Ventral Abdominal Hernia Repair: MIS Extraperitoneal ... · Minimally invasive surgery (MIS) ventral hernia repairs were first described by Le Blanc in 1993 with the laparoscopic

271© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery, https://doi.org/10.1007/978-3-319-78411-3_20

F. M. M. de Oliveira (*) Montefiore Medical Center, Bronx, NY, USA

L. T. Cavazzola Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil

A. S. Weltz · I. BelyanskyDepartment of Surgery, Anne Arundel Medical Center, Annapolis, MD, USAe-mail: [email protected]; [email protected]

20Ventral Abdominal Hernia Repair: MIS Extraperitoneal Repair Techniques: eTEP Rives, MILOS/EMILOS, and Onlay MIS Repair

Flavio Malcher Martins de Oliveira, Leandro Totti Cavazzola, Adam S. Weltz, and Igor Belyansky

Introduction

Minimally invasive surgery (MIS) ventral hernia repairs were first described by Le Blanc in 1993 with the laparoscopic approach and an intraperitoneal onlay mesh (IPOM) implant. The use of IPOM was never the gold standard in open ventral hernia repairs because of the fear of placing uncoated mesh materials in direct con-tact with abdominal viscera [1]. The development of laparoscopic techniques included several modifications such as the use of new coated meshes, new fixation devices, and, perhaps most importantly, changes in surgical technique. These tech-nical changes included the abandonment of the traditional onlay and retromuscular/preperitoneal options. The intraperitoneal era had begun. Laparoscopic techniques have proven themselves in the last 20 years as safe and effective treatments for ven-tral hernias, despite increased rates of intra-abdominal complications [2].

The adoption of laparoscopic repairs plateaued at approximately 20% of all ven-tral hernia repairs, despite their noted benefits. Several reasons have been postu-lated, such as increased cost (fixation devices) and difficult learning curve.

Advances in MIS ventral hernia repair, such as the robotic platform, have enhanced the ability to operate on the abdominal wall through fully articulated

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instruments and improved optics and visualization. Surgeons quickly began per-forming MIS repairs without IPOM, returning to traditional techniques such as onlay and sublay. After robotic surgery ushered this trend, several MIS surgeons without robotic access began performing these techniques using traditional laparo-scopic/endoscopic instruments. In this chapter, we will explore several of these extraperitoneal techniques.

eTEP

Preoperative Planning and Considerations

All potential minimally invasive abdominal wall reconstruction candidates must undergo a comprehensive workup to ensure they are appropriately selected for sur-gery. This includes a comprehensive past medical and surgical history, physical exam, and laboratory testing with emphasis placed on screening for absolute and relative contraindications to the eTEP approach (Table 20.1). An up-to-date com-puted tomography study of the abdomen and pelvis is recommended for effective preoperative planning [3]. All major comorbidities must be addressed by means of a multidisciplinary approach before proceeding to the operating room. Preoperative antibiotics should be properly selected and dosed according to hospital protocol [3, 4]. We recommend routine administration of subcutaneous heparin for DVT pro-phylaxis in our patient population, beginning prior to the induction of anesthesia and administered throughout the typical duration of the procedure [5, 6].

Operating Room Setup and Patient Positioning

After induction of general anesthesia, all patients are positioned supine with arms tucked to the side. A Foley catheter is placed to decompress the bladder. The operat-ing table is flexed with the legs extending downward at a minimum of 30° to afford the surgeon greater instrument range of motion (Fig. 20.1). Failure to sufficiently flex the operating table will result in hand collisions with the patient’s body during dissection.

The enhanced-view totally extraperitoneal (eTEP) access approach was previ-ously described for laparoscopic inguinal hernia repair by Daes in 2012 [7]. This approach introduced the notion that the extraperitoneal domain is a limitless space

Table 20.1 Absolute and relative contraindications to eTEP approach

Relative AbsolutePrevious incision extending from xiphoid process to the pubic bone

Active mesh infection

Loss of domain Presence of fistulaDystrophic or ulcerated skinExtensive intra-abdominal adhesions

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once the confluence of arcuate line and semilunar line is taken down. This technique relies on proper anatomic identification and dissection in the naturally occurring retromuscular spaces. Typically, dissection is initiated in one of the retrorectus spaces and then crossed over to the contralateral side, thus joining the two spaces into one large operative field. Since Daes’ initial description, we have adopted this technique for ventral and incisional hernia repair [7, 8].

