|Year : 2018 | Volume
| Issue : 3 | Page : 87-93
Laparoscopic transversus abdominis release for the treatment of complex ventral hernia
Li Binggen1, Miao Jinchao2, Shi Shange2, Qin Changfu3
1 Department of General Surgery, Affiliated Hexian Memorial Hospital of Southern Medical University, Guangzhou 511400, China
2 Department of General Surgery, Pengpai Memorial Hospital Affiliated to Guangdong Medical University, Shanwei 516400, China
3 Department of Hernia and Abdominal Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100043, China
|Date of Submission||19-Jul-2018|
|Date of Acceptance||23-Aug-2018|
|Date of Web Publication||19-Nov-2018|
Dr. Qin Changfu
Department of Hernia and Abdominal Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100043
Source of Support: None, Conflict of Interest: None
BACKGROUND: Posterior component separation through transversus abdominis muscle release (TAR) is an increasingly accepted technique worldwide for complex ventral hernia repair. Recently, researchers have attempted to perform the TAR procedure using minimally invasive approaches. In this study, we present our experience of laparoscopic TAR (Lap-TAR). The procedure will be described in detail and its feasibility evaluated.
PATIENTS AND METHODS: To learn and be proficient in the procedure through soft cadaver workshop practice, we accumulated the necessary knowledge and minimally invasive surgery skills for the Lap-TAR procedure. We selected an appropriate patient and performed a Lap-TAR operation to treat complex ventral hernia.
RESULTS: The Lap-TAR operation was successfully performed in a 73-year-old female patient with a giant lower abdominal incisional hernia, without open conversion. The estimated blood loss was 60 mL and the operative time was 365 min. The postoperative pain was mild, and the visual analog pain scale score was 3 on postoperative day (POD) 2. The patient was discharged on POD 7. All subfascial drains were removed before patient discharge. On an initial follow-up period of 3 months, there was no evidence of wound complication, bulging, or hernia recurrence.
CONCLUSIONS: The Lap-TAR operation is technically feasible with a deliberate preparation. It could be an alternative for complex abdominal wall reconstruction with the potential to reduce pain, facilitate recovery, and decrease the length of hospital stay of patients.
Keywords: Abdominal wall reconstruction, complex ventral hernia, laparoscopic, minimally invasive surgery, transversus abdominis muscle release
|How to cite this article:|
Binggen L, Jinchao M, Shange S, Changfu Q. Laparoscopic transversus abdominis release for the treatment of complex ventral hernia. Int J Abdom Wall Hernia Surg 2018;1:87-93
| Introduction|| |
Hernia surgery has tremendously evolved in the last three decades, increasing the popularity of abdominal wall reconstruction (AWR) techniques. Among them, undoubtedly, the technique of posterior component separation through transversus abdominis muscle release (TAR), developed by Novitsky et al. in 2006, plays a landmark role in complex AWR. The TAR technique breaks through the traditional anatomical boundary, allows for significant posterior rectus fascia advancement, wide lateral dissection, and preservation of the neurovascular supply of the rectus abdominis muscle, and provides a large space for mesh sublay. Most importantly, this technique allows for medicalization of abdominal wall components without raising lipocutaneous flaps and thus dramatically improves the outcome of complex AWR.
However, the traditional open TAR procedure requires a large midline incision with massive trauma, thus causing significant wound morbidity, increased postoperative pain, and prolonged hospital stay. To address the shortfalls of traditional TAR, Belyansky et al. recently described their experience with laparoscopic TAR (Lap-TAR) for complex ventral hernia repair. Preliminary outcomes showed its potential to reduce pain, facilitate recovery, and shorten hospital stay. However, Lap-TAR is extremely technically challenging and time-consuming. Although Belyansky et al.'s initial report involved only 3 cases, the average operative time was >6 h. To our knowledge, complete laparoscopic repair of complex ventral hernias with TAR has not been previously described in China.
In this study, the operating team accumulated the necessary knowledge and surgical skills for Lap-TAR through soft cadaver workshop practice. Then, through prudent patient selection and enrollment, we finally performed a successful Lap-TAR procedure in a female patient with complex ventral hernia.
| Patients and Methods|| |
From September 2017, the operators participated in a series of Asia-Pacific Hernia Society essential workshop, to learn and be proficient in the procedure through soft cadaver practice, and to accumulate the necessary knowledge and surgical skills for the Lap-TAR procedure.
