Laparoscopic Repair of Suprapubic Ventral Hernias

Alfredo M. Carbonell, DO

he laparoscopic approach to ventral hernia repair appears to be superior to the traditional open operation. The use of laparoscopy is associated with less pain, a better cosmetic result, a lower incidence of mesh and wound complications, and possibly a lower recurrence rate. As a result of their low prevalence, hernias located in atypical areas may not be seen as frequently by surgeons, leading to a relative inexperience in their repair; and a subsequent higher recurrence rate. The suprapubic incisional hernia is one which is located in close proximity to the pubic bone, arising after urologic or gynecologic procedures. The repair of these hernias can be difficult because of the complexity of dissection and their anatomic proximity to bony, vascular, and nerve structures. This technique article gives the operating surgeon a thorough understanding of the nature of suprapubic hernias and an illustrated step by step approach to the laparoscopic repair of this difficult problem; particularly the transabdominal suture fixation to the bony and ligamentous structures of the pelvis. Although technically demanding and time-consuming, the laparoscopic repair of suprapubic hernias yields a durable hernia repair. It is safe, technically feasible, results in a low recurrence rate, and is applicable to large or multiply recurrent hernias. Incisional hernias can develop in up to 20% of patients undergoing laparotomy, and, after a primary repair, these hernias may recur in up to 63% of patients.1 With the development of laparoscopic techniques, the recurrence rate for ventral hernia repair is frequently reported to be below 4%.2-5 Based on the open, retrorectus, Rives-Stoppa6 repair mandating wide coverage of the hernia defect, the laparoscopic approach is associated with few recurrences, rapid hospital discharge, improved cosmesis, a reduced risk of infection, and possibly less postoperative pain.2-5 Certain critical steps are required to ensure a reliable laparoscopic ventral hernia repair, such as a minimum of 4 to 5 cm mesh overlap of the hernia defect, and mesh fixation with both full-thickness transabdominal sutures and helical tacks.7,8 Although no randomized, prospective studies have been performed, a strong association has been made in the literature between hernia recurrences and the lack of mesh fixation with full-thickness

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transabdominal sutures.2,7,8 Additionally, animal studies have demonstrated the superior fixation strength of sutures compared with tacks for mesh fixation.9,10 The terms suprapubic and parapubic are often used interchangeably. When used to describe hernias, they refer to those located just above the symphysis pubis. They may occur as a result of low mid-line, Pfannenstiel, Maylard, and Cherney incisions used principally for gynecologic, prostatic, or rectal procedures.11 These hernias have also been reported after suprapubic catheterization.12 There is limited experience with the repair of these difficult hernias using both the open11,13-15 and laparoscopic approach.16-18 The abdominal oblique aponeurosis, rectus abdominus musculature, and rectus sheath insert on the symphysis pubis. In the event an incision is placed in proximity to this musculotendinous insertion, a hernia may develop as a result of inadequate tissue purchase inferiorly when re-approximating the fascia. The complexity of dissection and the close proximity of these hernias to bony, vascular, and nerve structures make the repair of suprapubic hernias a formidable operation. We developed a unique technique in the repair of these hernias, and present our 10-year experience, discussing in detail the operative approach.

Preoperative Workup
Patient selection for the laparoscopic approach is up to the individual surgeon. Preoperative workup should include a thorough history of all past surgeries and review of operative reports, particularly if a previous hernia repair with mesh was undertaken. On physical examination the surgeon should palpate the entire incision both in the supine and upright position. Provocative maneuvers should be used to accentuate the hernia bulge and attempt to delineate the inferiormost edge of the defect. For the laparoscopic ventral hernia repair, a minimum 4 cm overlap of mesh past the edge of the hernia defect is recommended; as a result, hernias less than 4 cm from the pubic symphysis are defined as suprapubic and will require this modified approach to repair. Computed tomography (CT) is helpful in determining the exact size of the hernia, its contents, and the relation of the inferior edge to the pubic symphysis. Although we do not typically have the patient undergo CT before hernia repair, we will do so if there is a question regarding proximity of the hernia to the pubic symphysis or if there has been a previous mesh repair. A previous repair with mesh may make the laparoscopic approach difficult, particularly if polypropylene mesh was used