Positioning of the surgeon, monitor, and trocars are dependent on the location of the hernia defect and decision where to cross the midline. Monitors are placed at the head of the bed with trocar sites on the lower abdomen when addressing an upper midline hernia defect and inverted in instances of lower midline hernia defects.

Upper Midline Defect

Figure 20.2 demonstrates the port position for upper midline defects. The first inci-sion is made 2 cm bellow a horizontal line drawn through umbilicus just medial to the right linea semilunaris. The anterior rectus sheath is identified and incised sharply. Single site balloon dissector is used to develop the right retrorectus space in cephalad and caudal directions. It is critical to avoid over-inflation which may rup-ture the linea semilunaris and consequently injure the rectus abdominis muscle. In addition, special care should be given to appreciating the inferior epigastric vessels that travel parallel and medial to the linea semilunaris in the vicinity of the #1 port. Once the space of Retzius is developed, ports #2 and #3 are placed under direct vision in the lower abdomen. The site of port #3 can also be used to pass the balloon space-maker in a cephalad direction to develop the left retrorectus space. Thus, even before any initiation of sharp dissection, the retromuscular space surrounding the hernia defect is completely dissected bluntly with the balloon space-maker.

We prefer to perform the crossover below the level of the umbilicus, develop-ing preperitoneal and retromuscular spaces that have not been previously violated. A 30° scope is placed through port #3 after which we proceed with division of the

Fig. 20.1 Positioning of the patient for laparoscopic eTEP. Patient is in Trendelenburg position with hips extended. Bed flexion is best avoided

20 Ventral Abdominal Hernia Repair: MIS Extraperitoneal Repair Techniques

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medial contributions of the posterior rectus sheath to the linea alba bilaterally from caudal to cephalad direction. In the middle we try to preserve the preperito-neal contributions to the posterior layer which are made up of the falciform and umbilical ligaments. In such a fashion, the division of posterior rectus sheath and preservation of falciform ligament and umbilical ligaments allow us to join the right and the left retrorectus spaces together with the midline preperitoneal space (Fig. 20.3).

Following the dissection in these planes, we then anticipate to encounter the neck of the hernia sac. In an incisional hernia, these layers surrounding the neck of the sack can be thoroughly fused together and difficult to differentiate. An attempt may be made in some cases to reduce the entirety of the sac by separating it from its distal attachments; however this is not often attempted. We frequently give consid-eration to sharply opening the peritoneal layer just proximal to the neck of the sac to reduce visceral contents under direct visualization and perform limited adhe-siolysis (Fig. 20.4). Any defects in the posterior layer can be fixed with running suture. Once the hernia contents are reduced, retromuscular dissection commences with release of the medial aspect of the posterior rectus sheath and concludes just below the level of the xiphoid process.

Fig. 20.2 Port positioning for upper midline defects. The balloon dissector is placed in port #1. Ports #2 and #3 are positioned under direct vision. The arrows show the working instruments with the camera vision demonstrated by the white triangle


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Lower Midline Defects

For a right-handed surgeon, we found that lower midline defects are easier to address by initiating the dissection in the upper portion of left retrorectus space. Figure 20.5 demonstrates the typical port position that we chose to use for this approach. Balloon dissector is used at port position #1 to develop the left retro-rectus space, followed by direct visualization for placement of port #2 into the developed space with an optional port #3. Blunt dissection in the left retrorectus space is performed in a caudal direction and the pubis is identified. As the upper midline has not previously been violated above the level of umbilicus, the medial aspect of the left posterior rectus sheath is incised and the preperitoneal space entered just superficial to falciform ligament (Fig. 20.6). The right posterior rec-tus sheath is identified and its medial aspect incised and released in a cephalad to caudal direction followed by blunt dissection in the right retrorectus space (Fig. 20.7). Port #4 is then placed under direct vision through the upper aspect of right rectus abdominis muscle which is then used as the camera port. The retro-rectus dissection is carried out in the caudal direction completing bilateral release of the posterior rectus sheathes. When encountering the hernia sac, we try to