Candidate selection and surgical strategy
Considering the complexity of the operation, we set the inclusion criteria as follows: (i) midline ventral hernia with a defect size of between 5 and 12 cm in the widest dimension; (ii) no active intra-abdominal infectious process, chronic wounds, or dystrophic skin; (iii) no >20% intra-abdominal domain loss; (iv) considering the prolonged operative time, the preoperative American Society of Anesthesiologists (ASA) score of ≤2; and (v) extensive informed consent from patients and their families, indicating that they are fully aware of and accept the Lap-TAR procedure, before the operation.
After prudent selection, a 73-year-old female patient with a lower midline abdominal incisional hernia was enrolled. The length of the defect was 12 cm, and the widest dimension of width was 9 cm. The patient was in a relatively good preoperative condition with an ASA score of 2 and a body mass index of 26.3 kg/m2.
Concerning the surgical strategy, as the defect was on the midline with a widest dimension of 9 cm, it was almost impossible to close the defect with direct suture. A component separation technique was required to re-approximate the fascia defect in the midline. The patient was in a good preoperative condition, with a moderate size defect and without loss of domain, which made her an ideal candidate for the Lap-TAR procedure. As a backup strategy, open conversion will be a feasible alternative when certain steps cannot be performed safely through a laparoscopic approach.
The patient was instructed to take an oral laxative for intestinal preparation before the operation. After general anesthesia induction through endotracheal intubation, the patient was placed in the supine position with both legs split. A Foley catheter was routinely placed and the upper extremities were tucked at the patient's sides. The abdomen was prepped from the nipples to the mid-thigh. Television monitors were placed on the left and right sides of the operating table.
Pneumoperitoneum establishment and optic/working port placement
Patients with complex ventral hernia usually have a history of multiple operations, resulting in morbidities of the abdominal cavity such as adhesions. In this situation, a safe entry is the first key priority of the operation. In this case, pneumoperitoneum was achieved by insertion of a Veress needle through Palmer's point and carbon dioxide insufflation to a pressure of 15 mmHg. Once pneumoperitoneum was established, a 12-mm Visiport was inserted on the left lateral site. The cavity was briefly inspected to ensure that there was no injury caused by the Veress needle or by the Visiport. Two more 5-mm ports were inserted under direct visualization. Normally, six ports are required to facilitate the whole operation. These ports were distributed equally at the bilateral anterior axillary line. The early left three ports were used for lysis of adhesions and the subsequent right-side TAR manipulation. Once separation was finished on one side, the operator shifted to the other side for contralateral separation [Figure 1]. Only the first port was 12 mm in caliber to facilitate the subsequent introduction of a large mesh. We recommend using a 5-mm laparoscope. Then, the optic scope and 5-mm working instruments can switch freely between different ports, to achieve better triangulation for component separation and fascia suturing manipulation.
Lysis of adhesions
After a thorough inspection of the whole abdominal cavity, the hernia contents should be reduced gently. Any adhesions to the hernia sac and the anterior abdominal wall should be taken down. To reduce the chance of bowel lesion formation, we recommend using cold scissors to divide the adhesions sharply. It is not necessary to divide the interloop adhesions unless the patient has a history of small-bowel obstruction. Once the adhesions are removed, the hernia defect should be evaluated and a decision should be made.
Posterior rectus sheath release and retrorectus space dissection
The right posterior rectus sheath (PRS) was incised on the edge of the defect and the linea alba [Figure 2]. Once the underlying rectus muscle fiber was visualized, the PRS was divided along its whole length from the pubic symphysis to the xiphoid process. Then, the free edge of the PRS was retracted medially and dorsally to expose the loose and areolar connective tissue in the retrorectus space and was divided using an electric hook or scissors.
This release proceeded laterally to the semilunaris and caudally to across the arcuate line of Douglas and then entered the Bogros space. During this dissection, care should be taken to identify the epigastric vessel, which runs along the posterior and caudal aspect of the rectus muscle, to avoid any injury.
The dissection continued caudally and medially; the urinary bladder was taken down, and then, the Retzius space was entered, exposing the pubis symphysis and Cooper's ligaments. This was rather similar to the dissection in routine totally extraperitoneal or transabdominal preperitoneal groin hernia repair.
The lateral border of the retrorectus dissection was the linea semilunaris. There will be several bunches of neurovascular bundles that travel between the internal oblique and transversus muscles, penetrating the lateral edge of the PRS just medial to the linea semilunaris, and running into the rectus abdominis muscle [Figure 3]. These bundles should be carefully preserved to avoid denervation of the rectus muscle.
|Figure 3: When developing the retrorectus space, care should be taken when manipulating the neurovascular bundles|
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Transversus abdominis muscle release
Once the retrorectus dissection has been extended to the linea semilunaris, the limit of the traditional Rives-Stoppa operation is reached. To achieve a more extensive lateral dissection and significant posterior rectus fascia advancement, to re-approximate the fascia edge in the midline, if necessary, the TAR maneuver is undertaken.
