Laparoscopic Flank Hernia Repair

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aparoscopic Flank Hernia Repairrchana Ramaswamy, MD, and Bruce Ramshaw, MD

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lank hernias occur between the costal margin and theiliac crest. Primary acquired hernias tend to form in the

nferior lumbar triangle (of Petit) and superior lumbar trian-le (of Grynfeltt). The superior lumbar triangle is bounded byhe 12th rib, paraspinal muscles, and internal oblique musclehereas the inferior lumbar triangle is bounded by the iliac

rest, latissimus dorsi muscle, and external oblique muscle.nnamed hernias can also occur in the flank anywhere

hrough muscular and fascial defects.Flank hernias are uncommon defects without any well-

eported incidence. The acquired defect can be primary orecondary to trauma, infection, or surgery. Primary defectsomprise 50% of flank hernias with secondary and congeni-al comprising the rest. Post surgical hernias can follow flankncisions primarily for kidney or adrenal surgery and lessrequently after iliac bone graft harvesting, retroperitonealascular procedures or abscess drainage. The incidence ofernia after flank incision for urologic surgery has recentlyeen reported as high as 31%. The risk of hernia formationas been associated with age greater than 50, wound infec-ion, abdominal wall hematoma, and hypoproteinemia. Over0% of these hernias were detected within 1 year of surgery.1

Flank hernias usually present as a posterior bulge that maye asymptomatic, or may be associated with mild or severeiscomfort from nerve compression. Acute incarceration,hough infrequent, is more commonly seen with a primarycquired defect. The diagnosis can be difficult and often im-ging studies are helpful to distinguish a hernia from a softissue lesion, hematoma, abscess, renal lesion or muscularaxity. Imaging studies (commonly CT or MRI) are also help-ul in identifying the anatomical boundaries of the hernia.

epartment of Surgery, University of Missouri, Columbia, MO.ddress reprint requests to Bruce Ramshaw, Department of Surgery, Uni-

versity of Missouri, 1 Hospital Dr. MC 414, Columbia, MO, 65212.E-
lmail: [email protected]
2 1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2006.04.009

his is useful for surgical planning because healthy tissueeeds to be identified for mesh fixation. With intraabdominalressure and presumed muscle atrophy, the natural historyf flank hernias tends to be an increase in size. Because repairf large flank hernias can become very complex with increas-ng size, consideration should be given to early repair inndividuals who do not have medical contraindications tourgery.

Techniques for open repair of flank hernias have rangedrom layered closure with muscular and fascial flaps to these of prosthetic material. Laparoscopic flank hernia repair isased on the principles of laparoscopic repair for ventralernias: adequate overlap of mesh with healthy tissue andppropriate fixation. These two requisites for a durable repairre often challenging in the flank. Posteriorly, the mesh issually fixed to the paraspinal muscles (sacrospinus, serratusosterior inferior, latissimus dorsi) with attention being paid,

n large hernias, to the position of the inferior vena cava.uperiorly, fixation can often be applied just below the costalargin with a flap of mesh extending up to the diaphragm. As

ur experience has increased with these hernias, we haveound that with defects that extend right to the costal marginack fixation can be performed at the level of a superior rib,eing careful to avoid the diaphragm and thus the mediasti-al organs. Inferior fixation can also be difficult with hernialefects extending to the iliac crest. In these situations, fixa-ion can be accomplished through the iliac crest by using

itek anchors or simply by drilling through the bone. Weave chosen to leave power tools to our orthopedic col-

eagues and perform a dissection similar to that for an ingui-al hernia, identifying Cooper’s ligament and the iliopubicract and obtaining solid fixation at Cooper’s ligament, drap-ng a leaf of mesh into the pelvis. Prosthetic material shoulde appropriate for intraperitoneal use: e-PTFE or composite

ightweight polypropylene or polyester.

Laparoscopic flank hernia repair 53

Operative Technique

Figure 1 After intubation, antibiotic administration (usually first generation cephalosporin) and thromboembolicprecautions, bladder catherization is performed. Patient positioning is then undertaken with diligence. We position thepatient in full lateral decubitus, using a bean bag if necessary, being careful to allow easy access to the area of theparaspinal muscles. The kidney rest can be used to open up the space between the costal margin and the iliac crest. Theipsilateral arm needs to be suspended in a similar manner as that used for positioning for adrenalectomy. The surgeonand assistant are positioned on the same side with the tower and monitor being placed just opposite. A monitor on theother side can be useful during suture fixation at the posteromedial border through the paraspinal muscles. The skinis then prepped widely and an adhesive skin barrier is used to keep the drapes in place.

Figure 2 Initial access is usually gained at the infraumbilical position using an open approach to place a 10 mm port.Two 5 mm ports are then usually placed in the midline above and below the camera port. A fourth trocar is sometimes
placed through the paraspinal muscles and will be discussed later.

54 A. Ramaswamy and B. Ramshaw

Figure 3 Initial view of the right flank hernia may demonstrate incarcerated contents including small and large bowel.Also important to note is that the initial view may not provide a realistic estimate of the hernia size because a large
portion of the defect is masked by the overlying colon.
Figure 4 After reduction of any incarcerated contents, the colon then needs to be mobilized. With significant incarcer-ated contents, the peritoneum is often stripped down allowing access into the retroperitoneal space as the contents arereduced. If there aren’t any incarcerated contents, the white line of Toldt can be incised to begin mobilizing the colon.The kidney may also have to be mobilized lateral to medial if the hernia defect extends posteriorly. Adequate dissectionhas been performed when there is at least 4 cm of exposed abdominal wall circumferentially around the hernial defect.
Energy sources are usually avoided during the initial dissection to avoid the risk of transmitted injury to the bowel.


