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Single-incision laparoscopic repair of Spigelian hernia.

Tran H, Tran K, Zajkowska M, Lam V, Hawthorne WJ - JSLS (2015 Jan-Mar)

Bottom Line: High-lying Spigelian defects were repaired with additional mesh.An additional piece of mesh was used for 3 hernias.There were no clinical recurrences during a mean follow-up period of 6 months (range, 1-15 months).

View Article: PubMed Central - PubMed

Affiliation: Discipline of Surgery, Sydney Medical School, University of Sydney at Westmead Hospital, Westmead, Australia.

ABSTRACT

Introduction: Spigelian hernias represent only 1% to 2% of all abdominal wall hernias. The treatment, however, remains controversial but depends on institutional expertise. This case series reports the first experience with single-incision laparoscopic totally extraperitoneal (SILTEP) repair of Spigelian hernias with telescopic extraperitoneal dissection in combination with inguinal hernia repair.

Methods: From February 2013 to April 2014, all patients referred with inguinal or Spigelian hernias, without histories of extraperitoneal intervention, underwent SILTEP repair with telescopic extraperitoneal dissection. A single-port device, 5.5 mm/52 cm/30° angled laparoscope, and conventional straight dissecting instruments were used for all cases. Extraperitoneal dissection was performed under direct vision with preservation of preperitoneal fascia overlying retroperitoneal nerves. Inguinal herniorrhaphy was performed with lightweight mesh that covered low-lying Spigelian defects. High-lying Spigelian defects were repaired with additional mesh.

Results: There were 131 patients with 186 (92 direct) inguinal hernias and 7 patients with 8 Spigelian hernias (6 incidental, including 1 bilateral and 2 preoperatively diagnosed), with a mean age of 51.3 years and a mean body mass index of 25.1 kg/m(2). An additional piece of mesh was used for 3 hernias. All Spigelian hernias were associated with direct inguinal hernias, and 8 combined inguinal and Spigelian hernias were successfully repaired with SILTEP repair with telescopic extraperitoneal dissection as day cases. There were no clinical recurrences during a mean follow-up period of 6 months (range, 1-15 months).

Conclusions: Combined Spigelian and inguinal hernias can be successfully treated with SILTEP herniorrhaphy with telescopic extraperitoneal dissection. The high incidence of Spigelian hernias associated with direct inguinal hernias suggests a high index of suspicion for Spigelian hernias during laparoscopic inguinal herniorrhaphy.

No MeSH data available.


Related in: MedlinePlus

Intraoperative views of a patient (from Figure 1) presenting with right Spigelian and direct inguinal hernia undergoing SIL Spigelian and inguinal hernia repair with mesh. (A) Intraperitoneal view of site of Spigelian hernia. (B) Direct inguinal hernia. (C) Incarcerated extraperitoneal fat via sharp small defect in the transversus abdominis. (D) Perforating blood vessels being clipped and divided to achieve adequate proximal clearance for mesh placement. (E) Mesh covering Spigelian defect. (F) Mesh covering the inguinal hernia to cover the inferior aspect of mesh covering Spigelian defect.
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Figure 2: Intraoperative views of a patient (from Figure 1) presenting with right Spigelian and direct inguinal hernia undergoing SIL Spigelian and inguinal hernia repair with mesh. (A) Intraperitoneal view of site of Spigelian hernia. (B) Direct inguinal hernia. (C) Incarcerated extraperitoneal fat via sharp small defect in the transversus abdominis. (D) Perforating blood vessels being clipped and divided to achieve adequate proximal clearance for mesh placement. (E) Mesh covering Spigelian defect. (F) Mesh covering the inguinal hernia to cover the inferior aspect of mesh covering Spigelian defect.

Mentions: The extraperitoneal dissection was performed under direct vision using a combination of blunt dissection and electrocautery that allowed small blood vessels to be cauterized or clipped, or both (Figures 2 and 3). The dissection followed a precise sequence, namely, the dissection of the suprapubic space and then, staying high and lateral to the inferior epigastric vessels, the lateral space before turning attention to reducing any direct, indirect inguinal, and/or femoral hernia and any associated lipoma of the cord. The peritoneum was dissected proximally by at least 5 cm, preserving the vas deferens and testicular vessels in men and the round ligament in women and, more important, the preperitoneal fascia overlying the retroperitoneal nerves akin to the dissection during a transabdominal preperitoneal repair. During conventional multiport laparoscopic total extraperitoneal inguinal hernia repair, the extraperitoneal space is partially created by the distension balloon, and the dissection takes place via the 5-mm ports, which are placed inferior to the structural balloon inflation bulb (Tyco Healthcare; Norwalk, Connecticut) at the umbilicus, and the dissection starts at the pubic symphysis and then laterally. The bulkiness of the structural balloon bulb tends to limit proximal dissection. However, during telescopic dissection with the Triport system, the dissection of the extraperitoneal space starts at the umbilicus and follows the rectus muscle down to the pubic symphysis. The low profile of the inner ring of the Triport system allows the dissection to proceed more laterally from the umbilicus diagonally toward the anterior superior iliac spine, across the Spigelian hernia belt. This allows dissection of both preoperatively diagnosed and incidental Spigelian hernias (Figure 2). Any Spigelian hernia sac and contained contents, usually extraperitoneal fat, were reduced. Perforating blood vessels in and around the Spigelian hernia were doubly clipped and divided and the dissection then continued some 5 cm proximal to the Spigelian hernia for adequate mesh coverage (Figure 3).


