JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 7, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2013.0381
Full Reports
Laparoscopic Management of Nonmidline Ventral Hernia Romesh Lal, MS, DNB, FMAS, Deborshi Sharma, MS, MRCS(Edin), FMAS, Priya Hazrah, MS, FMAS, Pawan Kumar, MS, FMAS, Saurabh Borgharia, MS, FMAS, and Abhinav Agarwal, MS
Abstract
Introduction: Ventral hernias may be primary or incisional and classified as midline ventral hernias (MVHs) or non-MVHs (NMVHs). NMVHs are rarer, and their laparoscopic management is technically challenging because of varied anatomic locations, differences in patient positioning at time of surgery, and lack of adequate lateral space for mesh fixation, compounded by the proximity of major organs and bony landmarks. A retrospective review of all the NMVHs operated on in a clinical unit is presented. Subjects and Methods: One hundred eighty-three cases met the criteria of ventral hernia, with 25 cases (13.66%) as NMVH. These NMVHs included lumbar (n = 5), suprapubic (n = 7), iliac (n = 10), and subcostal (n = 3). Univariate and multivariate analyses were done using SPSS version 19 software (IBM, Armonk, NY). Continuous data were analyzed using the Mann–Whitney U test/t test, and categorical data were analyzed using the chi-squared test. A P value of p.05 was considered significant. Results: Demographic profile and presentation were similar in all groups. One case each had seromuscular intestinal injury in the iliac group (P = .668), splenic injury in the lumbar group, and liver injury in the subcostal group (P = .167). In the iliac group there was 1 patient with hematoma (P = .668), whereas seroma was seen in 1 lumbar group patient and 2 iliac group patients (P = .518). Persistent cough impulse was seen in 1 case each in the iliac and lumbar groups (P = .593). One case in the iliac group recurred after primary surgery (P = .668). Conclusions: NMVHs have a similar spectrum of difficulty and complication profile as those of laparoscopic MVH repairs. Laparoscopic repair of a non-midline hernia is technically challenging but definitely feasible. The incidence of complications and recurrence rate might be more than those for MVHs, but its actual validation needs a much larger comparative study having a longer follow-up.
Introduction
V
entral hernias of the abdominal wall may be primary and incisional types. They are further classified according to their location as midline ventral hernias (MVHs) or lateral ventral hernias. Lateral hernias are essentially defined as hernias occurring in the ‘‘lateral area’’ (i.e., lateral to the rectus muscle).1 Lateral hernias of the abdominal wall, henceforth referred to as non-MVHs (NMVHs), are relatively rare, with a reported prevalence of 6%–17% in various series.2 The classification and management of these hernias differ from those of the archetypal midline counterparts. Their apocentric location in close proximity to bony structures and vital organs relatively restricts accessibility for mesh placement and fixation. They were often treated with primary tissue repairs and had high recurrence rates.3 Despite their obviously different characteristics and rarity, NMVHs have failed to be recognized as a separate entity and have been frequently
described in amalgamation with midline hernias. Their unglamorous nature has led to unenthusiastic attention from the laparoscopic fraternity, and very few reports are available in literature. In the treatment of ventral hernias there is a definite role of minimally invasive surgery, as it hastens postoperative recovery and minimizes wound-related complications. Nevertheless, controversies exist with regard to type of repair, mesh placement, and fixation. Laparoscopic management of NMVHs can pose a difficulty in both planning and execution due to the rare incidence and paucity of scientific studies with adequate follow-up. Thus it remains to be determined whether the attributed benefits of minimally invasive surgery can be safely translated to NMVHs as well. Here we describe our experience in the laparoscopic management of NMVHs with respect to presentation characteristics and treatment outcome in different anatomic locations.
Department of Surgery, Lady Hardinge Medical College & Dr. RML Hospital, New Delhi, India.
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LAL ET AL.
Patients and Methods Study design and duration
A retrospective review was conducted of records of all abdominal wall hernias that were laparoscopically operated on in a single surgical unit from June 2007 to May 2012, and cases fulfilling the criteria of NMVH as defined below were included for the study purpose. Definition of NMVH
NMVHs were defined as any abdominal wall hernia lateral to the rectus muscle as well as flank hernias. The diagnosis of hernia was primarily clinical (Fig. 1), and radiological aids were used only when there was an ambiguity in the establishment of diagnosis. A hernia occurring at the lateral extent of a transverse midline scar beyond the rectus was also included as a lateral incisional hernia (Fig. 2). Both primary and incisional hernias were included. They were further subclassified based on the sublocation and etiology as follows: Sublocation. Hernias were subcostal, lumbar, iliac, or
suprapubic. Etiology. In primary hernias there was no history of prior surgical intervention or trauma in the region. Secondary hernias were either (1) incisional (at or adjacent to the scar of previous surgery) or (2) traumatic. There were no cases of traumatic hernia. Port-site, parastomal, and recurrent hernias were not included. Procedure
All patients included in the study underwent laparoscopic repair of NMVHs with an intraperitoneal onlay mesh placement fixed with transabdominal fixation sutures and tacks. The demographic features, clinical characteristics, parameters of intraoperative difficulty (viz., operative time/ complications), postoperative recovery, and recurrence rates were compared. Results were analyzed using SPSS version 19 software (IBM, Armonk, NY). The groups were compared for preoperative, intraoperative, and postoperative characteristics, including age, body mass index (BMI), size of hernia, diameter of the neck of the hernia, operative time, complications, and early recurrence (within 12 months). Because the data were not normally distributed, continuous
FIG. 2. hernia.