Fig. 20.3 View of the retrorectus space. After crossing over and dissection, the retrorectus spaces on both sides are combined into one large retrorectus space. This falciform ligament can be seen below

Fig. 20.4 Sharp opening of the peritoneal layer proximal to the neck of the hernia sac, allowing for reducing visceral contents under direct visualization and limited adhesiolysis


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sharply dissect the distal attachments, thus mobilizing it downward. Alternatively, the sac can be sharply entered and laparoscopic adhesiolysis performed as needed.

Transversus Abdominis Release (TAR)

For more complex defects that require large mesh placement, the TAR procedure is added [9, 10]. We have found that incorporation of TAR is beneficial in cases with wide (>10 cm) defects, narrow (<5 cm) retrorectus spaces, or when dealing

Fig. 20.5 Port placement for a right-handed surgeon addressing a lower midline defects. We initiate the dissection in the upper portion of left retrorectus space. Balloon dissector is used at port position #1 to develop the left retrorectus space, followed by direct visualization for placement of port #2 into the developed space with an optional port #3. Port #4 is used as a camera port

Fig. 20.6 Medial aspect of the left posterior rectus sheath is incised and the preperitoneal space entered just superficial to falciform ligament


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with a poorly compliant abdominal wall. Any defects in the posterior layer are closed with 2-0 absorbable suture. The abdominal wall defect is primarily closed using 0 barbed suture in running fashion, while pneumoperitoneum is dropped to 8 mmHg.

For defects wider than 10 cm, primary fascial closure can rarely be achieved under physiologic tension unless additional component separation in the form of TAR is added to the procedure. The edge of the cut posterior rectus sheath (PRS) on one side is retracted medially, and a thin, almost transparent layer of connec-tive tissue that covers the transversus fibers is identified as the posterior lamina of the internal oblique muscle and incised with hook electrocautery, thus expos-ing the transversus abdominis muscle fibers (Fig. 20.8). Care must be taken to stay medial to the perforating nerves and vessels at the linea semilunaris to main-tain functional segmental innervation to the rectus (Fig. 20.9). Hook cautery is used to elevate and transect the exposed transversus fibers, revealing the glisten-ing transversalis fascia underneath. This is continued from cephalad to caudad until the transversalis fascia is seen as a glistening line extending the entire cra-niocaudal length of the abdominal wall. Blunt dissection is now used to develop the plane just deeper to the transversus muscle fibers and superficial to the trans-versalis fascia resulting in a retromuscular preperitoneal plane, thereby achiev-ing TAR (Fig. 20.10). The plane can be extended in the lateral direction as far as

Fig. 20.7 The right posterior rectus sheath is identified and its medial aspect incised and then released in a cephalad to caudal direction followed by blunt dissection in the right retrorectus space

Fig. 20.8 The cut edge of PRS is retracted medially revealing the posterior lamina of the internal oblique muscle, a thin layer of connective tissue covering. Once identified and incised with hook electrocautery, the transversus abdominis muscle fibers can be appreciated


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the midaxillary line. A unilateral TAR can achieve as much as 7 cm of medial fascial mobilization at the level of the umbilicus. Bilateral TAR can be performed as needed.

Closure

Posterior layer: The edges of the PRS are sutured together in the midline with 2-0 absorbable or barbed suture starting near the xiphoid process running caudally. Starting at the dome of the bladder, the surgeon and assistant switch positions, and suture is run cranially, meeting in the middle where the two sutures are tied together.

