Hernia DOI 10.1007/s10029-016-1470-1
HOW-I-DO-IT
Proposed technique for open repair of a small umbilical hernia and rectus divarication with self-gripping mesh B. J. Privett1,2 • M. Ghusn1,3
Received: 26 August 2015 / Accepted: 5 February 2016 Ó Springer-Verlag France 2016
Abstract Introduction There are a group of patients in which umbilical or epigastric hernias co-exist with rectus divarication. These patients have weak abdominal musculature and are likely to pose a higher risk of recurrence following umbilical hernia repair. We would like to describe a technique for open repair of small (\4 cm) midline hernias in patients with co-existing rectus divarication using selfadhesive synthetic mesh. The use of a self-adhesive mesh avoids the need for suture fixation of the mesh in the superior portion of the abdomen, allowing for a smaller skin incision. Results In 173 patients, preperitoneal self-fixating mesh has been used for the repair of midline hernias \4 cm in diameter. In 58 of these patients, the mesh was extended superiorly to reinforce a concurrent divarication. Discussion The described technique offers a simple option for open repair of small midline hernias in patients with co-existing rectus divarication, to decrease the risk of upper midline recurrence in an at-risk patient group. This initial case series is able to demonstrate a suitably low rate of recurrence and complications. Keywords Umbilical hernia Rectus divarication Selfgripping mesh
& B. J. Privett [email protected] 1
The Tweed Hospital, Tweed Heads, Australia
2
School of Medicine, Griffith University, Gold Coast, Australia
3
John Flynn Private Hospital, Tugun, Australia
Introduction Umbilical and epigastric hernias are a common surgical complaint accounting for a significant portion of primary abdominal wall hernias. A variety of surgical techniques have been described for repair of these defects. In recent times, the use of mesh and tension free repair has gained wide spread acceptance as an option for small umbilical defects (\2 cm) [1]. Rectus divarication (diastasis) describes an apparent herniation caused by separation of the two rectus muscles as a result of linea alba thinning. As divarication does not represent a true hernia there is no risk of strangulation or incarceration [2]. As such, repair of these defects is largely performed for cosmetic reasons. There are a group of patients in which these two pathologies co-exist. These patients have weak abdominal musculature and are likely to pose a higher risk of recurrence following umbilical hernia repair alone [3]. Described techniques for repair in divarication in combination with umbilical hernia repair vary between laparoscopic and open techniques. The open procedures described in the literature tend to involve extensive skin incisions along the length of the divarication or large Pfannenstiel incisions [4]. Larger skin incisions can give poor cosmetic results and increase the risk of wound complications. Laparoscopic intraabdominal approaches have the advantages of a minimally invasive approach however they require entry into the peritoneal cavity with an associated risk of morbidity [5]. We would like to describe a technique for open repair of small (\4 cm) midline hernias in patients with co-existing rectus divarication with self-adhesive synthetic mesh. The use of a self-adhesive mesh avoids the need for suture fixation of the mesh in the superior portion of the abdomen, allowing for a smaller skin incision.
123
Hernia
Fig. 2 Schematic representation of fascial defect
Fig. 1 Preoperative marking to define to superior and lateral extent of the rectus divarication
Technique The patient is marked preoperatively to define the superior and lateral extent of the rectus divarication (Fig. 1). The site of the ventral hernia is also marked as part of the standard preoperative procedure. The patient is prepped and draped in the usual fashion in the supine position. In the case of an umbilical or supra-umbilical hernia, a transverse incision is made 1–2 cm superior to the umbilicus. The skin is incised to subcutaneous tissue. The hernial sac is identified and dissected free from the umbilicus. In the case of epigastric hernias an incision is made overlying the defect. The sac is again identified and defined. The fascial neck of the hernia is clearly defined and dissected free from the sac. A small hernia sac may be reduced en bloc or alternatively the sac is opened in the typical fashion and the contents reduced. The peritoneal defect is closed with a 2-0 vicryl or other absorbable suture. The preperitoneal plane is then defined around the extent of the defect. The fascial defect may need to be extended superiorly to enable adequate preperitoneal dissection (Fig. 2). A combination of sharp and blunt dissection is used to demonstrate the plane. Counter traction on the fascial edge will also help develop the plane. Once a preperitoneal space is opened circumferentially around the defect by at least 1 cm the dissection can proceed superiorly.