Division of General Surgery, Minimally Invasive Surgery Center, Virginia Commonwealth University Medical Center, Richmond, VA. Address reprint requests to Alfredo M. Carbonell, D.O., Division of General Surgery, Virginia Commonwealth University Medical Center, 1200 East Broad Street, PO Box 980519, Richmond, VA 23298. E-mail: amcarbonell@vcu.edu

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1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2006.04.005

Laparoscopic repair of suprapubic ventral hernias
or a previous laparoscopic repair attempted. This information helps plan out the operative approach.

11 bladder as a tumescent to aid in determination of the bladder’s location in the preperitoneal space so as to avoid injury to it during the procedure. Should an injury be suspected, methylene blue can be instilled in the irrigant to help identify a cystotomy. The patient is positioned supine with both arms padded and tucked. This allows the surgeon and the assistant to work on the same side of the patient without interference from the patient’s extended arm. With more obese patients, padding to elevate the tucked arm will ensure there is no undue traction placed on the brachial plexus. The pubic hair is shaven to ensure complete access to the area of the pubic symphysis during the operation. Using a standard iodine skin prep, the abdomen is prepped up to the nipple line, as far lateral as the arms allow, and down onto the thighs. An iodine-impregnated skin drape is used on the abdomen for an added antimicrobial barrier.

Equipment
Instrumentation for the repair is similar to that of the typical laparoscopic ventral hernia repair. We use from three to four trocars for the procedure; at least one being 10 mm in size, the rest may be 5 mm. Because most of the trocars are 5 mm, we use a 5 mm, 30-degree angled laparoscope that will allow the surgeon to change the position of the camera between multiple ports. The angle allows the surgeon to “look around corners” during difficult portions of the procedure. A Maryland dissector, atraumatic graspers, and laparoscopic shears are required for the lysis of adhesions. We refrain from the use of ultrasonic coagulating shears to take down adhesions because this can result in an unnoticed thermal injury to the intestine. Sharp division of adhesions is advised. Simple monopolar cautery attached to the scissors should suffice if nuisance bleeding arises. The use of a 5 mm clip applier can serve as an added measure for hemostasis. For mesh we use expanded polytetrafluoroethylene (ePTFE, DualMesh GoreTex, WL Gore & Associates, Flagstaff, AZ), however, several other tissue-separating mesh products are available that are safe to use in direct contact with the intestine. The four cardinal sutures used to initially hold the mesh in place are CV-0 sutures constructed of ePTFE (Gore-Tex, WL Gore & Associates). The additional fixation sutures should be size #0 or #1 polypropylene or polybutester that are both nonabsorbable. Our preferred fixation construct device is the ProTack (United States Surgical, Norwalk, CT) that employs titanium spiral tacks. Several other fixation construct devices are available as well. For passing and retrieving the transabdominal sutures, a Gore Suture Passer (WL Gore & Associates) is used.

Trocar Placement
The procedure commences with an open cutdown to enter the abdomen safely away from any previous incisions and placement of a 10-mm trocar. The incision can be made in the midline above the umbilicus, distant to the hernia defect. Placing the first trocar this far above allows a more expanded view of the abdomen and ensures the trocar is out of the way should it be required to place a large piece of mesh. Two additional 5 mm trocars are placed in a horizontal line.

Lysis of Adhesions
The procedure proceeds with a sharp enterolysis, avoiding injury to any hollow viscus. Care should be taken in dissecting the inferior-most aspect of the hernia because it often contains herniated bladder. The herniated contents should be completely reduced, and no effort made to remove the hernia sac. At this point, a metric ruler is placed into the abdomen to determine the proximity of the inferior edge of the hernia defect to the pubic symphysis. If this measures less than 4 cm, plans should be made to proceed with this modified technique.