Anterior layer: Pneumoperitoneum is dropped to 8–10 mmHg to decrease the tension placed on the anterior layer closure. The defect being closed is at the top of the monitor and is sutured “upside down” with back-handed needle driving. A 0 barbed suture is used for this closure due to technical ease of use afforded in this situation. If a large subcutaneous sac is present, one or more bites of the sac are included in the suture line for plication in order to reduce the likelihood of develop-ing a postoperative seroma (Fig. 20.11). With the previously performed posterior

Fig. 20.9 When incising the lateral edge of the PRS sheath to expose the transversus abdominis, care must be taken to prevent injury to the neurovascular bundles near the linea semilunaris

Fig. 20.10 The transversalis fascia is separated from the transversus abdominis by blunt dissection achieving TAR


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CS, the defect edges should come together in a tension-free fashion. The defect is closed with v-lock suture, completed with four or five throws run in a backward fashion.

Mesh Placement

Once both anterior and posterior fascial layers are closed, the mesh is deployed in the retromuscular sublay position. The developed retromuscular space is measured for appropriate mesh size selection. Our preference is medium-weight macroporous polypropylene mesh which is deployed through our 12-mm trocar (Fig. 20.12). There is no need for antiadhesion barriers as there now exists an autologous barrier between the mesh and viscera, a significant advantage of the sublay position. Mesh placement in the retromuscular space has allowed for the discontinuation of aggres-sive penetrating fixation techniques with transfascial sutures, transitioning first to fibrin glue and, more recently, to complete cessation of mesh fixation as our data illustrates penetrating fixation is associated with higher incidence of chronic pain without the added benefit of lowered rates of recurrence. Pneumoperitoneum is released under direct vision, assuring the mesh is lying flat and wrinkle-free between the posterior and anterior layers.

Formerly, we once placed drains just superficial to the mesh in all hernia repair cases. We are now more selective with drain placement and do not utilize it for most patients. To date we have not observed an increase in wound morbidity as a result.

Transabdominal Approach

Alternatively, traditional laparoscopic transabdominal approach can be used. Standard laparoscopic entry to the peritoneal cavity can be achieved and adhesions taken down. The PRS is then incised just lateral to the defect or the linea alba. Dissection can proceed from there as we described in l-TAR originally, prior to our adoption of the eTEP access approach [11]. This lateral approach comes with higher degree of difficulty on the midline suturing for closure.

Fig. 20.11 Closure of the anterior layer. A 0 barbed suture is used in a back-handed fashion with an “upside down” view to take bites of the edges of the defect while including the sac (if a large subcutaneous portion is present) in between to reduce the chance of postoperative seroma


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Postoperative Management

Patients are transferred from the PACU for admission to the wards or alternatively discharged to home as determined by the complexity of the surgery and other patient factors. Those that underwent an eTEP access Rives-Stoppa repair (retrorectus mesh placement) are typically discharged home the day of surgery. Diet is advanced as tolerated, and patients are encouraged to ambulate early and often as possible to prevent postoperative ileus or thromboembolism. The average length of stay at our center following eTEP access TAR procedures is approximately 1–2 days. Prolonged postoperative ileus, although uncommon, is the primary cause for increased length of hospital stay.

Patients are discharged from the hospital once they are sufficiently ambulating, tolerating oral intake, have a return of bowel function, and tolerating pain control without the need for intravenous medications. Typically, patients are seen 4 weeks following surgery for their first postoperative clinic visit; however, visits are sched-uled sooner (typically at 1 week) if they are discharged with a drain in place.

MILOS and EMILOS Approaches

Since the space to be dissected is the same of eTEP, the contraindications are the same for the MILOS approach.

