
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 Table of Contents     
UNUSUAL CASE
Year : 2013  |  Volume : 9  |  Issue : 4  |  Page : 187-189
 

Single incision Laparoscopic repair of post CABG sternotomy sub xiphoid hernia


1 Department of General Surgery, ESIPGIMSR, Andheri (East), Mumbai - 400 093, Maharashtra, India
2 Department of Anaesthesia, ESIPGIMSR, Andheri (East), Mumbai - 400 093, Maharashtra, India

Date of Submission19-Mar-2012
Date of Acceptance21-Sep-2012
Date of Web Publication27-Sep-2013

Correspondence Address:
Haresh K Shah
12A Gokul Nivas, 122 L T Kotnis Marg, Opp. Fire-station, Mahim (West) - 400 016, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.118845

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 ¤ Abstract 

The current decade has witnessed the evolution of Minimal Access Surgery (MAS) from Multi port Laparoscopy to Single Port Laparoscopy. The reduction of ports, subsequent scars and pain makes MAS more patients friendly. Symptomatic Subxiphoid Incisional hernias in patients having post CABG Sternotomy are surgically challenging. This is because of the difficult anatomical position i.e. sternum and the ribs superiorly and the diaphragm posteriorly. Another reason is high intra-abdominal pressure with the shearing forces of the musculature in the upper abdomen. Consequently the conventional open primary anatomical or mesh repairs are difficult to perform and have a high recurrence rate. Laparoscopy promises to be an effective technique to treat this condition. In this case report we describe the use of Laparoscopy in particular: Single Incision for the repair of CABG Sternotomy Subxiphoid Hernia along with relevant literature. This is the first report in English Language Literature.


Keywords: Incisional Hernia, intra peritoneal onlay mesh, Post CABG Sternotomy, single incision laparoscopic surgery, sub xiphoid hernia


How to cite this article:
Shah HK, Chaudhari N, Khopade S, Thombare B, Chavan SG. Single incision Laparoscopic repair of post CABG sternotomy sub xiphoid hernia. J Min Access Surg 2013;9:187-9

How to cite this URL:
Shah HK, Chaudhari N, Khopade S, Thombare B, Chavan SG. Single incision Laparoscopic repair of post CABG sternotomy sub xiphoid hernia. J Min Access Surg [serial online] 2013 [cited 2019 May 24];9:187-9. Available from: http://www.journalofmas.com/text.asp?2013/9/4/187/118845



 ¤ Introduction Top


Now a days with an increase in the number of CABGs, the incidence of Subxiphoid Incisional hernia after median Sternotomy is on the rise. The precise incidence is not known, but the reported incidence is 1% to 4.2%. [1],[2],[3] The repair of Subxiphoid hernia is a difficult procedure which results in a high rate of recurrence. Laparoscopic approach is a promising new technique for more efficacious treatment of this condition. [2] In this case report we describe the use of Single Incision Laparoscopy for the repair of Post CABG Subxiphoid Hernia as Single Incision. Such Transumbilical Single Incision minimises surgical invasion without compromising accessibility, exposure and operating time. It also almost completely abolishes post-operative pain and ensures early ambulation.


 ¤ Case Report Top


Our patient: Male, 65 yrs; BMI 28; 4 yrs post CABG presented with a painful, increasing Subxiphoid Hernia. [Figure 1]. CT scan was done in view of the unusual hernia site to rule out thoracic defect (diaphragm) and the defect was 4cm X 4cm [Figure 2]. Under Combined General Epidural Anaesthesia the hernia was repaired with Transumbilical Single Incision Intra Peritoneal Onlay Dual layered Meshplasty with four transfascial sutures and absorbable tacks for mesh fixation. A Covidien SILS port [Figure 3] and standard laparoscopic straight instruments [Figure 4] were used for hernioplasty. The transfacial sutures were placed as follows: just below the xiphoid process, in the right and left subcostal region and above the umbilicus.
Figure 1: Post cabg subxiphoid incisional hernia

