An incisional hernia is usually defined as a chronic postoperative

Transcription

1 Retro Rectus Approach to Ventral Hernia Repair Jean Bernard Flament, MD, FACS, FRCS (London) An incisional hernia is usually defined as a chronic postoperative defect of the abdominal wall through which intra-abdominal viscera protrude. Progress in surgical techniques, even with laparoscopic surgery, has not led to the elimination of incisional hernias. On the contrary, the incidence of this complication seems to be increasing as more major and lengthy operations are being performed, especially in elderly patients with concomitant organic disease. The incidence of this condition has been reported to be as high as 11% of all laparotomies. 1 Surgical repair is difficult in the patient with a large abdominal wall defect, especially if the herniated viscera has lost its right of domain in the abdominal cavity. It must be remembered that surgical repair of an incisional hernia is not the same thing as closure of a laparotomy. Weakening of the abdominal wall and the consequences of decreased abdominal pressure on diaphragmatic mobility and respiratory function must also be considered. Placement of a prosthetic mesh is essential because without mesh, the recurrence rate is prohibitive, varying from 30% to 60%. 1 The retromuscular prefascial mesh hernia repair, which is the subject of this article, was popularized by Jean Rives and has been used in our department since Described as early as 1973, 2 this technique was clearly described in 1977 in the French Encyclopedia of Surgery. 3 The drawings were later reproduced in the first and second edition of Abdominal Wall Surgery by Chevrel. 4 They have also been reproduced, with minor modifications, by Wantz, 5 Stoppa, 6 and Bauer. 1 We consider this technique to be the gold standard for the repair of midline incisional hernias. 7 PREOPERATIVE ASSESSMENT Clinical features are usually so evident that the diagnosis is obvious at first sight. The bulge is readily seen when the surgeon asks the patient to push or cough to increase abdominal pressure. Palpation identifies the edges of the musculo-aponeurotic defect, but precise measurement of From the Service de Chirurgie Générale, Hôpital Robert Debré Centre Hospitalier Universitaire de Reims, and Département de Chirurgie, Faculté de Médecine de Reims Université de Champagne-Ardenne, Reims, France. Address reprint requests to Jean Bernard Flament, MD, FACS, FRCS, Service de Chirurgie Générale, Hôpital Robert Debré, Avenue du Général Koenig, Reims, France Elsevier Inc. All rights reserved X/04/ $30.00/0 doi: /j.optechgensurg the dimensions of the defect may be difficult, particularly in very obese patients. Therefore, computed tomography is helpful for assessing the dimensions of the defect, the distance the lateral muscles of the abdominal wall have retracted, and the volume of the mushroom-like mass of bowel exteriorized outside the abdominal cavity. Decreased intra-abdominal pressure leads to general and local disturbances, as a consequence of the extra-abdominal protrusion of the viscera. The rectus and lateral muscles are compromised because they have lost their midline insertion on the linea alba; specifically, the rectus muscles become attenuated and heaped up in a dome-like configuration, and the flat lateral muscles (external oblique, internal oblique, and transversus) retract and become fatty and sclerotic. The skin is also involved in the abdominal wall disease; trophic (ischemic) ulcerations are often observed in large hernia masses. They are located over the midline and at the apex of the protrusion and are the result of weakening of the subcutaneous cellular tissue and flattening of blood vessels due to pressure from viscera. 8 Perhaps more important are respiratory consequences related to the disruption of the normal contribution of abdominal muscles and diaphragm in breathing. These disturbances must be evaluated by appropriate respiratory function tests to avoid a catastrophic postoperative course. Arterial blood gases should be obtained. In some cases, the herniated organs have lost their right of domain, and the hernia contents cannot be returned to the abdomen. These patients may require specific preparation by the creation of a preoperative pneumoperitoneum. 9 PREOPERATIVE CARE At the time of initial contact with the patient, respiratory function must be assessed (history of smoking, cough, expectorations). Preparation includes withdrawal of tobacco, respiratory physiotherapy, and, if possible, weight loss. In cases where the hernia has lost the right of domain in the abdominal cavity, as evaluated by preoperative computed tomography scanning, the technique of preoperative therapeutic pneumoperitoneum is useful; air is injected into the peritoneal cavity until the patient feels discomfort (scapular pain). The amount of air that can be injected during each session varies greatly according to the patient (from half a liter to more than a liter). Sessions of pneumoperitoneum creation are repeated every 2 or 3 days, and the patient is monitored with radiographs (subdiaphragmatic air images). This technique not only in- Operative Techniques in General Surgery, Vol 6, No 3 (September), 2004: pp