Figure 5 The hernia defect is then sized using spinal needles if needed. The mesh is chosen to provide at least 4 to 5 cmoverlap with healthy tissue. This overlap with healthy tissue can be limited depending on the extent of the defect;hernias which extend to the costal margin or the iliac crest will be addressed later. With large posterior extension of thedefect, it is imperative to assure that there is adequate tissue lateral to the spine for fixation. If this is lacking, there is ahigh expected risk of recurrence since the mesh will pull away from the defect edge. Preoperative CT scan is of valueto identify these situations and to appropriately select patients for surgical management. Once the appropriate sizemesh is chosen, four nonabsorbable sutures are placed, knots tied, and the tails left long. Sites for pulling through thetransfascial sutures are marked on the skin, and the mesh is then marked for orientation, inserted into the abdominalcavity and unrolled. The sutures are then grasped with a suture passer and pulled through the abdominal wall. Theseare not tied down until all four sutures have been pulled through to allow adequate visualization of the entry of thesuture passer and of the suture tails. We begin with the posteromedial suture because there can often be no modifica-
tions made to the site of suture pull through because of limitations in this area secondary to the spine.


Figure 6 The next suture pulled through the abdominal wall can be the inferior or superior one. After fixation with thefirst two sutures, tension should be placed on these to pull the mesh up to the abdominal wall. The mesh should thenbe pulled taut at the unfixed superior or inferior end to see if the site marked externally for suture pull through needsto be modified. This maneuver is similarly performed for the anteromedial suture. The mesh should be stretched taut
so that once the pneumoperitoneum is deflated the mesh will configure to the natural curve of the abdominal wall.
Figure 7 Tacks are then placed circumferentially at 1 cm intervals. Additional transfascial sutures should be placed
when a large mesh is being used, at 4 to 5 cm intervals around the mesh.


Figure 8 (A,B) For large defects, a trocar may need to be placed through the paraspinal muscles to obtain an angle toapply fixation for the anteromedial edge of the mesh. Depending on the posteromedial extent of the mesh fixation, this
5-mm trocar may be medial to the mesh or come through the mesh.


Figure 9 A hernia defect that extends to the level of the iliac crest will require either fixation through the bone, or fixationdown in the pelvis. We choose to identify Cooper’s ligament and place tacks at this level, leaving a skirt of mesh drapedinto the pelvis. The inferior edge of the mesh is also fixed just anterior to the iliopubic tract, both with tacks and sutures.Similar to an inguinal hernia repair, no fixation should be placed below the iliopubic tract to avoid nerve and vascular
injury.


Figure 10 For fixation, with the defect edge bordering on or in close proximity to the costal margin, the mesh is sizedand positioned to provide a 5 cm flap above the costal margin. Transfascial fixation is then performed just subcostallyand tack fixation is performed at the level of a rib. Intercostal vessel injury is a theoretical risk, though unlikely sincethe tacks are only 3.8 mm long and need to first go through at least a 1 mm mesh. Of importance here is to avoid placing
any tacks in the diaphragm to minimize risk of cardiac or lung injury.

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igure 11 Appearance after the final fixation has been completed,
pplicable in a patient with a small hernia.
Falevel of Cooper’s ligament and up to the diaphragm.

igure 12 Appearance after the final fixation has been completed,pplicable for a large hernia when fixation is required both at the
evel of Cooper’s ligament and up to the diaphragm.
igure 13 Appearance after the final fixation has been completed,pplicable for a large hernia when fixation is required both at the

Figure 14 CT scan image of right flank hernia following repair.

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Postoperative care is similar to that for laparoscopic ventralernia repair. Early ambulation is encouraged. The bladderatheter is removed in the immediate postoperative periodor simple cases or on ambulation for large repairs. Adequatenalgesia can be achieved with regular administration of non-teroidal anti-inflammatory agents in addition to narcoticsith a PCA if needed. Epidural analgesia is currently being

valuated for efficacy in patients undergoing laparoscopicentral hernia repair. Oral intake is allowed on the day ofurgery and advanced as tolerated by the patient. Venoushromboembolic prophylaxis should be undertaken untilhere is adequate ambulation. Postoperative seromas are fre-uent and usually resolve spontaneously over 4 to 6 weeks.bdominal binders may be used for patient comfort. We doot routinely drain seromas, and will only consider it after arolonged period in a severely symptomatic patient since theisk of introduction of bacteria into a sterile collection exists.

Short term outcomes have been good in our initial experi-

nce. Of our first 10 cases, nine were incisional hernias, andne was posttrauma. Median hernia diameter was 222 cm2

25-780 cm2) and median size of mesh was 600 cm2 (96-368 cm2). Median operative time was 137 minutes (81-322inutes). There were no intraoperative or postoperative

omplications and median hospital stay was 2.5 days (0-6ays). There were no complications or recurrences at 1onth follow up.In conclusion, laparoscopic repair is well suited for flank

ernias because there is clear visualization, and wide cover-ge and secure fixation can be achieved. Good knowledge ofroin and retroperitoneal anatomy is required and patientositioning is key to accessing this difficult region.

eference. Delgado MS, Urena MAG, Garcia MV, Marquez GP: La Eventracion

Lumbar Como Complicacion de la Lumbotomia Por el Flanco: Revisio
de Nuestra Serie. Actas Urol Esp 26:345-350, 2002

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Laparoscopic Flank Hernia Repair