123
Fig. 3 Superior dissection using a lighted mammary retractor
A gauze swab in the non-dominant hand provides downward traction and the assistant provides upward traction on the fascia. Initially this can be achieved with a pair of Littlewood–Moynihan forceps on the fascial edge. However, as the dissection extends superiorly a lighted mammary retractor can be used to provide upward (anterior) counter traction (Fig. 3). Any inadvertent peritoneal defects made at the inferior end of the preperitoneal dissection can be easily repaired with an absorbable suture. Care should be taken at the superior end of the preperitoneal dissection, as peritoneal defects are difficult to repair. Once the preperitoneal space is adequately dissected beyond the extent of the rectus divarication superolaterally and inferolaterally beyond the defect, a mesh is placed. Using a self-fixating mesh is ideal as no sutures are required at the superior or lateral edges of the defect. As the peritoneum is intact deep to the mesh, composite or coated mesh is not required. The authors use Parietex ProGripTM rectangular mesh 15 cm 9 9 cm or 15 cm 9 15 cm trimmed to size. The mesh is inserted and positioned
Hernia
by the described technique. Primarily, a 15 cm 9 9 cm mesh was used and trimmed to size. The average size was 14 cm 9 6 cm. Over this period there was one recurrence in each group and one superficial wound infection in a patient undergoing an umbilical hernia repair only. The wound infection was treated with antibiotics and did not require removal of the mesh. The recurrence in the extended repair group was a lateral recurrence in a patient with a BMI of 37 kg/m2. Both recurrences were treated by laparoscopic repair and intraoperative findings demonstrated a well-incorporated mesh with recurrences beyond the extent of the mesh.
Fig. 4 Mesh is inserted and positioned with the adhesive surface facing upwards (anteriorly)
Fig. 5 Fascial defect is closed over the mesh
with the adhesive surface facing upwards (anteriorly) (Fig. 4). Folding the mesh inwards, such that the adhesive surface is in contact with itself, allows for the mesh to be passed through a small defect without catching on the surrounding tissues. Once the mesh is adequately positioned the fascial defect is closed in an interrupted fashion or standard Mayotype repair with a non-absorbable suture (Fig. 5). The umbilical stalk is secured and the superficial fascia closed with a 2-0 vicryl suture. The dermis is approximated with a 3-0 absorbable suture.
Results The supervising author of this paper (MG) has been performing this technique over a 2-year period from February 2013. In 173 patients, preperitoneal self-fixating mesh has been used for the repair of midline hernias \4 cm in diameter. In 58 of these patients, the ProGripTM mesh was extended superiorly to reinforce a concurrent divarication
Discussion We believe the described technique offers a simple option for open repair of small (\4 cm) midline hernias in patients with co-existing rectus divarication. This initial case series is able to demonstrate a suitably low rate of recurrence and complications. We know of one case series that indicates concurrent midline hernia and rectus diastasis is an independent risk factor for recurrence [3]. Our series is too small to demonstrate a significant difference in recurrence rates between groups. Intuitively, reinforcing the divarication superiorly with mesh should decrease the risk of a superior midline recurrence. With respect to the single recurrence in the group with extended mesh, this is likely a result of poor patient selection. In should be noted that the authors are not suggesting this technique as a replacement or alternative to laparoscopic ventral hernia repair, but another option in the repair of small midline hernias with associated divarication. This technique is not recommended for morbidly obese patients and in this group laparoscopic ventral hernia repair would be more suitable. The primary aim of this technique is to decrease the risk of upper midline recurrence in an at-risk patient group. The cosmetic results from this technique are variable. Some patients did note a decrease in the prominence and size of the rectus divarication but this was not universal. This series demonstrates the safety of the technique; however, a large randomised control trial with a longer duration of follow-up would be required to definitively demonstrate superiority or this technique over repair of the fascial defect alone. Acknowledgments The authors would like to thank Savo Djukic from Covidien for the illustrations. Conflict of interest BP reports non-financial support from Covidien, during the conduct of the study. MG reports non-financial support from Covidien, during the conduct of the study and personal fees and support outside the conduct of this study.
