A, Sagittal view of a parapubic hernia. B, Axial view of a parapubic hernia (a), similar to that seen from within the peritoneum. Note that this space is typically more anterior and medial relative to the location of a direct inguinal hernia (b) and an indirect inguinal hernia (c).
Schematic diagram demonstrating the positions of equipment and operators in laparoscopic parapubic herniorrhaphy.
Laparoscopic view of a typical parapubic hernia. Note the small bowel within the hernial sac.
The contents of the hernial sac are reduced and the defect in the fascia is sized using the open jaws of a 5-mm laparoscopic grasper.
The relationship between the borders of the hernia and the surrounding structures must be fully recognized. Note the dome of the bladder at the bottom of the figure. The absence of a catheter allows the expansion of the bladder and facilitates recognition of its borders.
A 2- to 3-cm circumferential margin is used for adequate reinforcement of the defect in the fascia.
Using a laparoscopic tacking device to secure an appropriately sized piece of synthetic mesh to the abdominal wall, the repair of the parapubic hernia is completed.
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Hirasa T, Pickleman J, Shayani V. Laparoscopic Repair of Parapubic Hernia. Arch Surg. 2001;136(11):1314–1317. doi:10.1001/archsurg.136.11.1314
Since the introduction of laparoscopic cholecystectomy in the late 1980s, video technology has continued to find new applications in the field of general surgery. Laparoscopic inguinal herniorrhaphy is touted by many to provide a minimally invasive approach to the most commonly performed general surgical procedure, possibly with a lower incidence of recurrence. Additionally, laparoscopic repair of an incisional hernia with synthetic mesh allows a tension-free procedure while potentially reducing the risk of complications such as wound and mesh infections by avoiding the use of large abdominal wall incisions through old surgical scars. The parapubic hernia is a rare form of incisional hernia resulting from the detachment of muscular attachments to the pubic bone. It is a diagnostic and therapeutic challenge that is often misdiagnosed and mismanaged. We have found the laparoscopic approach to the parapubic hernia to be a superior method of managing this often challenging condition.
Parapubic hernia (Figure 1) is a rare form of incisional hernia that may develop in patients with prior abdominal surgery; it involves the dissection of musculotendinous attachments of the abdominal wall off the pubic bone.1-3 Radical prostatectomy is the most common operative procedure that leads to the development of a parapubic hernia, although similar defects can result from operations involving the uterus, bladder, and sigmoid colon.1,2 Diagnosis of a parapubic hernia may be difficult because associated symptoms are similar to those of an ordinary inguinal hernia. Most patients initially experience pain or heaviness in the affected area. A physical examination may yield a palpable mass in the groin, often mistaken for an inguinal hernia. On close examination, the protruding hernia is always adjacent to the pubis and not the external inguinal ring. The fascial defect is bordered by the urinary bladder. In addition to the preoperative diagnostic challenges, operative identification of the fascial defect through the anterior groin is often complex if not impossible, especially if the operation is performed through a previous surgical incision.
Previously described approaches to parapubic herniorrhaphy use an anterior position and advocate the placement of synthetic mesh anterior to the defect with anchoring sutures to the Cooper ligament, the arcuate ligament, and the anterior abdominal wall.1 We have previously published our institutional experience with the posterior approach to this repair.2 Since 1997, we have modified the posterior approach for repair of the parapubic hernia by using video technology. The following is a description of our technique for the laparoscopic repair of a parapubic hernia.
The patient is given general endotracheal anesthesia and placed in the supine position. If the patient's body habitus allows, both arms should be placed to the side (Figure 2). Monitors are positioned on either side near the patient's feet; often a single monitor is adequate. The stomach is decompressed using an orogastric tube. The urinary bladder intentionally is not catheterized for this operation because a filled bladder allows for easy identification of its borders, thereby minimizing the risk of inadvertent and unrecognized injuries.
The abdominal cavity may be entered using either the open (Hasson) technique or the needle insufflation technique. Our preference is the open technique to minimize the risk of inadvertent visceral or vascular injuries. The open technique is also considered safer in a patient whose urinary bladder is not catheterized. The abdomen is insufflated with the minimal amount of carbon dioxide necessary to create a working space; in most instances an intra-abdominal insufflation pressure of 12 mm Hg is adequate. After an initial laparoscopic examination of the abdomen, 2 additional 5-mm laparoscopic ports are inserted. These ports are placed at the level of the umbilicus on either side of the midline.