MILOS stands for mini and less open sublay and uses the hernia itself to get access to the preperitoneal space with a 2–6-cm skin incision directly over the cen-ter of the hernia defect, followed by exposure of the hernia sac (this can be widened for large incisional hernias), as described by Reinpold [12]. The hernia sac can be opened at this time to inspect the abdominal cavity, and this can be followed by open or laparoscopic adhesiolysis if necessary. The abdominal wall is lifted with retractors. After transhernial mini-open dissection of an extraperitoneal space of at least 8 cm in diameter and closing of the peritoneal cavity, one can continue the procedure as total extra peritoneal gas endoscopy (TEP of the abdominal wall) using either standard trocars or a transhernial single port. Here the medial aspect of the posterior rectus sheath is opened under direct vision in both sides of the

Fig. 20.12 Placement of a medium-weight macroporous polypropylene mesh deployed through the 12-mm trocar. There is no need for antiadhesion barriers as there now exists an autologous barrier between the mesh and viscera


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abdominal wall, enabling a large retromuscular pocket that can receive the mesh. This can be achieved using regular surgical and/or laparoscopic instruments. A spe-cial laparoscopic light source with a working channel in his middle designed to allow the use of regular laparoscopic instruments to dissect this space, normally without the use of a laparoscopic camera port is suggested [12, 13]. This device is called EndoTORCH Light Tube® (Richard Wolf GmbH, Knittlingen, Germany). Very large synthetic meshes can be implanted if the size of the hernia requires it. A total sublay repair of the abdominal wall can be achieved with excellent results according to recent publications [12, 13] (Figs. 20.13, 20.14, 20.15, 20.16, 20.17, and 20.18).

The endoscopic mini/less open sublay (EMILOS) technique consists of a modi-fication described by Reinpold where the dissection of the retromuscular space is performed in an endoscopic fashion, using regular laparoscopic instruments and carbon dioxide insufflation (or, e.g., using a single port) [14]. The procedure is the same as for MILOS operation until the transhernial exploration is done [13, 14]. After that the endoscopic part (which stands for the E in EMILOS) of the MILOS operation starts with the incision of the posterior sheath of the rectus muscle on one side. The rims of the opened fascia are marked with holding sutures. A sponge for-ceps is placed into the rectus sheath and directed toward the pubis, in a caudal direc-tion. In the original description, a balloon dissector is positioned down and inflated, creating a space for safe introduction of the camera port. Carbon dioxide is started at this point, allowing gas to gain the preperitoneal space (sutures at the entrance to the rectus sheath are fixed to the port to avoid leak). In the original description, a port is placed in this space and the 10-mm port is removed.

At this point, the opposite side of the posterior sheath of the rectus muscle is incised. These incisions on both sides are continued caudally and cranially as far as it is convenient in relation to the small skin incision. During this step, the

Fig. 20.13 MILOS technique—Transhernial exploration with exposition of the hernia defect [13]


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abdominal wall is elevated by retractors, always taking care to preserve the linea alba. Blunt detachment of the posterior sheath of the rectus muscle using the curved sponge forceps as far as it is possible is accomplished, accompanied by tight clo-sure of the skin incision. The camera is positioned in the lower trocar facing up and the carbon dioxide insufflation restarted, which allows endoscopic visualization of the retromuscular space with the surgeon standing between the legs and the video tower behind the head of the patient. Dissection cephalad is achieved after

dorsal view of theventral abdominal wall

posterior laminaof the rectus sheath

Peritoneum

Linea Alba long narrow retractors

anterior laminaof the rectussheath

Fig. 20.14 MILOS technique—Lifting of the abdominal wall with retractors and dissection of the preperitoneal space. Incision of the medial aspect of the posterior rectus sheath bilaterally to gain access to retromuscular space [12]

Fig. 20.15 MILOS technique—Retromuscular final positioning of the mesh, allowing a big overlap [12]


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introducing 5-mm working trocars on each side laterally to the midline in the medio-clavicular line and about 3–5 cm above of the umbilicus under direct view. In a comfortable position, the surgeon can continue the incision of the posterior rectus sheath cranially up to the costal margin and the xiphoid. The space behind the costal margin as well as behind the sternum (fatty triangle) is easily dissected and opened for later mesh placement. It is always important to remember to pre-serve the linea alba; otherwise one will be working on the subcutaneous space. Detachment of the fascia from the rectus muscle while carefully preserving the vessels and the nerves perforating the fascia laterally is easily performed.

