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UNUSUAL CASE |
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| Year : 2018 | Volume
: 14
| Issue : 4 | Page : 338-340 |
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Laparoscopic retromuscular incisional hernia repair
Guido Luis Busnelli, Walter Sebastián Nardi, Carola Featherston, Daniel E Pirchi, Pablo José Medina
Department of General Surgery, British Hospital of Buenos Aires, Buenos Aires, Argentina
| Date of Submission | 19-Oct-2017 |
| Date of Acceptance | 29-Dec-2017 |
| Date of Web Publication | 3-Sep-2018 |
Correspondence Address:
Dr. Guido Luis Busnelli
Department of General Surgery, British Hospital of Buenos Aires, Perdriel 74, Caba, Buenos Aires
Argentina
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmas.JMAS_207_17
A 67-year-old male with a history of a conventional right colectomy and hypertension was referred to our department for an incisional hernia and abdominal discomfort. Physical examination also showed a supraumbilical defect that was confirmed with a computed tomography scan. Laparoscopic Rives technique repair was done to repair the defect avoiding direct contact of the mesh with the intra-abdominal viscera.
Keywords: Incisional hernia, laparoscopy, mini-invasive, Rives technique
How to cite this article:
Busnelli GL, Nardi WS, Featherston C, Pirchi DE, Medina PJ. Laparoscopic retromuscular incisional hernia repair. J Min Access Surg 2018;14:338-40 |
| ¤ Introduction | |  |
Abdominal wall hernia, primary ventral hernia and recurrences for incisional hernia repairs are the most common diseases addressed by general surgeons. The Rives–Stoppa repair is the gold standard for incisional hernia repair, offering low recurrence rate with the benefit of restoration of anterior abdominal wall function.
We describe a laparoscopic approach to ‘abdominal wall reconstruction’ using an abdominis components release following the same principles and technical steps used as Rives open technique:[1] closure of the incisional hernia defect, approximation of the posterior sheath and a large mesh placement in the retromuscular space.
| ¤ Case Report | | |
A 67-year-old male with a history of a conventional right colectomy and hypertension was referred to our department for an incisional hernia associated with abdominal discomfort. Physical examination showed a supraumbilical incisional hernia without complications and a bulging of the midline above the umbilicus that caused the patient an aesthetic discomfort. Computed tomography scan confirmed the diagnosis [Figure 1]a and [Figure 1]b. | Figure 1: (a) Pre-operative view of the upper midline defect. (b) Computed tomography scan showing incisional hernia. (c) Suprapubic port placement and bulging of the upper midline defect
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We decided to perform a laparoscopic Rives technique repair with plication of both recti muscles and midline defect measuring 10 cm × 6 cm. Finally, a polypropylene mesh measuring 12 cm × 15 cm was placed in the retromuscular space and fixed with transfascial sutures [Figure 2]d. Closure of both posterior rectus sheaths (PRSs) and peritoneum was done with a continuous cephalocaudal non-absorbable barbed suture. | Figure 2: (a) Identification and incision of edges of the posterior rectus sheaths. (b) Connecting retrorectus spaces. (c) Closure of the posterior rectus sheaths. (d) Mesh placement in retrorectal space
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Under general anaesthesia, the patient is positioned in the supine position with both legs open and the surgeon is located between them. The monitor is located at the head of the patient and the assistant on his left. Pneumoperitoneum is achieved by the placement of Veress needle through Palmer's point. Once pneumoperitoneum is established, a 10 mm trocar is introduced in the suprapubic midline [Figure 1]c and two 5 mm trocars are placed under direct vision on each side of the midline by around 5 cm. After doing lysis of all previous wall adhesions, PRSs are identified and incised at the edge of the defect [Figure 2]a. Then, both retrorectal spaces are created along its whole length in cephalad and caudal directions [Figure 2]b. This release, which exposes the posterior portion of the rectus abdominis muscle, can allow up to 3 cm of medial mobilisation of the edge of the defect.
If no acceptable midline fascia approximation is achieved, videoscopic component separation technique or laparoscopic transversus abdominis release (TAR) can be done to achieve a tension-free plication.[2]
Plication of both recti muscles with the anterior defect was done using transmural stitches of non-absorbable sutures with a laparoscopic suture passer device such as ‘Endo Closer™’.