Using a 10-mm angled (30°) laparoscope with the patient in the Trendelenburg position, the parapubic hernia is identified. The hernial sac often contains portions of the intestinal tract or omentum (Figure 3). The contents of the hernia are reduced, and all scar tissue involving the hernial sac is divided using a combination of sharp dissection and limited electrosurgery (Figure 4). Anatomic relationships to important surrounding structures such as the bladder or iliac vessels must be fully recognized (Figure 5). After complete delineation of the borders of the fascial defect using external finger impression, its margins are marked on the patient's skin. The dimensions of the margins are measured, and an appropriately sized piece of mesh is designed to reinforce the defect. In general, a 2- to 3-cm overlapping margin is used circumferentially to adequately cover the defect (Figure 6). Because the mesh will come into contact with abdominal viscera, we recommend the use of a dual-surface mesh. By placing the abrasive surface of the mesh against the abdominal wall, scar tissue formation is promoted and the mesh will adhere to the abdominal wall over time. The use of materials such as polytetrafluoroethylene against the abdominal viscera may result in decreased intra-abdominal scar tissue formation.3,4
At this point, we switch to a 5-mm laparoscope that is inserted through one of the lateral ports. The appropriately sized mesh is tightly rolled and inserted into the abdomen through the 10- to 12-mm umbilical port. (It is often necessary to remove the port and insert the mesh directly through the abdominal incision.) The mesh is unrolled, placed against the abdominal wall completely covering the fascial defect, and secured against the borders of the fascia using a laparoscopic tacking device (Figure 7). The tacks are placed approximately 1 cm apart, avoiding the bladder and any vascular structures.
At the conclusion of the procedure, the lateral ports are removed using direct laparoscopic visualization. These incisions are closed in 1 layer (skin only). The umbilical port site is closed in 2 layers (fascia and skin). The area of previous protrusion is compressed with a pressure dressing to minimize fluid collection superficial to the implanted mesh. Patients are typically discharged from the recovery room or after overnight observation.
Since March 1999, we have performed this operation on 7 consecutive patients (6 men and 1 woman). Follow-up results are available for 6 of the 7 patients, with a range of 4 to 9 months (mean, 5.8 months). All patients had undergone at least 1 previous attempt at traditional repair of their hernia that ultimately failed. All operations were completed laparoscopically, and patients were discharged within 48 hours of their operation. No perioperative complications were encountered. Five patients available for follow-up were symptom-free, with 1 recurrence 8 months postoperatively in which the lateral margin of the mesh separated from the abdominal wall. This patient underwent a revision of his repair, which was achieved by placing new mesh over the defect.
Successful laparoscopic parapubic hernia repair requires adherence to the basic principles of abdominal wall herniorrhaphy and safe laparoscopy. Several factors contribute to the success of this operation.
The laparoscopic approach to the parapubic hernia allows unequivocal identification of the fascial defect from a posterior position (intraperitoneal in this case), which is often difficult to establish using a groin incision. The laparoscopic approach should eliminate the risk of recurrence secondary to an inadequate repair of an unrecognized defect. Additionally, routine lysis of intestinal adhesions that fix the bowel to the hernial sac may minimize the tendency for the bowel to protrude through the newly re-inforced defect.
The use of synthetic mesh during the laparoscopic procedure allows a tension-free repair of this unusual incisional hernia. We believe that almost all abdominal wall hernias are best repaired using synthetic mesh to eliminate any tension on the repair. Clearly this operation should be performed in an elective setting and in the absence of any local or systemic infectious processes, minimizing the risk of subsequent mesh infection.
Peritoneal fluid invariably collects in the dependent space superficial to the new implanted mesh. The previously stretched skin does not create adequate hydrostatic pressure; therefore, the parapubic region initially remains protuberant, resulting in significant anxiety for both the patient and the surgeon. This fluid will ultimately be absorbed over time, which may take up to 6 months. To minimize this phenomenon, a pressure dressing must be applied immediately after the operation and is often left in place for 1 to 2 weeks. Considering the challenges involving sustained compression of the area, the use of an individualized compression garment may produce the best outcome.
For the laparoscopic repair of parapubic hernia to become the accepted standard of care, the operation must be performed with a minimal incidence of complications and a very low incidence of recurrence. In addition to the previous recommendations, the principles of safe laparoscopy must be closely followed. We believe that the routine use of open entry into the peritoneum, the use of a 30°-angled laparoscope, and the limited use of electrosurgery during the dissection of the bowel from the hernial sac minimize the risk of complications related to laparoscopy.
Corresponding author and reprints: Vafa Shayani, MD, Department of Surgery, Minimally Invasive Laboratory, Loyola University Medical Center, 2160 S First Ave, Maywood, IL 60153 (e-mail: firstname.lastname@example.org).
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