Patient Set-up
After anesthetic induction, a three-way Foley catheter is placed into the bladder. This is used to instill saline into the

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Operative Technique

Figure 1 After initial access to the abdomen via an open cutdown technique, laparoscopic ports are placed in a horizontal configuration far above the hernia defect to allow manipulation and placement of a large enough piece of mesh without interfering with the ports. This picture demonstrates the surgeon working in the pelvis on a suprapubic hernia associated with a large Pfannenstiel incision. (Color version of figure appears online.)

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Figure 2 With suprapubic hernias the inferior edge of the defect may be intimately associated with the superior edge of the bladder. (A) The intraoperative photo demonstrates the bladder filled with saline and the hernia defect completely abutting the pubic bone. (B) The CT shows a portion of the bladder herniating into the defect. When the hernia edge lies within 4 cm of the superior most aspect of the pubic bone the surgeon must create a peritoneal flap to enter the prevesical space of Retzius so as to identify the proper bony and vascular structures for safe suture mesh fixation. (Color version of figure appears online.)

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Figure 3 If the hernia defect edge is less than 4 cm from the pubis, then a peritoneal flap will need to be created to enter the space of Retzius and Bogros to expose the posterior aspect of the pubic bone, Cooper’s ligaments, and the inferior epigastric vessels bilaterally. Identification of these key structures will allow the surgeon to place the transabdominal sutures and tacks with pinpoint precision, avoiding injury to any of the surrounding neurovascular structures. The peritoneum is grasped in the midline at the median umbilical ligament at a level immediately below the hernia defect edge. The surgeon can avoid injury to the bladder at this point by instilling approximately 200 mL of saline through the three-way Foley catheter, allowing the bladder to become more visible. The peritoneum is sharply incised in a horizontal fashion toward the epigastric vessels (Lateral umbilical ligaments) on either side. The prevesical space of Retzius is entered and blunt dissection similar to that used for the laparoscopic, transabdominal, preperitoneal, inguinal hernia repair is performed. (Color version of figure appears online.)

Figure 4 The flap is raised inferiorly to expose the underlying bony pelvic structures. The dissection proceeds until the posterior aspect of the pubic bone, Cooper’s ligaments, and the inferior epigastric vessels are identified bilaterally. (Color version of figure appears online.)

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Figure 5 (A) After completely delineating the edges of the hernia, 3.5 long 20 gauge spinal needles are placed at the extreme edges of the hernia defect. These spinal needles mark the edges of the hernia, helping to measure the exact size of the hernia using an intracorporeally placed thin, plastic, metric ruler. Once the maximum vertical and horizontal measurements of the hernia are taken, the overlap superiorly and laterally should be no less than 4 cm. (B) Inferiorly, the overlap onto the pubic bone is calculated as the distance from the edge of the hernia to the superior most aspect of the pubic bone plus 1 to 2 cm for overlap below the pubis. (Color version of figure appears online.)

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Figure 6 Pretied CV-0 ePTFE sutures are placed with a 1 cm bite, 1 cm in from the mesh edge at the four corners of the mesh to serve as the initial transabdominal fixation sutures. Because the inferior portion of the mesh will overlap onto the pubic bone, the inferior suture should be placed 2 cm from the actual mesh edge. (Color version of figure appears online.)

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Figure 7 (A) The mesh is rolled from the top and the bottom concomitantly like a scroll. (B) This allows for the mesh to be dragged directly into the abdomen. (C) The mesh is then unrolled without having to reorient the mesh once it is in the abdomen. (Color version of figure appears online.)

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Figure 8 After unrolling the mesh, the inferior transabdominal suture needs to be retrieved first to ensure adequate overlap inferiorly where it is most important. (A,B) The suture passer is advanced into the abdomen, puncturing the periosteum of the pubic bone and grasping one limb of the inferior suture, a second path through the periosteum grasps the second limb of the suture and brings the inferior portion of the mesh against the pubic bone. (C) Note, the inferior suture is not tied down immediately, rather, the suture limbs are held under tension with a hemostat. (Color version of figure appears online.)