TAR normally starts from the cephalad-most part of the retrorectus dissection because the medial extension of transversus abdominis (TA) muscle fiber is more prominent in the upper abdomen. The free edge of the PRS was retracted medially; then, the lateral portion of the PRS was incised, and the underlying TA fibers were identified. It is important to make the incision just medial to the perforating neurovascular bundles to minimize their damage and the chance of subsequent rectus muscle defunctionalization and atrophy.
The TA muscle was then divided along its entire medial portion using a hook electrocautery device [Figure 4]. This release allowed entrance to the plane between the transversalis fascia and the divided TA muscle. This is the ideal plane for the subsequent lateral dissection. Blunt dissection was performed in this plane, advancing laterally and past the midaxillary line [Figure 5]. This release could be continued caudally, and the fascia was separated from the iliopsoas muscle. Occasionally, the transversalis fascia could be broken through and the real preperitoneal plane entered. However, care should be taken in this situation to avoid tearing the very thin peritoneum.
Normally, unilateral TAR manipulation could provide 5–7 cm myofascial medial mobilization, although this could vary according to the patient's abdominal wall compliance. Once bilateral TAR releases are completed, the hernia defect should be reevaluated, and it should be assessed whether the left and right rectus muscles could be re-approximated in the midline without undue tension.
Closure of the posterior rectus sheath
On completion of bilateral releases, the released PRS should be closed with sutures to separate the visceral sac from the subsequent implemented mesh. We used two 1-0 Vicryl absorbable sutures to close the whole length of the PRS in a running fashion: one starting from the xiphoid and extending caudally and the other starting from the dome of the bladder and running cephalad to meet the first suture. Then, the two sutures were tied together in the middle of the course [Figure 6].
Once the posterior layers are reconnected, the whole operative field should be inspected. Tears of the peritoneum should be sutured close. If the tear is too large to close, stitches can be used to pick up the underlying omentum as a plug to seal this hole; otherwise, the operator can tailor some hernia sac tissue to patch these peritoneal tears.
Closure of the anterior defect
This manipulation was undertaken on the roof of the operative field. From our experience, this is probably the most challenging step of the entire procedure. We used a 1-0 long-acting, absorbable, barbed suture (SXPP1A405; Ethicon LLC; Guaynabo, Puerto Rico) to facilitate this repair. Starting from the caudal edge, the operator manipulated this suture in a backhanded fashion. The sac tissue should be included in the bites to eliminate the dead space, thus preventing postoperative bulging and seroma [Figure 7]. The operator should switch sides and use different ports to optimize positioning and triangulation for the suturing course. In some difficult instances, the suture passer could also be utilized to make interrupted transmural sutures, to facilitate closure of this defect.
The whole operative filed was once again inspected. The developed retrorectus/preperitoneal space was measured for appropriate mesh size selection. Then, this space was thoroughly irrigated before mesh placement. In this case, we chose a 30 cm × 30 cm macroporous polypropylene mesh, each corner of which was trimmed to fix the hexagonal sublay/extraperitoneal pocket. Four axial sutures were prefixed extracorporeally; then, the mesh was rolled and introduced into the space through a 12-mm port. The rolled mesh was placed to a caudocephalad direction and then unrolled. We adjusted the mesh and made sure that its inferior edge was extending into the retropubic space to achieve at least 3 cm overlapping. Then, a suture passer was used to bring out the prefixed axial sutures. These sutures were tied subsequently, and the mesh would be fixed and taught in its final position [Figure 8]. Two 22-gauge negative drains were placed on the top of the mesh. The cavity was then slowly deflated. The prefixed sutures were tied after deflation. The skin wounds were closed using 4-0 absorbable subcuticular sutures and dressed with adhesive bandage [Figure 9].
| Results|| |
The operation was successfully performed without conversion to open surgery. The operative time was 365 min, with an estimated blood loss of 60 mL. The patient was kept in the Intensive Care Unit overnight, and she remained sedated and intubated. When the patient awakened 14 h later, she was extubated and transferred to the general ward. She started oral intake 24 h after the operation. The Foley catheter was removed on postoperative day (POD) 2, and off-bed ambulation was encouraged. The daily output from the drainages decreased over time, and the drainages were removed on POD3 and POD4 when the output was <20 mL.