Intraoperative photograph showing the lateral
data were analyzed using the Mann–Whitney U test as applicable, and categorical data were analyzed using the chisquared test. A P value ofp.05 was considered significant. Results
In total, 183 cases of abdominal wall hernias were operated on in the unit during the above study duration, of which 25 fulfilled the study definition criteria of NMVH (Figs. 1 and 2). Table 1 shows further subclassification of hernias based on location and etiology. Primary hernias were rare and constituted 24% (n = 6) of all NMVHs in our series. The commonest site of location was the iliac and suprapubic regions, followed by the lumbar and subcostal areas. Table 2 shows the demographic, clinical, operative, and postoperative characteristics of the patients with respect to the various subgroups. The mean age of the study cohort was 40.3 – 12 years. The mean BMI was 29 – 1.7 kg/m2. Patients in the iliac subgroup were youngest, with a mean age of 29.7 – 5.96 years; compared with patients in the lumbar and subcostal subgroups, the difference was significant. The iliac group had the lowest BMI (28.65 – 1.35 kg/m2), whereas the BMI was highest in the subcostal group (30.133 – 1.30 kg/m2). NMVH was commoner in females than males, with a male/ female ratio of 8:17. Lumbar hernias were commoner in males (4 of 5, 80%). Excluding lumbar hernias, the percentage of male patients was 20%. The diameter of hernia defect ranged
Table 1. Classification of Nonmidline Ventral Hernias Based on Location and Etiology Etiology (n) Location of NMVH Lumbar Suprapubic Iliac Subcostal a c
Clinical image of a lateral (subcostal) hernia.
Secondary
1 0 1 0
4 7a 9b 3c
Total (%) 5 7 10 3
(20%) (28%) (40%) (12%)
Extension of midline scar. Post-appendicectomy, n = 4; post-Pfannensteil incision, n = 5. Post-cholecystectomy. NMVH, nonmidline ventral hernia. b
FIG. 1.
Primary
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Table 2. Comparison of Clinical Parameters, Perioperative Variables, Postoperative Recovery, and Recurrence Among the Groups and Their Significance Parameter Age (years) Sex (M/F) BMI (kg/m2) Diameter of defect (cm) Operative time (minutes) Intraoperative injury Hospital stay (days) Hematoma Seroma Chronic pain Persistent cough impulse (nonexpansile) Recurrence
Lumbar (n = 5) Suprapubic (n = 7) Iliac (n = 10) Subcostal (n = 3) P value 51.6 – 8.7 4/1 28.7 – 2.3 5.4 – 1.6 90 – 11.2 1a 3.8 – 0.4 0 1 0 1 0
42.6 – 7.0 1/6 29.1 – 1.8 6.1 – 1.1 113.6 – 7.0 0 4.6 – 0.5 0 0 0 0 0
29.7 – 6 3/7 28.7 – 1.4 7.2 – 1.4 110.5 – 15.4 1b 4.4 – 1.3 1 2 0 1 1
51.3 – 13.2 0/3 30.1 – 1.3 5.8 – 2.1 101.7 – 2.9 1c 4–0 0 0 0 0 0
.001 .052 .441 .212 .014 NS .05 NS NS NS NS
Data are mean – standard deviation values or number of patients as indicated. A P value of p.05 was considered significant. a Spleen. b Intestine. c Liver. BMI, body mass index; F, female; M, male; NS, not significant.
from 3.5 cm to 9.5 cm, with a minimal mean diameter of 5.40 – 1.59 cm in the lumbar group and maximal mean diameter of 7.20 – 1.43 cm in the iliac group. Lumbar hernias took the least operative time, with a mean operative time of 90.0 – 11.18 minutes, whereas the suprapubic extension group took the longest, with a mean operative time of 113.15 – 6.90 minutes (the difference was significant). None of the above parameters had any statistically significant difference among all the subgroups. Major complications were minimal. Perioperative injuries (12%) included 1 case of intestinal injury in the iliac subgroup, a splenic injury in the lumbar subgroup, and a liver injury in the subcostal subgroup. The injured bowel was sutured, and the defect was repaired primarily without a mesh. The splenic and liver injuries were repaired by suturing. All cases underwent successful hernioplasty. The mean hospital stay was 4.3 – 0.9 days. The groups differed significantly with respect to age, sex, operative time, and hospital stay. In the postoperative period, 1 patient in the iliac subgroup had a hematoma (4%), whereas seroma was seen in 1 patient of the lumbar subgroup and 2 patients of the iliac subgroup (12%). The initial evaluation for seroma and hematoma was largely by clinical examination. Ultrasonography was done for confirmation of the clinical findings and to aid in distinguishing from a recurrence. As routine ultrasonography was not done in all patients, it is possible that subclinical seromas could have been missed. Persistent nonexpansile cough impulse was seen in 1 case each in the iliac and lumbar subgroups (4%), but further investigations failed to demonstrate recurrence in these 2 cases. The followup ranged from 6 months to 5 years. One case in the iliac subgroup recurred after primary surgery (4%); this patient had a bowel injury, and hence the defect was closed using polypropylene suture primarily without mesh. Discussion
Non-midline hernias include all hernias through abdominal wall defects located outside the midline or more precisely in the ‘‘lateral area.’’ The borders of the lateral area are defined as follows: cranially, the costal margin; caudally, the
inguinal region; medially, the lateral margin of the rectus; and laterally, the lumbar region.1 Abdominal wall hernias have been variously classified, and several different variables have been used for the purpose (viz., etiology, location, size, and number of hernia defects, BMI, prior surgery, recurrences, etc.). A classification system based on grades of difficulty has been proposed,4 but the prognostic values of the scoring system do not reflect clinical outcome with respect to recurrence.1 A comprehensive taxonomical classification system of the European Hernia Society classifies lateral hernias based on etiology, location, size, and recurrences.5 In most classifications, lateral abdominal wall hernia occurring at the extreme end of a transverse midline scar remains ambiguous. In our study the diagnosis of incisional hernia was by and large clinical; radiological imaging was used only for confirmation of a doubtful clinical case. We have classified these hernias based on etiology and location. Arbitrary cutoff limits based on size was not used in our study; rather, size was taken as a continuous variable. There were no cases of recurrent incisional hernias in our series. Lateral incisional hernias usually occur secondary to appendicectomy, cholecystectomy, or urinary tract surgery. Port-site hernias and parastomal hernias are the relatively rarer variants of NMVH of incisional etiology. Although port-site hernias have been commonly reported to occur through the larger 10-mm ports, which are often placed centrally, instances of port-site hernias through smaller (5-mm) laterally placed ports have also been reported.6 Another often-overlooked etiology is the traumatic or handlebar hernia, which frequently occurs in the lower abdominal ilioinguinal or lumbar areas outside the conformity of regions ascribed to nontraumatic inguinal hernias. Such hernias can present acutely after trauma or may have an insidious delayed presentation.7–9 In our study cohort, which constituted all laparoscopically operated abdominal wall hernias in a single surgical unit in the time frame of 5 years, 13.7% were NMVH. We have included hernias occurring in the lateral edge of a transverse scar as a NMVH because of their location in the premises of the area defined as the lateral area. Most were NMVHs of