Fig. 20.16 EMILOS technique—Positioning of a suprapubic trocar after creating the preperito-neal space downward to the pubis [14]

Fig. 20.17 EMILOS technique—Trocar positioning with the surgeon between patient legs and dissecting cephalad. Two port positioned in the hernia defect in this picture [12]


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Introducing a 10-mm optic trocar about 5–7 cm superior to the working trocars under view through the rectus muscle will allow continuation of the incision of the posterior rectus sheath downward to the arcuate line. The space of Retzius will be opened, and the dissection may be proceeded down to the pubic bone and below of the inferior suprapubic trocar.

A large mesh can be positioned in the enormous preperitoneal space prepared with the dissection described above. Drains are introduced via the 5-mm working trocars. The skin is reopened, the hernia defect is closed with a nonabsorbable run-ning suture in small bite technique, but the posterior rectus sheath is left open. The wound is closed and dressed, and an abdominal binder is placed [13, 14].

Onlay MIS Repair: Subcutaneous Onlay Laparoscopic Approach (SCOLA) and Endoscopic-Assisted Linea Alba Reconstruction (ELAR)

This technique has previous anecdotal descriptions and consists of performing a “subcutaneoscopic” dissection and is directed specially to small umbilical and epi-gastric hernias with concomitant rectus muscle diastasis [15]. Recently, a large series with description of the technique and results was published [16]. In this sub-set of patients, if one only corrects the hernia, the patient might still complain of the abdominal bulge of the rectus diastasis and will result in a higher recurrence rate [15, 16]. Only correcting the diastasis in an onlay fashion will result in a large scar, which is unacceptable from a cosmetic standpoint, especially since there’s no true hernia (and its consequences) in the diastasis part of the operation.

Fig. 20.18 EMILOS technique—Endoscopic view of the cephalad aspect of the dissection [14]


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Patient Positioning and Trocar Placement

The patient is positioned supine with the left arm tucked at the side and the right arm abducted. Another alternative is to open the patient’s legs. The endoscopic equip-ment is positioned to the left of the patient. The access route consists of a half loop on the left around the umbilicus, extending 2–3 cm cranially in the midline (Fig. 20.19). Dissection of the umbilical hernia (if present) is performed as usual, and the anterior layer of the rectus sheath is exposed on both sides from the xiphoid process and extends several centimeters below the umbilicus. The anterior layer of the rectus sheath is freed from subcutaneous tissue by diathermy on both sides in a width of around 4–5 cm. The original description uses regular surgical instruments, but one can use laparoscopic instruments and carbon dioxide insufflation if desired. When using regular instruments, the surgeon has a direct view of the surgical area via the skin incision but needs the light source to that effect, while the two assistants watch the monitor of the video endoscopic equipment positioned to the right of the patient. A more ergonomic approach (SCOLA) is to be positioned in between the legs, with three ports positioned in the suprapubic area, 6 cm apart each other (Fig. 20.20). A robotic approach can be performed as well, with docking from the left shoulder after the suprapubic port access.

SC Space Creation and Midline Plication

The surgeon starts the subcutaneous dissection from bottom up, until he or she reaches the subxiphoid area, going through the entire midline and associated her-nias, creating a 15-cm wide space (Fig. 20.21). At this point, the surgeon can decide if only an approximation of the linea alba is necessary or if an incision needs to be made around 2 cm from the medial margin of the rectus sheath to reinforce linea alba or to allow approximation without tension (described as endoscopic-assisted linea alba reconstruction—ELAR [15, 16]). If not, the plication can be done with barbed sutures to facilitate after measuring the space and mesh size required

Fig. 20.19 ELAR—Size of the mesh (in blue line) and extent of skin incision [15]


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(Figs. 20.22, 20.23, and 20.24). If done, this incision runs bilaterally from the xiphoid process to the subumbilical area, thus exposing the bellies of both rectus muscles, and the two medial segments of the anterior layer of the rectus sheath are sutured together using continuous, nonabsorbable loop sutures (Fig. 20.25). Inward plication of the rectus abdominis diastasis is effected, and a new linea alba is formed once suturing is complete. With that, both rectus muscles are restored to their posi-tion at the midline adjacent to the reconstructed linea alba.