2 166 Jean Bernard Flament creases the size of the abdominal cavity, but it also helps the diaphragm to adapt to the higher intra-abdominal pressure that will be present after surgery. SURGICAL TREATMENT The general goals of the operation are to place prosthetic material in the retromuscular prefascial space. The prosthesis should be sutured with some tension via transfixing sutures. This leads to recovery of lateral muscle function, because the physiological tension lost due to the midline detachment of the muscle is reestablished. Septic conditions, occult abscess, or accidental enterotomy precludes the use of a nonabsorbable mesh. OPERATIVE TECHNIQUE 1 The second abdominal cavity.

3 Retro Rectus Approach to Ventral Hernia Repair In most patients with huge incisional hernias, the herniated organs have lost their right of domain in the abdominal cavity and cannot be returned readily into the abdomen. In this situation, there are really two abdominal cavities. This concept of a second abdominal cavity was first described by Jean Rives in Computed tomography scan provides an accurate assessment of the size of the protruded viscera in relation to the volume of the residual abdominal cavity. (A) Artists view; (B) clinical aspect; (C) computed tomographic scan.

4 168 Jean Bernard Flament 2 An overview of the procedure provided by the transverse cross sectional depiction of the abdominal wall. The prosthesis is placed in the rectus sheath, in contact with the muscular fibers of the rectus muscle, between the muscle and its posterior sheath. The posterior layer of the rectus sheath is always closed to prevent contact of the prosthesis with intra-abdominal viscera. Lateral fixation by transfixing stitches placed through stab incisions prevents displacement of the prosthesis and recreates the physiological tension of the lateral muscles of the abdominal wall.

5 Retro Rectus Approach to Ventral Hernia Repair The direction of skin incision is chosen according to the previous incision or the long axis of the hernia mound. We usually resect a large diamond-shaped segment of skin, because the hernia sac invariably adheres to the skin. In patients with subcutaneous ulceration, the resected area should be as large as possible, extending well behind the zone of cellulitis. 8 After opening the sac, adherent bowel loops, often present mainly in cases of multi-recurrent hernia, must be freed. The margins of the orifice must be identified. Secondary orifices must be searched for carefully and connected with the main hernia defect. Residual aponeurotic bands extending from one margin to the other have no structural value and cannot be used for repair. When the abdominal cavity is free after lysis of bowel adhesions, the posterior rectus sheath is opened (either with scalpel or electrocautery) near the linea alba to expose the posterior layer of the rectus muscle.

6 4 The area of insertion of the mesh must be as large a possible; suturing the mesh to the margins of the defect offers no guarantee of long-term continuity and usually results in recurrence of the hernia caused by lateral detachment of the mesh. Accordingly, the mesh should extend widely beyond the limits of the myoaponeurotic orifice. The dissection of the retromuscular space is conducted with a swab or with scissors. It is a blunt dissection and is usually bloodless because it runs in an avascular plane. The dissection must be extended to the lateral margins of the rectus muscle, which is easily recognized by the perforating branches of intercostal neurovascular bundles. (A) Artist s view; (B) intraoperative aspect.

7 Retro Rectus Approach to Ventral Hernia Repair Below the arcuate line, there is no posterior layer of the rectus sheath; thus, the prosthesis will be placed in the so-called pre- or properitoneal space (Retzius space medially, Bogros space laterally). The dissection must be meticulous because branches of the inferior epigastric artery cross the operative field and may be the cause of postoperative hematomas if injured. They should be ligated. The dissection must be continued to the pubic symphysis medially and Cooper s ligament laterally. Sutures can be placed through Cooper s ligament. This dissection may be difficult in cases of previous prostatic or bladder surgery. The peritoneal cavity must be closed before implantation of the mesh. In most cases, suture of the fascial margins can be achieved when the posterior rectus sheath has been correctly and widely freed. When fascial closure cannot be achieved, we close the defect with a patch of an absorbable mesh. Omentum, when present, can also be used to protect viscera from any contact with the prosthesis because the posterior surface of the omentum allows good peritonealization, whereas its anterior surface offers a surface of granulation tissue that invests the prosthesis. (A) Dissection below the arcuate line; (B) closure of a defect posteriorly with an absorbable mesh.