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incisional etiology (92%), and only 2 cases of primary hernia were noted (lumbar, n = 1; Spigelian, n = 1). Our findings corroborate with those in the literature wherein most reported series of NMVHs are observed to be of incisional etiology.2,3,10,11 Pfannensteil incision, usually used for the lower abdominal approach to gynecological diseases, was the most common prior surgery, followed by appendicectomy, urinary tract surgery, and cholecystectomy (Table 1). Our small series does not include cases of traumatic, port-site, or parastomal hernias. The commonest site of NMVH is again controversial, with some authors reporting the iliac location as the most common3 and others quoting the lumbar or infraumbilical areas.2 In a series of 199 cases wherein 26.6% were NMVHs, most were situated in the infraumbilical region.10 In our series the most common site of herniation was the iliac region, followed by the suprapubic, lumbar, and, lastly, subcostal area. As most hernias of the iliac group were those occurring after appendicectomy, understandably the mean age was lower in these patients. A difference in sex predilection was also seen in our study, with lumbar hernias being commoner in males, in contrast with other NMVHs, which were more frequent in females. Unlike midline hernias, wherein use of a mesh is routine, lateral hernias have often been treated with primary tissue repair in up to 35% cases,3 because of the relative abundance of healthy musculo-aponeurotic tissue in the lateral abdominal region. In this series of 41 lateral hernias, which included both primary (15 cases) and recurrent (26 cases) hernias treated with pure tissue repair or mesh placement, 11.5% of patients undergoing mesh repair had mesh infection, and 15.4% reported chronic pain. There were no complications in patients who underwent primary tissue repair. There were no recurrences in either group.3 Nevertheless, most authors report high recurrence rates with pure tissue repairs of incisional hernia, and mesh repair is the advocated norm.11 In the last two decades, laparoscopic repair of ventral hernias has enjoyed a considerable popularity due to decreased postoperative pain, a hastened recovery, fewer wound-related complications, and lower recurrence rates in experienced hands.11,12 One of the prominent advantages of the laparoscopic approach is that it can provide a panoramic view of the entire ventral abdominal wall and thus address other defects that may be present simultaneously because of diffuse weakening of the abdominal wall, often termed a ‘‘Swiss cheese appearance.’’11 Authors have reported the successful treatment of these hernias with placement of a preperitoneal mesh, especially in suprapubic, Spigelian, iliac, and lumbar hernias, in a procedure akin to the transabdominal preperitoneal approach for inguinal hernias.10,13–18 A total extraperitoneal approach in the management of some variants of these hernias has also been reported.18 A preperitoneal mesh placement, which is relatively difficult in MVHs because of limitations imposed by the attachment of the rectus sheath and insufficient preperitoneal fat, may be easier in the iliac, Spigelian, lumbar, and flank hernias of the nonmidline variants owing to the relative abundance of preperitoneal fat in these regions, as well as a space unrestricted by aponeurotic attachments. Another variation is the placement of the mesh between layers of muscle or muscle and aponeurosis in an effectively ‘‘sandwich’’ manner, which succeeds in eliminating tension.3
LAL ET AL.
However, like most surgeons, we prefer to lay the mesh intraperitoneally as it is technically much simpler. Recurrences are an important outcome measure of hernia repair. The technical factors proposed to affect recurrences after ventral hernia repair are insufficient fixation, increased abdominal pressure, and inadequate overlap. Mesh fixation constitutes an integral step in the laparoscopic management of ventral hernias and is paramount to prevent recurrences. Traditionally, mesh fixation in laparoscopic surgery is done using sutures, tacks, or staples. Studies have demonstrated that the use of tacks alone is often insufficient to prevent recurrence in laparoscopic ventral incisional hernias, and use of transabdominal nonabsorbable sutures in addition to tacks is advised.11,19 The site of fixation varies with the type of hernia, with Cooper’s ligament and pubic bone being the preferred sites in the iliac and suprapubic subtypes and to the iliac crest, psoas muscle, parietal wall, and above the 10th rib in the lumbar and subcostal types. The use of bone anchors has been proposed to ensure better fixation of the mesh to bony structures and ligaments.11 We use both helical tacks and transabdominal sutures for fixation. In addition to the usual disadvantages of the laparoscopic approach to MVHs, in NMVHs the difficulty is compounded by the relatively complex contour of the lateral abdominal wall, unavailability of adequate space, juxtaposition of major organs, and close proximity to bony structures, making mesh placement and fixation difficult.3 Whereas pneumoperitoneum distends the abdominal wall and creates a potential workspace, it needs to be realized that the distension is nonuniform, with consequently more space in central abdominal regions compared with the lateral abdominal areas, which have relatively fixed viscera like the colon, ureters, kidneys, liver, and spleen. Mobilization of these structures may be necessary for adequate mesh placement and fixation,2 with resultant potential danger of injury to these organs. Also, the close proximity of bony structures like the ribcage and vertebrae add to the limitations of access, mesh placement, and risk of injury to the parietal wall nerves, which can be entrapped in the fixation. In our small series we did note a small incidence of nonserious injury to the spleen, liver, and bowel (11.5%). The biomechanics of the abdominal wall have been proposed to be important factors in recurrences following laparoscopic ventral hernia repair that may differ in NMVH and MVH. In an interesting cadaveric study it was observed that stretching of the mesh due to rise in intraabdominal pressure during cough or defecation can cause disruptions at mesh fascia fixation, with such distortions being commoner in the midline and other areas of high elasticity and resulting in mismatch in elastic properties of tissue and mesh.19 A difference has also been noted in elasticity of the abdominal wall in the longitudinal when compared with the horizontal direction. This observation can have pertinent implications in the incisional type of NMVH as most lateral abdominal wall incisions are transverse as opposed to the commoner longitudinal midline incisions.19 Additionally, the relative advantage hypothesized is that there may be less distortion of the mesh after decompression of the pneumoperitoneum due to the lesser degree of recoil of the abdominal wall as a result of lesser initial deformation due to pneumoperitoneum in lateral as opposed to midline locations. There is also less subsequent deformations with the rise in intraabdominal pressure in NMVH compared with MVH. Whether the