The postoperative pain was mild. The visual analog scale score was 3, 3, and 2 on POD2, POD4, and POD7, respectively. The patient was discharged on POD7. In the initial follow-up at 3 months, she showed good convalescence, with no evidence of wound complications, bulging, or hernia recurrences. The computed tomography scan showed no liquid collection in the subfascial plane. The restoration of the abdominal wall contour was satisfactory.
| Discussion|| |
Complex AWR remains the most challenging procedure in the field of hernia repair. Patients with large abdominal wall defects often experience significant deformity, pain, and decreased energy due to loss of normal abdominal wall mechanics, or they may even have experienced multiple repair attempts, resulting in a hostile abdomen. A successful definitive hernia repair requires a hernia surgeon with a wide spectrum of expertise and clinical armamentarium.
Various AWR techniques have been described by hernia surgeons. Among them, TAR is rapidly becoming one of the common approaches in major AWRs. This reconstruction not only provides a durable repair but may also facilitate restoration of the physiologic properties of the repaired abdominal wall.,,,
However, undeniably, when this procedure is performed in an open manner, it is accompanied by massive trauma, subjecting patients to extensive dissections and considerable physiologic challenges. In a series of reported studies, the wound complication rate after the TAR operation can be as high as 20%–30%. These disadvantages limit the application of TAR.
Recently, some researchers have reported on minimally invasive AWR through the endoscopic release of external oblique muscles to relieve the tension on the medial edges of the hernia defect, followed by laparoscopic-assisted fascial closure and intraperitoneal onlay mesh placement., However, this technique still requires an expensive barrier-coated mesh and a traumatic fixation device. In addition to increasing the medical expense, the so-called “antiadhesive” mesh also causes the problem of visceral adhesion and erosion. Moreover, the use of fixation tackers is considered to be strongly correlated with postoperative pain.
The Lap-TAR procedure can address these aforementioned problems. It can obtain the major benefits of the traditional open TAR procedure and provide a reliable AWR, while keeping the merits of minimally invasive surgery such as dramatically diminishing wound complications, reducing postoperative pain, and shortening the hospital stay of patients.
Undeniably, the LAP-TAR procedure is extraordinarily complicated. To be competent for this procedure, the operator is required to have the following: (i) expertise in all kinds of operative skills under a laparoscope, especially suturing techniques in difficult laparoscopic settings, (ii) knowledge of the essential anatomy of the abdominal wall and its feasible surgical approaches, and (iii) comprehensive familiarization with the principle of TAR and its surgical manipulations.
To ensure the success of the operation, operators need to make sufficient preparations. We gained the necessary surgical skills for the Lap-TAR procedure from cadaveric workshop practice and then made a prudent candidate selection. The operative time was >6 h, which was in accordance with the experience of Belyansky et al. The prolonged operative time was attributed to the learning curve. Nevertheless, despite the long operative time, gains were achieved from avoiding large incisions and large subcutaneous flaps with improvement in the patient's postoperative pain and decreased length of hospital stay. As experience accumulates, we predict that the operative time for Lap-TAR should fall at <4 h, which makes this operation more promising.
Nevertheless, at present, while the Lap-TAR technique is still in the early stage of exploration, candidate selection should be limited to relatively moderate cases. In comparison with the classic open TAR operation, Lap-TAR shows less efficiency in handling complex AWR cases. Thus, extremely complex cases, such as defects >13 cm in width, or a secondary abdominal cavity containing the hernia sac that is >20% of the original cavity, or cases in which the patient with hernia has a loss of domain, should be excluded from the indication.
More recently, researchers have reported the use of a robot to perform the TAR procedure., This could undoubtedly facilitate the component separation and the subsequent suturing manipulation, especially showing advantages in the step of anterior fascia defect closure. However, unfortunately, the availability of robots is limited in most hospitals. As additional time is needed for robot preparation and docking, there is no benefit in terms of operative time. Moreover, the use of robotic equipment will dramatically increase the medical costs.
The Lap-TAR technique described in this paper is a typical transabdominal approach, perhaps we can conceive to fulfill the TAR maneuver in a completely extraperitoneal fashion. Up to present as our knowledge, the most possible approach to fulfill this extraperitoneal TAR maneuver is the endoscopic mini/less open sublay (EMILOS) technique which was described by Schwarz et al. Even though the linea semilunaris is the lateral limit of EMILOS dissection, if necessary, operator could perform the TAR maneuver to achieve further lateral dissection under this extraperitoneal circumstance.
| Conclusions|| |
Our preliminary experience showed that the Lap-TAR procedure is feasible and could be performed successfully by experienced surgeons in minimally invasive surgery. It could be a valuable alternative procedure in the surgeons' armamentarium for complex AWR. However, it is still in the early stages of practice, and many technical details remain to be explored. Large-scale studies with a long-term follow-up are needed to determine the place of Lap-TAR in the field of AWR.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was financially supported by Beijing Municipal Administration of Hospitals' Youth Programme, code: QML20170307.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]