Mesh Placement

Next step is the placement of a polypropylene mesh. Medium-weight macroporous meshes are preferred due to the proximity to the skin. The mesh is tailored to size. Only then is the mesh sutured to the anterior layer of the dissected rectus sheath

Fig. 20.20 SCOLA—Alternative access from the suprapubic area. Three-low-port incision for a patient with a recurrent umbilical hernia, an epigastric hernia, and a diastasis (shown as marked)

Fig. 20.21 SCOLA—Measurement of the defect and diastasis, after the rise of the entire SC flap and defect closure (Prolene sutures)


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Fig. 20.22 SCOLA—Intra-op picture with the three trocars in place and entire subcutaneous dissected/raised from the fascia

Fig. 20.23 SCOLA—Midline plication

Fig. 20.24 SCOLA—Final aspect after midline plication and defect closure


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Fig. 20.25 ELAR—New formed linea alba after suturing the medial portions of the two rectus sheaths at the midline [15]

Fig. 20.26 SCOLA—Final aspect after laparoscopic mesh fixation with running sutures

Fig. 20.27 SCOLA—Robotic suturing of the mesh


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using continuous nonabsorbable suturing material (Figs. 20.26 and 20.27). Drains are placed, the subcutaneous tissue is sutured, and the skin is closed in a regular fashion. Patients are advised to use an abdominal binder for 6 weeks after the opera-tion [16].

Conclusion

MIS for ventral hernias have been changing for the last few years, with a clear trend to reproduce traditional open techniques and avoiding IPOM meshes. As what happens with the open techniques, there is no one gold standard, but each different approach described in this chapter has its own indications and contrain-dications. The role of the surgeons is to analyze and decide the best technique for each patient.

References

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2. Patel PP, Love MW, Ewing JA, Warren JA, Cobb WS, Carbonell A. Risks of subsequent abdominal operations after laparoscopic ventral hernia repair. Surg Endosc. 2017;31(2):823–8.

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4. Sanchez-Manuel FJ, Lozano-Garcia J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2012;(2):CD003769.

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10. Tandon A, Pathak S, Lyons NJ, Nunes QM, Daniels IR, Smart NJ. Meta-analysis of clo-sure of the fascial defect during laparoscopic incisional and ventral hernia repair. Br J Surg. 2016;103(12):1598–607.

11. Belyansky I, Zahiri HR, Park A. Laparoscopic transversus abdominis release, a novel minimally invasive approach to complex abdominal wall reconstruction. Surg Innov. 2016;23(2):134–41.

12. Reinpold W, Schröder M, Schröder A, Berger C, Nehls J, Stoltenberg W, Köckerling F. Minimally invasive sublay mesh repair of incisional and primary abdominal wall hernias using the MILOS technique. Eur Surg. 2017;49:59–64.

13. Bittner R, Schwarz J. Endoscopic mini/less open sublay operation for treatment of primary and secondary ventral hernias of the abdominal wall. Eur Surg. 2017;49:65–70.

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15. Köckerling F, Botsinis MD, Rohde, Reinpold W. Endoscopic-assisted linea alba reconstruction plus mesh augmentation for treatment of umbilical and/or epigastric hernias and rectus abdom-inis diastasis – early results. Front Surg. 2016;3:27. https://doi.org/10.3389/fsurg.2016.00027.

16. Köckerling F, Botsinis MD, Rohde C, Reinpold W, Schug-Pass C. Endoscopic-assisted linea alba reconstruction. New technique for treatment of symptomatic umbilical, trocar, and/or epigastric hernias with concomitant rectus abdominis diastasis. Eur Surg. 2017;49:71–5.


https://doi.org/10.3389/fsurg.2016.00027

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Ventral Abdominal Hernia Repair: MIS Extraperitoneal ... · Minimally invasive surgery (MIS) ventral hernia repairs were first described by Le Blanc in 1993 with the laparoscopic