NONMIDLINE VENTRAL HERNIA
proposed theory will hold true in the clinical scenario to reduce recurrences is presently conjectural owing to lack of clinical evidence. Laparoscopic hernioplasty has been applied to nonmidline defects and has been variably reported as individual case reports, retrospective collective review, or isolated prospective nonrandomized comparative trials. In a comparative evaluation of midline and nonmidline incisional hernias repaired using the laparoscopic approach, a less favorable outcome was noted in NMVH with respect to requirement of postoperative analgesics, hospital stay, wound hematomas, and recurrence.10 Ambulatory surgery was more frequently deployed in MVH (73%) in contrast with NMVH (27%). There were two minor hematomas, both in the lumbar subgroup; pain was also commonly observed in the lumbar subgroup, and two early recurrences were noted, one each in the subcostal and lumbar subcategories. Insufficient parietal fixation of the mesh was reported as the commonest cause of recurrence.10 In a long-term prospective follow-up study2 of 73 consecutive patients with large NMVHs treated by the laparoscopic approach, the authors concluded that the approach could be completed safely without any need for conversion. Hematomas were more common in iliac hernias, versus seromas in the lumbar subtype. An 8.2% recurrence was seen at 72 months, with recurrence being more common in the subcostal type in the series. Increased BMI, large defect size ( > 15 cm), multiple defect (Swiss cheese), high operative time, and presence of local morbidity were the factors predictive of recurrence. Obesity was an important predictor of local morbidity.2 In another long-term prospective study17 comparing outcomes after laparoscopic and open approaches in the treatment of primary and secondary lumbar hernias, an equivalent outcome was noted with respect to recurrences. The authors proposed that the open technique is advisable in diffuse hernias with a large, >15-cm defect.17 In our small series with short follow-up, 1 patient in the iliac group (4%) developed a recurrence. Although BMI has been quoted as a factor predictive of recurrence, incidentally the iliac group had the lowest BMI and the subcostal group the highest BMI in our series. Wound-related complication was noted in 16%. Seroma was the commonest complication, which was seen in 3 patients (12%): 1 in the lumbar and 2 in the iliac group. One patient in the iliac subgroup developed hematoma (4%). The relative drawback of our study is the small study population, which made further categorization and analysis based on subgroup location and etiology difficult. Conclusions
NMVHs are rare. They have therefore been described collectively with midline hernias. However, these hernias differ from midline hernias by virtue of their location, and their treatment can be complicated because of juxtaposition of viscera and bony structures, making mesh fixation difficult and posing risk to vital organs. A relative difference in biomechanics has also been proposed in lateral MVHs as opposed to NMVHs, the clinical implications of which needs to be determined. Thus laparoscopic management of these hernias can be technically challenging, and at present outcomes are inferior compared with the more common midline variety. Nevertheless, the laparoscopic approach to the
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treatment of NMVH is evolving and appears to be promising. As the evidence of planned studies exclusively on NMVH is meager in contemporary literature, more of these planned studies are warranted. Disclosure Statement
No competing financial interests exist. References
1. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P, Hidalgo Pascual M, Hoeferlin A, Klinge U, Montgomery A, Simmermacher RK, Simons MP, Smietan´ski M, Sommeling C, Tollens T, Vierendeels T, Kingsnorth A. Classification of primary and incisional abdominal wall hernias. Hernia 2009;13:407–414. 2. Moreno-Egea A, Carrillo-Alcaraz A. Management of nonmidline incisional hernia by the laparoscopic approach: Results of a long-term follow-up prospective study. Surg Endosc 2012;26:1069–1078. 3. Martı´n-Duce A, Noguerales F, Lozano O, Villeta R, Martı´n J, Mugu¨erza J, Dı´ez M. Treatment of lateral incisional hernias. Eur J Surg 1999;165:1187–1188. 4. Chowbey PK, Khullar R, Mehrotra M, Sharma A, Soni V, Baijal M. Sir Ganga Ram Hospital classification of groin and ventral abdominal wall hernias. J Minim Access Surg 2006;2:106–109. 5. Miserez M, et al. The European Hernia Society groin hernia classification: Simple and easy to remember. Hernia 2007; 11:113–116. 6. Dulskas A, Lunevicius R, Stanaitis J. A case report of incisional hernia through a 5 mm lateral port site following laparoscopic cholecystectomy. J Minim Access Surg 2011; 7:187–189. 7. Ogundiran TO, Obamuyide HA, Adesina MA, Ademola AF. Case report of traumatic abdominal wall hernia following blunt motorcycle handlebar injury and review of the literature. Niger J Clin Pract 2012;15:238–240. 8. Kumar A, Hazrah P, Bal S, Seth A, Parshad R. Traumatic abdominal wall hernia: A reappraisal. Hernia 2004;8: 277–280. 9. Moreno-Egea A, Girela E, Parlorio E, Aguayo-AlbasiniJ L. Controversies in the current management of traumatic abdominal wall hernias [in Spanish]. Cir Esp 2007;82:260–267. 10. Moreno-Egea A, Carrillo A, Aguayo JL. Midline versus nonmidline laparoscopic incisional hernioplasty: A comparative study. Surg Endosc 2008;22:744–749. 11. Craft RO, Harold KL. Laparoscopic repair of incisional and other complex abdominal wall hernias. Perm J 2009;13:38–42. 12. Friedrich M, Mu¨ller-Riemenschneider F, Roll S, Kulp W, Vauth C, Greiner W, Willich S, von der Schulenburg JM. Health technology assessment of laparoscopic compared to conventional surgery with and without mesh for incisional hernia repair regarding safety, efficacy and cost-effectiveness. GMS Health Technol Assess 2008 March 7;4:Doc01. 13. Cox TC, Pearl JP, Ritter EM. Rives-Stoppa incisional hernia repair combined with laparoscopic separation of abdominal wall components: A novel approach to complex abdominal wall closure. Hernia 2010;14:561–567. 14. Palanivelu C, Vijaykumar M, Jani KV, Rajan PS, Maheshkumaar GS, Rajapandian S. Laparoscopic transabdominal preperitoneal repair of spigelian hernia. JSLS 2006; 10:193–198.