8 172 Jean Bernard Flament 6 Preparation of the prosthesis. Choice of the prosthesis is based on its physical and biological properties. The ideal material is a mesh with large interstices so that a rapid fibroblastic response is able to invest the prosthesis, facilitating its incorporation. The ideal material must also be light, with a certain degree of elasticity and suppleness. This allows the prosthesis to conform freely to the curvatures of the visceral sac. According to the classification given by Amid, 10 we used either a type III (macroporous with microporous components, Mersuture ; Ethicon, Somerville, NJ) or a totally macroporous prosthesis (Prolene ; Ethicon). The force of the abdominal pressure holds the prosthesis against the deep surface of the muscle, achieving a measure of suture by apposition. However, this pressure-induced apposition is not sufficient to maintain the prosthesis correctly during the first postoperative week. Therefore, it is necessary to ensure secure peripheral fixation of the prosthetic material. Both ends of the nonabsorbable sutures are placed through the infolded edge of the prosthesis.

9 Retro Rectus Approach to Ventral Hernia Repair Passing the sutures through the abdominal wall. A Reverdin needle is often necessary when the subcutaneous fat is thick (as it usually is in our patients). Each limb of the suture is passed through the abdominal wall separately but through the same stab wound. In some patients, when the abdominal wall is not too fatty, a stitch with a straight needle may be passed through the abdominal wall from the skin to the retromuscular space. The prosthesis is incorporated with a u-stitch, and the needle is brought out through the abdominal wall with a separate fascial location but the same skin incision.

10 174 Jean Bernard Flament 8 Both ends of the transfixing suture are brought through the abdominal wall through separate musculofascial incisions but the same skin incision, which will be closed at the end of the procedure with a single cutaneous stitch. The passage of each end of the suture through the muscle must be separated by at least 1.5 cm. If they are closer, the muscle fibers may be cut by the knot, which can result in small lateral recurrences. The surgeon should stand on the opposite side of the suture being placed. This affords a better view of the retromuscular space and allows for easier and more precise tailoring of the prosthesis. The transfixing sutures are placed clockwise along each semilunar line (Spiegel line) and at each extremity of the laparotomy. Usually 12 transfixing sutures are sufficient, but in the patient with a huge incisional hernia, up to 21 sutures may be used. The sutures are tied on one side and then the other side of the defect. Tailoring of the prosthesis is important so that the sutures result in some tension of the prosthesis to re-establish the lateral muscle function that was lost because of their midline detachment. (A) Artist s view; (B) clinical aspect.

11 9 In epigastric incisional hernias, the upper part of the prosthesis is placed between the rectus abdominis anteriorly and the ribs and internal oblique posteriorly. If there is loss of substance caused by retraction of the very short muscular fibers in this location, the prosthesis may be anchored with a suture passed around the rib on each side. The surgeon must be careful not to pass the suture through the cartilage, because this may cause postoperative pain. At the end of the procedure, excess prosthetic material is trimmed. Two closed suction drains are placed in contact with the prosthesis. Closure of the musculoaponeurotic layer, in front of the prosthesis, is always possible due to the tension of the prosthesis. Two drains are placed beneath the skin. Dermolipectomy in obese patients provides a much better cosmetic result. (A) Epigastric hernia; (B) trimming of excess prosthesis.

12 176 Jean Bernard Flament 10 Early postoperative appearance of the stab wounds, which were used for the full-thickness abdominal wall sutures.

13 Retro Rectus Approach to Ventral Hernia Repair Varying prosthetic positions depending on the type of hernia: (A) suprapubic, (B) peri-umbilical, and (C) epigastric.