123
Hernia
References 1. Christoffersen MW, Helgstrand F, Rosenberg J, Kehlet H, Bisgaard T (2013) Lower reoperation rate for recurrence after mesh versus sutured elective repair in small umbilical and epigastric hernias. A nationwide register study. World J Surg 37(11):2548–2552. doi:10.1007/s00268-013-2160-0 2. Hickey F, Finch JG, Khanna A (2011) A systematic review on the outcomes of correction of diastasis of the recti. Hernia 15(6):607–614. doi:10.1007/s10029-011-0839-4 3. Kohler G, Luketina RR, Emmanuel K (2015) Sutured repair of primary small umbilical and epigastric hernias: concomitant rectus
123
diastasis is a significant risk factor for recurrence. World J Surg 39(1):121–126 (discussion 127). doi:10.1007/s00268-014-2765-y 4. Kulhanek J, Mestak O (2013) Treatment of umbilical hernia and recti muscles diastasis without a periumbilical incision. Hernia 17(4):527–530. doi:10.1007/s10029-013-1047-1 5. Prasad P, Tantia O, Patle NM, Khanna S, Sen B (2011) Laparoscopic transabdominal preperitoneal repair of ventral hernia: a step towards physiological repair. Indian J Surg 73(6):403–408. doi:10.1007/s12262-011-0366-7
HOW-I-DO-IT
Proposed technique for open repair of a small umbilical hernia and rectus divarication with self-gripping mesh B. J. Privett1,2 • M. Ghusn1,3
Received: 26 August 2015 / Accepted: 5 February 2016 Ó Springer-Verlag France 2016
Abstract Introduction There are a group of patients in which umbilical or epigastric hernias co-exist with rectus divarication. These patients have weak abdominal musculature and are likely to pose a higher risk of recurrence following umbilical hernia repair. We would like to describe a technique for open repair of small (\4 cm) midline hernias in patients with co-existing rectus divarication using selfadhesive synthetic mesh. The use of a self-adhesive mesh avoids the need for suture fixation of the mesh in the superior portion of the abdomen, allowing for a smaller skin incision. Results In 173 patients, preperitoneal self-fixating mesh has been used for the repair of midline hernias \4 cm in diameter. In 58 of these patients, the mesh was extended superiorly to reinforce a concurrent divarication. Discussion The described technique offers a simple option for open repair of small midline hernias in patients with co-existing rectus divarication, to decrease the risk of upper midline recurrence in an at-risk patient group. This initial case series is able to demonstrate a suitably low rate of recurrence and complications. Keywords Umbilical hernia Rectus divarication Selfgripping mesh
& B. J. Privett [email protected] 1
The Tweed Hospital, Tweed Heads, Australia
2
School of Medicine, Griffith University, Gold Coast, Australia
3
John Flynn Private Hospital, Tugun, Australia
Introduction Umbilical and epigastric hernias are a common surgical complaint accounting for a significant portion of primary abdominal wall hernias. A variety of surgical techniques have been described for repair of these defects. In recent times, the use of mesh and tension free repair has gained wide spread acceptance as an option for small umbilical defects (\2 cm) [1]. Rectus divarication (diastasis) describes an apparent herniation caused by separation of the two rectus muscles as a result of linea alba thinning. As divarication does not represent a true hernia there is no risk of strangulation or incarceration [2]. As such, repair of these defects is largely performed for cosmetic reasons. There are a group of patients in which these two pathologies co-exist. These patients have weak abdominal musculature and are likely to pose a higher risk of recurrence following umbilical hernia repair alone [3]. Described techniques for repair in divarication in combination with umbilical hernia repair vary between laparoscopic and open techniques. The open procedures described in the literature tend to involve extensive skin incisions along the length of the divarication or large Pfannenstiel incisions [4]. Larger skin incisions can give poor cosmetic results and increase the risk of wound complications. Laparoscopic intraabdominal approaches have the advantages of a minimally invasive approach however they require entry into the peritoneal cavity with an associated risk of morbidity [5]. We would like to describe a technique for open repair of small (\4 cm) midline hernias in patients with co-existing rectus divarication with self-adhesive synthetic mesh. The use of a self-adhesive mesh avoids the need for suture fixation of the mesh in the superior portion of the abdomen, allowing for a smaller skin incision.