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15. Alaedeen D. Laparoscopic trans-abdominal pre-peritoneal repair of a traumatic Petit lumbar hernia with mesh. Am Surg 2011;77:E292–E293. 16. Nam SY, Kee SK, Kim JO. Laparoscopic transabdominal extraperitoneal mesh repair of lumbar hernia. J Korean Surg Soc 2011;81(Suppl 1):S74–S77. 17. Moreno-Egea A, Alcaraz AC, Cuervo MC. Surgical options in lumbar hernia: Laparoscopic versus open repair. A long-term prospective study. Surg Innov 2013;20: 331–344. 18. Mittal T, Kumar V, Khullar R, Sharma A, Soni V, Baijal M, Chowbey PK. Diagnosis and management of Spigelian hernia: A review of literature and our experience. J Minim Access Surg 2008;4:95–98. 19. Smietan´ski M, Bury K, Tomaszewska A, Lubowiecka I, Szymczak C. Biomechanics of the front abdominal wall
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as a potential factor leading to recurrence with laparoscopic ventral hernia repair. Surg Endosc 2012;26:1461– 1467.
Address correspondence to: Deborshi Sharma, MS, MRCS(Edin), FMAS Department of Surgery Lady Hardinge Medical College & Dr. RML Hospital New Delhi, 110001 India E-mail: [email protected] [email protected]
Full Reports
Laparoscopic Management of Nonmidline Ventral Hernia Romesh Lal, MS, DNB, FMAS, Deborshi Sharma, MS, MRCS(Edin), FMAS, Priya Hazrah, MS, FMAS, Pawan Kumar, MS, FMAS, Saurabh Borgharia, MS, FMAS, and Abhinav Agarwal, MS
Abstract
Introduction: Ventral hernias may be primary or incisional and classified as midline ventral hernias (MVHs) or non-MVHs (NMVHs). NMVHs are rarer, and their laparoscopic management is technically challenging because of varied anatomic locations, differences in patient positioning at time of surgery, and lack of adequate lateral space for mesh fixation, compounded by the proximity of major organs and bony landmarks. A retrospective review of all the NMVHs operated on in a clinical unit is presented. Subjects and Methods: One hundred eighty-three cases met the criteria of ventral hernia, with 25 cases (13.66%) as NMVH. These NMVHs included lumbar (n = 5), suprapubic (n = 7), iliac (n = 10), and subcostal (n = 3). Univariate and multivariate analyses were done using SPSS version 19 software (IBM, Armonk, NY). Continuous data were analyzed using the Mann–Whitney U test/t test, and categorical data were analyzed using the chi-squared test. A P value of p.05 was considered significant. Results: Demographic profile and presentation were similar in all groups. One case each had seromuscular intestinal injury in the iliac group (P = .668), splenic injury in the lumbar group, and liver injury in the subcostal group (P = .167). In the iliac group there was 1 patient with hematoma (P = .668), whereas seroma was seen in 1 lumbar group patient and 2 iliac group patients (P = .518). Persistent cough impulse was seen in 1 case each in the iliac and lumbar groups (P = .593). One case in the iliac group recurred after primary surgery (P = .668). Conclusions: NMVHs have a similar spectrum of difficulty and complication profile as those of laparoscopic MVH repairs. Laparoscopic repair of a non-midline hernia is technically challenging but definitely feasible. The incidence of complications and recurrence rate might be more than those for MVHs, but its actual validation needs a much larger comparative study having a longer follow-up.
Introduction
V
entral hernias of the abdominal wall may be primary and incisional types. They are further classified according to their location as midline ventral hernias (MVHs) or lateral ventral hernias. Lateral hernias are essentially defined as hernias occurring in the ‘‘lateral area’’ (i.e., lateral to the rectus muscle).1 Lateral hernias of the abdominal wall, henceforth referred to as non-MVHs (NMVHs), are relatively rare, with a reported prevalence of 6%–17% in various series.2 The classification and management of these hernias differ from those of the archetypal midline counterparts. Their apocentric location in close proximity to bony structures and vital organs relatively restricts accessibility for mesh placement and fixation. They were often treated with primary tissue repairs and had high recurrence rates.3 Despite their obviously different characteristics and rarity, NMVHs have failed to be recognized as a separate entity and have been frequently
described in amalgamation with midline hernias. Their unglamorous nature has led to unenthusiastic attention from the laparoscopic fraternity, and very few reports are available in literature. In the treatment of ventral hernias there is a definite role of minimally invasive surgery, as it hastens postoperative recovery and minimizes wound-related complications. Nevertheless, controversies exist with regard to type of repair, mesh placement, and fixation. Laparoscopic management of NMVHs can pose a difficulty in both planning and execution due to the rare incidence and paucity of scientific studies with adequate follow-up. Thus it remains to be determined whether the attributed benefits of minimally invasive surgery can be safely translated to NMVHs as well. Here we describe our experience in the laparoscopic management of NMVHs with respect to presentation characteristics and treatment outcome in different anatomic locations.
Department of Surgery, Lady Hardinge Medical College & Dr. RML Hospital, New Delhi, India.
445
446
LAL ET AL.