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Figure 2: Computed tomogram

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Figure 3: Single incision port

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Figure 4: 2.5-cm single transumbilical port

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In between the transfascial sutures [Figure 5], the mesh was secured with 5 mm absorbable tacks [Figure 6]. The total operative time for the hernioplasty was 40 minutes.
Figure 5: Suture passer

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Figure 6: Absorbable tacks

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 ¤ Discussion Top


Post-strenotomy sub-xiphoid incisional hernia is uncommon and is a difficult location for hernia repair like the Flank and Suprapubic Hernias. The hernia defect is located in the caudad portion of the Sternotomy, where the incision enters the epigastrium. The defect is relatively protected from intestinal incarceration by the anterior surface of the liver.

Factors predisposing this area to herniation include lateral traction forces on the abdominal wall, [2] male sex, obesity, postoperative wound infection, and left heart failure. [1] As with all hernias, operative repair of Subxiphoid hernias is indicated for symptoms or incarceration. Due to its anatomical position in the epigastrium, open hernia repair is cumbersome. [2] Adequate exposure of the hernia and mesh placement usually requires dissection of the falciform ligament. Securing the mesh in this region is especially difficult due to the proximity of the ribs, diaphragm, and central tendon of the diaphragm. Abdominal pressure secures the mesh and adds strength to the repair, and the left lobe of the liver and stomach make this region relatively protected. Conventional open primary repair of abdominal wall hernias has a high recurrence rate. A recurrence rate of 43% to 80% has been reported with primary midline reapproximation of the fascia. Proper placement of mesh requires dissection of the retro-xiphoid space to allow a subfascial position and adequate overlap [Figure 7]. The laparoscopic approach to repair of Subxiphoid epigastric hernias has been described in few reports in the literature with good success. [1],[2],[3] Laparoscopy is useful because it allows for excellent sub fascial visualization of the epigastrium and edges of the defect, avoidance of the previous incision and minimal tissue trauma. As with all laparoscopic ventral hernia repairs, proper fixation of the mesh depends on the use of both transfascial sutures [Figure 5] and absorbable tacks [Figure 6]. The use of only a 2.5-cm Single Transumbilical Incision [Figure 4] further minimizes surgical invasion without compromising on the surgical accessibility, exposure, technique or increasing the time of surgery [Figure 7]. The use of Combined General Epidural Anaesthesia here was advantageous as it decreases the requirement of anaesthetic agent and ensures better post-operative analgesia and early ambulation decreases thromboembolic, cardiac, pulmonary and gastrointestinal postoperative morbidity. The patient returned early to work. [5]
Figure 7: Final look

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 ¤ Conclusion Top


Post CABG Sub xiphoid hernioplasty is undoubtedly better managed by Laparoscopy than by Open Surgery. Laparoendoscopic Single Site Surgery is definitely cosmetically better and less invasive than Multiport Laparoscopy for this kind of hernia repair.

 
 ¤ References Top

1.Davidson BR, Bailey JS. Incisional herniae following median Sternotomy incisions: Their incidence and aetiology. Br J Surg 1986;73:995-6.   Back to cited text no. 1
[PUBMED]    
2.Landau O, Raziel A, Matz A, Kyzer S, Haruzi I. Laparoscopic repair of poststernotomy subxiphoid epigastric hernia. Surg Endosc 2001;15:1313-4.  Back to cited text no. 2
[PUBMED]    
3.Mackey RA, Brody FJ, Berber E, Chand B, Henderson JM. Subxiphoid incisional hernias after median sternotomy. J Am Coll Surg 2005;201:71-6.  Back to cited text no. 3
[PUBMED]    
4.Cohen MJ, Starling JR. Repair of Subxiphoid Incisional hernia with Marlex mesh after median Sternotomy. Arch Surg 1985;120:1270-1.   Back to cited text no. 4
[PUBMED]    
5.Eldor J. Combined spinal-epidural-general anesthesia. Med Hypotheses 1995;45:86-90.  Back to cited text no. 5
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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