123
Hernia
Fig. 2 Schematic representation of fascial defect
Fig. 1 Preoperative marking to define to superior and lateral extent of the rectus divarication
Technique The patient is marked preoperatively to define the superior and lateral extent of the rectus divarication (Fig. 1). The site of the ventral hernia is also marked as part of the standard preoperative procedure. The patient is prepped and draped in the usual fashion in the supine position. In the case of an umbilical or supra-umbilical hernia, a transverse incision is made 1–2 cm superior to the umbilicus. The skin is incised to subcutaneous tissue. The hernial sac is identified and dissected free from the umbilicus. In the case of epigastric hernias an incision is made overlying the defect. The sac is again identified and defined. The fascial neck of the hernia is clearly defined and dissected free from the sac. A small hernia sac may be reduced en bloc or alternatively the sac is opened in the typical fashion and the contents reduced. The peritoneal defect is closed with a 2-0 vicryl or other absorbable suture. The preperitoneal plane is then defined around the extent of the defect. The fascial defect may need to be extended superiorly to enable adequate preperitoneal dissection (Fig. 2). A combination of sharp and blunt dissection is used to demonstrate the plane. Counter traction on the fascial edge will also help develop the plane. Once a preperitoneal space is opened circumferentially around the defect by at least 1 cm the dissection can proceed superiorly.
123
Fig. 3 Superior dissection using a lighted mammary retractor
A gauze swab in the non-dominant hand provides downward traction and the assistant provides upward traction on the fascia. Initially this can be achieved with a pair of Littlewood–Moynihan forceps on the fascial edge. However, as the dissection extends superiorly a lighted mammary retractor can be used to provide upward (anterior) counter traction (Fig. 3). Any inadvertent peritoneal defects made at the inferior end of the preperitoneal dissection can be easily repaired with an absorbable suture. Care should be taken at the superior end of the preperitoneal dissection, as peritoneal defects are difficult to repair. Once the preperitoneal space is adequately dissected beyond the extent of the rectus divarication superolaterally and inferolaterally beyond the defect, a mesh is placed. Using a self-fixating mesh is ideal as no sutures are required at the superior or lateral edges of the defect. As the peritoneum is intact deep to the mesh, composite or coated mesh is not required. The authors use Parietex ProGripTM rectangular mesh 15 cm 9 9 cm or 15 cm 9 15 cm trimmed to size. The mesh is inserted and positioned
Hernia
by the described technique. Primarily, a 15 cm 9 9 cm mesh was used and trimmed to size. The average size was 14 cm 9 6 cm. Over this period there was one recurrence in each group and one superficial wound infection in a patient undergoing an umbilical hernia repair only. The wound infection was treated with antibiotics and did not require removal of the mesh. The recurrence in the extended repair group was a lateral recurrence in a patient with a BMI of 37 kg/m2. Both recurrences were treated by laparoscopic repair and intraoperative findings demonstrated a well-incorporated mesh with recurrences beyond the extent of the mesh.