Patients and Methods Study design and duration
A retrospective review was conducted of records of all abdominal wall hernias that were laparoscopically operated on in a single surgical unit from June 2007 to May 2012, and cases fulfilling the criteria of NMVH as defined below were included for the study purpose. Definition of NMVH
NMVHs were defined as any abdominal wall hernia lateral to the rectus muscle as well as flank hernias. The diagnosis of hernia was primarily clinical (Fig. 1), and radiological aids were used only when there was an ambiguity in the establishment of diagnosis. A hernia occurring at the lateral extent of a transverse midline scar beyond the rectus was also included as a lateral incisional hernia (Fig. 2). Both primary and incisional hernias were included. They were further subclassified based on the sublocation and etiology as follows: Sublocation. Hernias were subcostal, lumbar, iliac, or
suprapubic. Etiology. In primary hernias there was no history of prior surgical intervention or trauma in the region. Secondary hernias were either (1) incisional (at or adjacent to the scar of previous surgery) or (2) traumatic. There were no cases of traumatic hernia. Port-site, parastomal, and recurrent hernias were not included. Procedure
All patients included in the study underwent laparoscopic repair of NMVHs with an intraperitoneal onlay mesh placement fixed with transabdominal fixation sutures and tacks. The demographic features, clinical characteristics, parameters of intraoperative difficulty (viz., operative time/ complications), postoperative recovery, and recurrence rates were compared. Results were analyzed using SPSS version 19 software (IBM, Armonk, NY). The groups were compared for preoperative, intraoperative, and postoperative characteristics, including age, body mass index (BMI), size of hernia, diameter of the neck of the hernia, operative time, complications, and early recurrence (within 12 months). Because the data were not normally distributed, continuous
FIG. 2. hernia.
Intraoperative photograph showing the lateral
data were analyzed using the Mann–Whitney U test as applicable, and categorical data were analyzed using the chisquared test. A P value ofp.05 was considered significant. Results
In total, 183 cases of abdominal wall hernias were operated on in the unit during the above study duration, of which 25 fulfilled the study definition criteria of NMVH (Figs. 1 and 2). Table 1 shows further subclassification of hernias based on location and etiology. Primary hernias were rare and constituted 24% (n = 6) of all NMVHs in our series. The commonest site of location was the iliac and suprapubic regions, followed by the lumbar and subcostal areas. Table 2 shows the demographic, clinical, operative, and postoperative characteristics of the patients with respect to the various subgroups. The mean age of the study cohort was 40.3 – 12 years. The mean BMI was 29 – 1.7 kg/m2. Patients in the iliac subgroup were youngest, with a mean age of 29.7 – 5.96 years; compared with patients in the lumbar and subcostal subgroups, the difference was significant. The iliac group had the lowest BMI (28.65 – 1.35 kg/m2), whereas the BMI was highest in the subcostal group (30.133 – 1.30 kg/m2). NMVH was commoner in females than males, with a male/ female ratio of 8:17. Lumbar hernias were commoner in males (4 of 5, 80%). Excluding lumbar hernias, the percentage of male patients was 20%. The diameter of hernia defect ranged
Table 1. Classification of Nonmidline Ventral Hernias Based on Location and Etiology Etiology (n) Location of NMVH Lumbar Suprapubic Iliac Subcostal a c
Clinical image of a lateral (subcostal) hernia.
Secondary
1 0 1 0
4 7a 9b 3c
Total (%) 5 7 10 3
(20%) (28%) (40%) (12%)
Extension of midline scar. Post-appendicectomy, n = 4; post-Pfannensteil incision, n = 5. Post-cholecystectomy. NMVH, nonmidline ventral hernia. b
FIG. 1.
Primary
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Table 2. Comparison of Clinical Parameters, Perioperative Variables, Postoperative Recovery, and Recurrence Among the Groups and Their Significance Parameter Age (years) Sex (M/F) BMI (kg/m2) Diameter of defect (cm) Operative time (minutes) Intraoperative injury Hospital stay (days) Hematoma Seroma Chronic pain Persistent cough impulse (nonexpansile) Recurrence
Lumbar (n = 5) Suprapubic (n = 7) Iliac (n = 10) Subcostal (n = 3) P value 51.6 – 8.7 4/1 28.7 – 2.3 5.4 – 1.6 90 – 11.2 1a 3.8 – 0.4 0 1 0 1 0
42.6 – 7.0 1/6 29.1 – 1.8 6.1 – 1.1 113.6 – 7.0 0 4.6 – 0.5 0 0 0 0 0
29.7 – 6 3/7 28.7 – 1.4 7.2 – 1.4 110.5 – 15.4 1b 4.4 – 1.3 1 2 0 1 1
51.3 – 13.2 0/3 30.1 – 1.3 5.8 – 2.1 101.7 – 2.9 1c 4–0 0 0 0 0 0
.001 .052 .441 .212 .014 NS .05 NS NS NS NS
Data are mean – standard deviation values or number of patients as indicated. A P value of p.05 was considered significant. a Spleen. b Intestine. c Liver. BMI, body mass index; F, female; M, male; NS, not significant.