14 178 Jean Bernard Flament POSTOPERATIVE CARE Respiratory physiotherapy is resumed as soon as possible after surgery. Aspiration drains are monitored and usually removed on the third or fourth postoperative day. Antithromboembolism therapy must be used. RESULTS In a recent series of 693 nonabsorbable prosthetic repairs, 11 the postoperative course was uneventful in 96.4% of patients. Five patients died postoperatively, one from infection. The other deaths were from cardiac or respiratory causes. Superficial infection occurred in eight patients (1.2%). Deep infection occurred in nine patients, one being lethal. Removal of the mesh was required in only one patient. Careful follow-up for long-term results was undertaken. There were 42 recurrences (6.7%). Most were small lateral recurrences; 30 have been re-repaired, for a final success rate of 98%. OTHER OPTIONS Although we consider this the optimal technique, other methods of prosthetic placement may be chosen based on a patient s individual anatomy. Intraperitoneal positioning of the prosthesis is easy, and some published studies report good results. 12 However, we do not believe that intraperitoneal implantation has any advantages other than speed. Of course, the peritoneum rapidly envelops the prosthesis and offers a good defense against infection without hematoma formation, but adhesions of the bowel loops to the prosthesis are frequent, thereby hindering intestinal transit and rendering another laparotomy dangerous. We have observed 17 cases of intraluminal migration of the intraperitoneal prosthesis. Similar cases have been reported in the literature. 13 When possible, interpositioning of the omentum between the viscera and the prosthesis, as advocated by Jean Rives in 1973, 2 can afford protection against these complications. Laparoscopic placement of the prosthesis is a variant of intraperitoneal placement. 14 We think this technique may be used for small hernias but is ineffective for large hernias, because the prosthesis cannot be placed under good tension due to the pneumoperitoneum. This technique may be dangerous because dissection of intra-abdominal adhesions is difficult and may lead to intestinal fistulae. Finally, laparoscopic incisional herniorrhaphy does not give as good a cosmetic result because it does not address the problem of excess skin. Premuscular positioning of the prosthesis is another option. 15 This technique consists of closing the midline by reflected flaps of the inner layer of the rectus sheath, followed by reinforcement with a large premuscular prosthesis, usually polypropylene. The problem with this technique is the need for creating huge cutaneous flaps, which may lead to long-lasting seromas. REFERENCES 1. Bauer JJ, Harris MT, Gorfine SR, et al: Rives-Stoppa procedure for repair of large incisional hernias: Experience with 57 patients. Hernia 6: , Rives J, Lardennois B, Pire JC, et al: Les grandes éventrations. Importance du volet abdominal et des troubles respiratoires qui lui sont secondaires. Chirurgie 99: , Rives J, Pire JC, Flament JB, et al: Traitement des éventrations, in Encyclopédie Médico-Chirurgicale. Techniques Chirurgicales Appareil Digestif. Paris, France, Elsevier, 1977, pp Flament JB, Rives J, Palot JP, et al: Major incisional hernia, in Chevrel JP (ed): Hernia and Surgery of the Abdominal Wall. Paris, France, Springer, 1997, pp Wantz GE: Incisional hernioplasty with mersilene. Surgery 172: , Stoppa R, Moungar F, Verhaeghe P: Traitement chirurgical des éventrations médianes sus ombilicales. J Chir 129: , Miedema B: Repair techniques for major incisional hernias [letter]. Am J Chir 187: , Flament JB, Avisse C, Palot JP, et al: Trophic ulcers in giant incisional hernias Pathogenesis and treatment. A report of 33 cases. Hernia 1:71-6, Flament JB, Palot JP: Prosthetic of massive abdominal ventral hernia, in Fitzgibbons RJ, Greenburg AG (eds): Nyhus and Condon s Hernia (ed 5). Philadelphia, PA, Lippincott, 2002, pp Amid PK: Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia 1:15-21, Flament JB, Palot JP, Lubrano D, et al: Retromuskuläre netplastik: Erfahrungen aus frankreich. Chirurg 73: , Arnaud JP, Cervi C, Tuech JJ, et al: Surgical treatment of post operative incisional hernias by intra-peritoneal insertion of a Dacron mesh. Hernia 1:97-99, Flament JB, Avisse C, Palot JP, et al: Complications in incisional hernia repairs by the placement of retromuscular prostheses. Hernia 4: , 2000 (suppl 1) 14. Flament JB, Palot JP: Prosthetic of massive abdominal ventral hernia, in Fitzgibbons RJ, Greenburg AG (eds): Nyhus and Condon s Hernia (ed 5). Philadelphia, PA, Lippincott, 2002, pp Chevrel JP: Traitement des grandes éventrations médianes par plastie en paletot et prothèse. Nouv Presse Med 8: , 1979