Then, the closure of the PRS is the next important step: first, for creating a virtual space between this and the posterior face of the rectus, where the mesh is placed, and on the other hand, for excluding the intra-abdominal viscera and prevent its contact with the mesh. This step was done using a continuous non-absorbable barbed suture from the subxiphoid to suprapubic region [Figure 2]c. In this way, we had access to the retrorectus space for placing the polypropylene prosthesis before closing entirely the PRS by fixing it to the muscle with ‘absorbable straps’ [Figure 2]d.
Finally, no drainage was placed in the cavity.
The patient underwent an uneventful recovery and was discharged at 36 h post-procedure. His long-term follow-up was asymptomatic with no complications.
| ¤ Discussion | | |
We sought to combine long-standing laparoscopic principles with a well-established hernia repair technique, thus avoiding the placement of prosthetic mesh in an intraperitoneal position and therefore the direct contact with the viscera. In addition, we were able to perform the releasing of all components of the abdominal wall with only three port of access.
Since the first report of laparoscopic approach to ventral hernia repair in 1993,[3] the advantages over the open approach became remarkable, distinguishing reduced wound complication rates and faster recovery. Conventionally, it did not include defect closure and the prosthetic mesh bridged the gap. However, we consider that primary closure is essential to complete abdominal wall reconstruction according to the principles of Rives technique. Even though there is no general agreement and long-term outcomes regarding the benefits of closing the main defect,[4] we think the key of this approach is identifying the plane and the dissection of the PRSs before releasing from caudal to cephalad direction and then connecting both retrorectus spaces.[5] Once this step is reached, the closure is performed before the mesh placement.
If no acceptable midline fascia approximation is achieved, videoscopic component separation technique can be done to achieve a tension-free plication.[2] Nevertheless, with the approach described in this case report, once the rectus sheaths are dissected, the TAR is easy to achieve. This is because the transversus abdominis aponeurosis contributes to the PRS. Once the dissection exceeds laterally the semilunar lane, an incision in the transversus muscle could be performed to expose underlying transversalis fascia. Therefore, performing the component separation technique allows for a better compliance and 4–5 cm (each side) for the approximation of the muscles to the midline.
The prosthetic mesh was placed through transabdominal pre-peritoneal (TAPP) approach trying to avoid the rare but ‘well known’ complications such as adhesive bowel obstruction, mesh erosion and enterocutaneous fistula from direct contact between the mesh and intraperitoneal viscera, described with the intraperitoneal onlay mesh repair.[6],[7]
| ¤ Conclusion | | |
In patients with large abdominal wall defects, this approach is a feasible and reproducible method with the advantages of minimal invasive TAPP approach and minimal complications. This approach can be considered an alternative in those cases with the main defect above the arcuate line.
We think it could be considered a previous step to the enhanced-view totally extraperitoneal technique for laparoscopic retromuscular hernia repair.[5]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| ¤ References | | |
| 1. | Rives J, Pire JC, Flament JB, Palot JP, Body C. Treatment of large eventrations. New therapeutic indications apropos of 322 cases. Chirurgie 1985;111:215-25.  |
| 2. | Belyansky I, Zahiri HR, Park A. Laparoscopic transversus abdominis release, a novel minimally invasive approach to complex abdominal wall reconstruction. Surg Innov 2016;23:134-41. |
| 3. | LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: Preliminary findings. Surg Laparosc Endosc 1993;3:39-41. |
| 4. | Nguyen DH, Nguyen MT, Askenasy EP, Kao LS, Liang MK. Primary fascial closure with laparoscopic ventral hernia repair: Systematic review. World J Surg 2014;38:3097-104. |
| 5. | Belyansky I, Daes J, Radu VG, Balasubramanian R, Reza Zahiri H, Weltz AS, et al. A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair. Surg Endosc 2018;32:1525-32. |
| 6. | Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13:545-54. |
| 7. | Prasad P, Tantia O, Patle NM, Khanna S, Sen B. Laparoscopic ventral hernia repair: A comparative study of transabdominal preperitoneal versus intraperitoneal onlay mesh repair. J Laparoendosc Adv Surg Tech A 2011;21:477-83. |
[Figure 1], [Figure 2]
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