from 3.5 cm to 9.5 cm, with a minimal mean diameter of 5.40 – 1.59 cm in the lumbar group and maximal mean diameter of 7.20 – 1.43 cm in the iliac group. Lumbar hernias took the least operative time, with a mean operative time of 90.0 – 11.18 minutes, whereas the suprapubic extension group took the longest, with a mean operative time of 113.15 – 6.90 minutes (the difference was significant). None of the above parameters had any statistically significant difference among all the subgroups. Major complications were minimal. Perioperative injuries (12%) included 1 case of intestinal injury in the iliac subgroup, a splenic injury in the lumbar subgroup, and a liver injury in the subcostal subgroup. The injured bowel was sutured, and the defect was repaired primarily without a mesh. The splenic and liver injuries were repaired by suturing. All cases underwent successful hernioplasty. The mean hospital stay was 4.3 – 0.9 days. The groups differed significantly with respect to age, sex, operative time, and hospital stay. In the postoperative period, 1 patient in the iliac subgroup had a hematoma (4%), whereas seroma was seen in 1 patient of the lumbar subgroup and 2 patients of the iliac subgroup (12%). The initial evaluation for seroma and hematoma was largely by clinical examination. Ultrasonography was done for confirmation of the clinical findings and to aid in distinguishing from a recurrence. As routine ultrasonography was not done in all patients, it is possible that subclinical seromas could have been missed. Persistent nonexpansile cough impulse was seen in 1 case each in the iliac and lumbar subgroups (4%), but further investigations failed to demonstrate recurrence in these 2 cases. The followup ranged from 6 months to 5 years. One case in the iliac subgroup recurred after primary surgery (4%); this patient had a bowel injury, and hence the defect was closed using polypropylene suture primarily without mesh. Discussion
Non-midline hernias include all hernias through abdominal wall defects located outside the midline or more precisely in the ‘‘lateral area.’’ The borders of the lateral area are defined as follows: cranially, the costal margin; caudally, the
inguinal region; medially, the lateral margin of the rectus; and laterally, the lumbar region.1 Abdominal wall hernias have been variously classified, and several different variables have been used for the purpose (viz., etiology, location, size, and number of hernia defects, BMI, prior surgery, recurrences, etc.). A classification system based on grades of difficulty has been proposed,4 but the prognostic values of the scoring system do not reflect clinical outcome with respect to recurrence.1 A comprehensive taxonomical classification system of the European Hernia Society classifies lateral hernias based on etiology, location, size, and recurrences.5 In most classifications, lateral abdominal wall hernia occurring at the extreme end of a transverse midline scar remains ambiguous. In our study the diagnosis of incisional hernia was by and large clinical; radiological imaging was used only for confirmation of a doubtful clinical case. We have classified these hernias based on etiology and location. Arbitrary cutoff limits based on size was not used in our study; rather, size was taken as a continuous variable. There were no cases of recurrent incisional hernias in our series. Lateral incisional hernias usually occur secondary to appendicectomy, cholecystectomy, or urinary tract surgery. Port-site hernias and parastomal hernias are the relatively rarer variants of NMVH of incisional etiology. Although port-site hernias have been commonly reported to occur through the larger 10-mm ports, which are often placed centrally, instances of port-site hernias through smaller (5-mm) laterally placed ports have also been reported.6 Another often-overlooked etiology is the traumatic or handlebar hernia, which frequently occurs in the lower abdominal ilioinguinal or lumbar areas outside the conformity of regions ascribed to nontraumatic inguinal hernias. Such hernias can present acutely after trauma or may have an insidious delayed presentation.7–9 In our study cohort, which constituted all laparoscopically operated abdominal wall hernias in a single surgical unit in the time frame of 5 years, 13.7% were NMVH. We have included hernias occurring in the lateral edge of a transverse scar as a NMVH because of their location in the premises of the area defined as the lateral area. Most were NMVHs of
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incisional etiology (92%), and only 2 cases of primary hernia were noted (lumbar, n = 1; Spigelian, n = 1). Our findings corroborate with those in the literature wherein most reported series of NMVHs are observed to be of incisional etiology.2,3,10,11 Pfannensteil incision, usually used for the lower abdominal approach to gynecological diseases, was the most common prior surgery, followed by appendicectomy, urinary tract surgery, and cholecystectomy (Table 1). Our small series does not include cases of traumatic, port-site, or parastomal hernias. The commonest site of NMVH is again controversial, with some authors reporting the iliac location as the most common3 and others quoting the lumbar or infraumbilical areas.2 In a series of 199 cases wherein 26.6% were NMVHs, most were situated in the infraumbilical region.10 In our series the most common site of herniation was the iliac region, followed by the suprapubic, lumbar, and, lastly, subcostal area. As most hernias of the iliac group were those occurring after appendicectomy, understandably the mean age was lower in these patients. A difference in sex predilection was also seen in our study, with lumbar hernias being commoner in males, in contrast with other NMVHs, which were more frequent in females. Unlike midline hernias, wherein use of a mesh is routine, lateral hernias have often been treated with primary tissue repair in up to 35% cases,3 because of the relative abundance of healthy musculo-aponeurotic tissue in the lateral abdominal region. In this series of 41 lateral hernias, which included both primary (15 cases) and recurrent (26 cases) hernias treated with pure tissue repair or mesh placement, 11.5% of patients undergoing mesh repair had mesh infection, and 15.4% reported chronic pain. There were no complications in patients who underwent primary tissue repair. There were no recurrences in either group.3 Nevertheless, most authors report high recurrence rates with pure tissue repairs of incisional hernia, and mesh repair is the advocated norm.11 In the last two decades, laparoscopic repair of ventral hernias has enjoyed a considerable popularity due to decreased postoperative pain, a hastened recovery, fewer wound-related complications, and lower recurrence rates in experienced hands.11,12 One of the prominent advantages of the laparoscopic approach is that it can provide a panoramic view of the entire ventral abdominal wall and thus address other defects that may be present simultaneously because of diffuse weakening of the abdominal wall, often termed a ‘‘Swiss cheese appearance.’’11 Authors have reported the successful treatment of these hernias with placement of a preperitoneal mesh, especially in suprapubic, Spigelian, iliac, and lumbar hernias, in a procedure akin to the transabdominal preperitoneal approach for inguinal hernias.10,13–18 A total extraperitoneal approach in the management of some variants of these hernias has also been reported.18 A preperitoneal mesh placement, which is relatively difficult in MVHs because of limitations imposed by the attachment of the rectus sheath and insufficient preperitoneal fat, may be easier in the iliac, Spigelian, lumbar, and flank hernias of the nonmidline variants owing to the relative abundance of preperitoneal fat in these regions, as well as a space unrestricted by aponeurotic attachments. Another variation is the placement of the mesh between layers of muscle or muscle and aponeurosis in an effectively ‘‘sandwich’’ manner, which succeeds in eliminating tension.3