Fig. 4 Mesh is inserted and positioned with the adhesive surface facing upwards (anteriorly)
Fig. 5 Fascial defect is closed over the mesh
with the adhesive surface facing upwards (anteriorly) (Fig. 4). Folding the mesh inwards, such that the adhesive surface is in contact with itself, allows for the mesh to be passed through a small defect without catching on the surrounding tissues. Once the mesh is adequately positioned the fascial defect is closed in an interrupted fashion or standard Mayotype repair with a non-absorbable suture (Fig. 5). The umbilical stalk is secured and the superficial fascia closed with a 2-0 vicryl suture. The dermis is approximated with a 3-0 absorbable suture.
Results The supervising author of this paper (MG) has been performing this technique over a 2-year period from February 2013. In 173 patients, preperitoneal self-fixating mesh has been used for the repair of midline hernias \4 cm in diameter. In 58 of these patients, the ProGripTM mesh was extended superiorly to reinforce a concurrent divarication
Discussion We believe the described technique offers a simple option for open repair of small (\4 cm) midline hernias in patients with co-existing rectus divarication. This initial case series is able to demonstrate a suitably low rate of recurrence and complications. We know of one case series that indicates concurrent midline hernia and rectus diastasis is an independent risk factor for recurrence [3]. Our series is too small to demonstrate a significant difference in recurrence rates between groups. Intuitively, reinforcing the divarication superiorly with mesh should decrease the risk of a superior midline recurrence. With respect to the single recurrence in the group with extended mesh, this is likely a result of poor patient selection. In should be noted that the authors are not suggesting this technique as a replacement or alternative to laparoscopic ventral hernia repair, but another option in the repair of small midline hernias with associated divarication. This technique is not recommended for morbidly obese patients and in this group laparoscopic ventral hernia repair would be more suitable. The primary aim of this technique is to decrease the risk of upper midline recurrence in an at-risk patient group. The cosmetic results from this technique are variable. Some patients did note a decrease in the prominence and size of the rectus divarication but this was not universal. This series demonstrates the safety of the technique; however, a large randomised control trial with a longer duration of follow-up would be required to definitively demonstrate superiority or this technique over repair of the fascial defect alone. Acknowledgments The authors would like to thank Savo Djukic from Covidien for the illustrations. Conflict of interest BP reports non-financial support from Covidien, during the conduct of the study. MG reports non-financial support from Covidien, during the conduct of the study and personal fees and support outside the conduct of this study.
123
Hernia
References 1. Christoffersen MW, Helgstrand F, Rosenberg J, Kehlet H, Bisgaard T (2013) Lower reoperation rate for recurrence after mesh versus sutured elective repair in small umbilical and epigastric hernias. A nationwide register study. World J Surg 37(11):2548–2552. doi:10.1007/s00268-013-2160-0 2. Hickey F, Finch JG, Khanna A (2011) A systematic review on the outcomes of correction of diastasis of the recti. Hernia 15(6):607–614. doi:10.1007/s10029-011-0839-4 3. Kohler G, Luketina RR, Emmanuel K (2015) Sutured repair of primary small umbilical and epigastric hernias: concomitant rectus
123
diastasis is a significant risk factor for recurrence. World J Surg 39(1):121–126 (discussion 127). doi:10.1007/s00268-014-2765-y 4. Kulhanek J, Mestak O (2013) Treatment of umbilical hernia and recti muscles diastasis without a periumbilical incision. Hernia 17(4):527–530. doi:10.1007/s10029-013-1047-1 5. Prasad P, Tantia O, Patle NM, Khanna S, Sen B (2011) Laparoscopic transabdominal preperitoneal repair of ventral hernia: a step towards physiological repair. Indian J Surg 73(6):403–408. doi:10.1007/s12262-011-0366-7