Single-incision laparoscopic repair of Spigelian hernia.

Tran H, Tran K, Zajkowska M, Lam V, Hawthorne WJ - JSLS (2015 Jan-Mar)

Intraoperative views of a patient (from Figure 1) presenting with right Spigelian and direct inguinal hernia undergoing SIL Spigelian and inguinal hernia repair with mesh. (A) Intraperitoneal view of site of Spigelian hernia. (B) Direct inguinal hernia. (C) Incarcerated extraperitoneal fat via sharp small defect in the transversus abdominis. (D) Perforating blood vessels being clipped and divided to achieve adequate proximal clearance for mesh placement. (E) Mesh covering Spigelian defect. (F) Mesh covering the inguinal hernia to cover the inferior aspect of mesh covering Spigelian defect.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4325554&req=5

Figure 2: Intraoperative views of a patient (from Figure 1) presenting with right Spigelian and direct inguinal hernia undergoing SIL Spigelian and inguinal hernia repair with mesh. (A) Intraperitoneal view of site of Spigelian hernia. (B) Direct inguinal hernia. (C) Incarcerated extraperitoneal fat via sharp small defect in the transversus abdominis. (D) Perforating blood vessels being clipped and divided to achieve adequate proximal clearance for mesh placement. (E) Mesh covering Spigelian defect. (F) Mesh covering the inguinal hernia to cover the inferior aspect of mesh covering Spigelian defect.
Mentions: The extraperitoneal dissection was performed under direct vision using a combination of blunt dissection and electrocautery that allowed small blood vessels to be cauterized or clipped, or both (Figures 2 and 3). The dissection followed a precise sequence, namely, the dissection of the suprapubic space and then, staying high and lateral to the inferior epigastric vessels, the lateral space before turning attention to reducing any direct, indirect inguinal, and/or femoral hernia and any associated lipoma of the cord. The peritoneum was dissected proximally by at least 5 cm, preserving the vas deferens and testicular vessels in men and the round ligament in women and, more important, the preperitoneal fascia overlying the retroperitoneal nerves akin to the dissection during a transabdominal preperitoneal repair. During conventional multiport laparoscopic total extraperitoneal inguinal hernia repair, the extraperitoneal space is partially created by the distension balloon, and the dissection takes place via the 5-mm ports, which are placed inferior to the structural balloon inflation bulb (Tyco Healthcare; Norwalk, Connecticut) at the umbilicus, and the dissection starts at the pubic symphysis and then laterally. The bulkiness of the structural balloon bulb tends to limit proximal dissection. However, during telescopic dissection with the Triport system, the dissection of the extraperitoneal space starts at the umbilicus and follows the rectus muscle down to the pubic symphysis. The low profile of the inner ring of the Triport system allows the dissection to proceed more laterally from the umbilicus diagonally toward the anterior superior iliac spine, across the Spigelian hernia belt. This allows dissection of both preoperatively diagnosed and incidental Spigelian hernias (Figure 2). Any Spigelian hernia sac and contained contents, usually extraperitoneal fat, were reduced. Perforating blood vessels in and around the Spigelian hernia were doubly clipped and divided and the dissection then continued some 5 cm proximal to the Spigelian hernia for adequate mesh coverage (Figure 3).

Bottom Line: High-lying Spigelian defects were repaired with additional mesh.An additional piece of mesh was used for 3 hernias.There were no clinical recurrences during a mean follow-up period of 6 months (range, 1-15 months).

View Article: PubMed Central - PubMed

Affiliation: Discipline of Surgery, Sydney Medical School, University of Sydney at Westmead Hospital, Westmead, Australia.

ABSTRACT

Introduction: Spigelian hernias represent only 1% to 2% of all abdominal wall hernias. The treatment, however, remains controversial but depends on institutional expertise. This case series reports the first experience with single-incision laparoscopic totally extraperitoneal (SILTEP) repair of Spigelian hernias with telescopic extraperitoneal dissection in combination with inguinal hernia repair.

Methods: From February 2013 to April 2014, all patients referred with inguinal or Spigelian hernias, without histories of extraperitoneal intervention, underwent SILTEP repair with telescopic extraperitoneal dissection. A single-port device, 5.5 mm/52 cm/30° angled laparoscope, and conventional straight dissecting instruments were used for all cases. Extraperitoneal dissection was performed under direct vision with preservation of preperitoneal fascia overlying retroperitoneal nerves. Inguinal herniorrhaphy was performed with lightweight mesh that covered low-lying Spigelian defects. High-lying Spigelian defects were repaired with additional mesh.

Results: There were 131 patients with 186 (92 direct) inguinal hernias and 7 patients with 8 Spigelian hernias (6 incidental, including 1 bilateral and 2 preoperatively diagnosed), with a mean age of 51.3 years and a mean body mass index of 25.1 kg/m(2). An additional piece of mesh was used for 3 hernias. All Spigelian hernias were associated with direct inguinal hernias, and 8 combined inguinal and Spigelian hernias were successfully repaired with SILTEP repair with telescopic extraperitoneal dissection as day cases. There were no clinical recurrences during a mean follow-up period of 6 months (range, 1-15 months).

Conclusions: Combined Spigelian and inguinal hernias can be successfully treated with SILTEP herniorrhaphy with telescopic extraperitoneal dissection. The high incidence of Spigelian hernias associated with direct inguinal hernias suggests a high index of suspicion for Spigelian hernias during laparoscopic inguinal herniorrhaphy.

No MeSH data available.


Related in: MedlinePlus