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However, like most surgeons, we prefer to lay the mesh intraperitoneally as it is technically much simpler. Recurrences are an important outcome measure of hernia repair. The technical factors proposed to affect recurrences after ventral hernia repair are insufficient fixation, increased abdominal pressure, and inadequate overlap. Mesh fixation constitutes an integral step in the laparoscopic management of ventral hernias and is paramount to prevent recurrences. Traditionally, mesh fixation in laparoscopic surgery is done using sutures, tacks, or staples. Studies have demonstrated that the use of tacks alone is often insufficient to prevent recurrence in laparoscopic ventral incisional hernias, and use of transabdominal nonabsorbable sutures in addition to tacks is advised.11,19 The site of fixation varies with the type of hernia, with Cooper’s ligament and pubic bone being the preferred sites in the iliac and suprapubic subtypes and to the iliac crest, psoas muscle, parietal wall, and above the 10th rib in the lumbar and subcostal types. The use of bone anchors has been proposed to ensure better fixation of the mesh to bony structures and ligaments.11 We use both helical tacks and transabdominal sutures for fixation. In addition to the usual disadvantages of the laparoscopic approach to MVHs, in NMVHs the difficulty is compounded by the relatively complex contour of the lateral abdominal wall, unavailability of adequate space, juxtaposition of major organs, and close proximity to bony structures, making mesh placement and fixation difficult.3 Whereas pneumoperitoneum distends the abdominal wall and creates a potential workspace, it needs to be realized that the distension is nonuniform, with consequently more space in central abdominal regions compared with the lateral abdominal areas, which have relatively fixed viscera like the colon, ureters, kidneys, liver, and spleen. Mobilization of these structures may be necessary for adequate mesh placement and fixation,2 with resultant potential danger of injury to these organs. Also, the close proximity of bony structures like the ribcage and vertebrae add to the limitations of access, mesh placement, and risk of injury to the parietal wall nerves, which can be entrapped in the fixation. In our small series we did note a small incidence of nonserious injury to the spleen, liver, and bowel (11.5%). The biomechanics of the abdominal wall have been proposed to be important factors in recurrences following laparoscopic ventral hernia repair that may differ in NMVH and MVH. In an interesting cadaveric study it was observed that stretching of the mesh due to rise in intraabdominal pressure during cough or defecation can cause disruptions at mesh fascia fixation, with such distortions being commoner in the midline and other areas of high elasticity and resulting in mismatch in elastic properties of tissue and mesh.19 A difference has also been noted in elasticity of the abdominal wall in the longitudinal when compared with the horizontal direction. This observation can have pertinent implications in the incisional type of NMVH as most lateral abdominal wall incisions are transverse as opposed to the commoner longitudinal midline incisions.19 Additionally, the relative advantage hypothesized is that there may be less distortion of the mesh after decompression of the pneumoperitoneum due to the lesser degree of recoil of the abdominal wall as a result of lesser initial deformation due to pneumoperitoneum in lateral as opposed to midline locations. There is also less subsequent deformations with the rise in intraabdominal pressure in NMVH compared with MVH. Whether the
NONMIDLINE VENTRAL HERNIA
proposed theory will hold true in the clinical scenario to reduce recurrences is presently conjectural owing to lack of clinical evidence. Laparoscopic hernioplasty has been applied to nonmidline defects and has been variably reported as individual case reports, retrospective collective review, or isolated prospective nonrandomized comparative trials. In a comparative evaluation of midline and nonmidline incisional hernias repaired using the laparoscopic approach, a less favorable outcome was noted in NMVH with respect to requirement of postoperative analgesics, hospital stay, wound hematomas, and recurrence.10 Ambulatory surgery was more frequently deployed in MVH (73%) in contrast with NMVH (27%). There were two minor hematomas, both in the lumbar subgroup; pain was also commonly observed in the lumbar subgroup, and two early recurrences were noted, one each in the subcostal and lumbar subcategories. Insufficient parietal fixation of the mesh was reported as the commonest cause of recurrence.10 In a long-term prospective follow-up study2 of 73 consecutive patients with large NMVHs treated by the laparoscopic approach, the authors concluded that the approach could be completed safely without any need for conversion. Hematomas were more common in iliac hernias, versus seromas in the lumbar subtype. An 8.2% recurrence was seen at 72 months, with recurrence being more common in the subcostal type in the series. Increased BMI, large defect size ( > 15 cm), multiple defect (Swiss cheese), high operative time, and presence of local morbidity were the factors predictive of recurrence. Obesity was an important predictor of local morbidity.2 In another long-term prospective study17 comparing outcomes after laparoscopic and open approaches in the treatment of primary and secondary lumbar hernias, an equivalent outcome was noted with respect to recurrences. The authors proposed that the open technique is advisable in diffuse hernias with a large, >15-cm defect.17 In our small series with short follow-up, 1 patient in the iliac group (4%) developed a recurrence. Although BMI has been quoted as a factor predictive of recurrence, incidentally the iliac group had the lowest BMI and the subcostal group the highest BMI in our series. Wound-related complication was noted in 16%. Seroma was the commonest complication, which was seen in 3 patients (12%): 1 in the lumbar and 2 in the iliac group. One patient in the iliac subgroup developed hematoma (4%). The relative drawback of our study is the small study population, which made further categorization and analysis based on subgroup location and etiology difficult. Conclusions
NMVHs are rare. They have therefore been described collectively with midline hernias. However, these hernias differ from midline hernias by virtue of their location, and their treatment can be complicated because of juxtaposition of viscera and bony structures, making mesh fixation difficult and posing risk to vital organs. A relative difference in biomechanics has also been proposed in lateral MVHs as opposed to NMVHs, the clinical implications of which needs to be determined. Thus laparoscopic management of these hernias can be technically challenging, and at present outcomes are inferior compared with the more common midline variety. Nevertheless, the laparoscopic approach to the
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treatment of NMVH is evolving and appears to be promising. As the evidence of planned studies exclusively on NMVH is meager in contemporary literature, more of these planned studies are warranted. Disclosure Statement
No competing financial interests exist. References
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15. Alaedeen D. Laparoscopic trans-abdominal pre-peritoneal repair of a traumatic Petit lumbar hernia with mesh. Am Surg 2011;77:E292–E293. 16. Nam SY, Kee SK, Kim JO. Laparoscopic transabdominal extraperitoneal mesh repair of lumbar hernia. J Korean Surg Soc 2011;81(Suppl 1):S74–S77. 17. Moreno-Egea A, Alcaraz AC, Cuervo MC. Surgical options in lumbar hernia: Laparoscopic versus open repair. A long-term prospective study. Surg Innov 2013;20: 331–344. 18. Mittal T, Kumar V, Khullar R, Sharma A, Soni V, Baijal M, Chowbey PK. Diagnosis and management of Spigelian hernia: A review of literature and our experience. J Minim Access Surg 2008;4:95–98. 19. Smietan´ski M, Bury K, Tomaszewska A, Lubowiecka I, Szymczak C. Biomechanics of the front abdominal wall
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Address correspondence to: Deborshi Sharma, MS, MRCS(Edin), FMAS Department of Surgery Lady Hardinge Medical College & Dr. RML Hospital New Delhi, 110001 India E-mail: [email protected] [email protected]