Laparoscopic repair of suprapubic ventral hernias

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Figure 8 Continued

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Figure 9 (A) The superior suture and the two lateral sutures are then retrieved transabdominally ensuring a minimum of 4 cm mesh-defect overlap. When the mesh lies tight against the anterior abdominal wall, then the superior and lateral sutures are tied. (B) The superior and lateral portion of the mesh is then fixated to the abdominal wall with spiral tacks every 1 to 2 cm apart and interrupted #1 permanent suture every 4 to 6 cm. (Color version of figure appears online.)

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Figure 10 (A–F) While holding the inferior-most midline suture untied outside the body, a minimum of two additional #1 polypropylene transabdominal sutures are passed through the periosteum of the pubis approximately 2 cm lateral to the first inferior midline suture. The suture must be taken in with the suture passer, advanced through the mesh and a second pass through the mesh retrieves the suture, forming a U-stitch. These sutures are not secured until all of the inferior sutures are placed. This allows the surgeon to hold the mesh loosely upwards with a grasper to allow direct visualization of the suture passer safely traversing the abdominal wall and periosteum. A minimum of three sutures are placed through the periosteum. More may be placed as space allows. After placing all the inferior sutures, they are individually tied. (Color version of figure appears online.)

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Figure 10 Continued

Laparoscopic repair of suprapubic ventral hernias

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Figure 10 Continued

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Figure 11 (A,B) Further mesh fixation is achieved with spiral tacks every 1 cm and transabdominal #1 polypropylene suture every 4 to 5 cm circumferentially around the mesh, avoiding placement of sutures or tacks below the iliopubic tract. Although several tacks are placed directly into the posterior pubis and Cooper’s ligament laterally, care should be taken because of the close proximity to neurovascular structures. It is unnecessary to reconstruct the peritoneal defect. (Color version of figure appears online.)

Laparoscopic repair of suprapubic ventral hernias

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Figure 12 At the conclusion of the procedure the 10 mm trocar site is closed with a permanent suture using a suture passer. All sutures are tied, skin is closed in the standard fashion, and sterile dressings are applied. Patients are typically admitted to the hospital and discharged once their pain is controlled and a diet is tolerated. (Color version of figure appears online.)

Procedure Outcomes
We published our outcomes in 36 patients (26 females and 10 males) with a mean age of 55.9 years (range, 33-76) and a mean BMI of 31.0 kg/m2 (range, 22-67) underwent LRSPH.19 Twenty-two (61%) of the repairs were for recurrent hernias, with an average of 2.3 previously failed open repairs each (range, 1-11). The mean hernia size was 191.4 cm2 (range, 20-768), with an average mesh size of 481.4 cm2 (range, 193-1428). All repairs were performed with ePTFE. Mean operating room time was 178.7 minutes (range, 95-290), with a mean blood loss of 40 mL (range, 20-100). One patient undergoing her fifth repair required conversion because of adhesions to previously placed polypropylene mesh. Hospital stay averaged 2.4 days (range, 1-7). Mean follow up was 21.1 months (range, 1-70). Complications (16.6%) included: deep venous thrombosis,1 prolonged pain greater than 6 weeks,1 trocar site cellulitis,1 ileus,1 prolonged seroma,1 and Clostridium difficile colitis.1 Hernias recurred in two of our first nine patients, for an overall recurrence rate of 5.5%. Since initiating the technique of applying multiple sutures directly to the pubis and Cooper’s ligament (in the subsequent 19 patients), no recurrences have been documented.

Discussion
Hermann Johann Pfannenstiel’s first description of his eponymous incision in 51 patients in 1900, reported no incisional

hernias after a 2-year follow up.20 Recent authors cite a 0.04% to 2.1% incisional hernia rate after Pfannenstiel incision.21,22 There is a paucity of literature regarding the technical aspects of the repair of suprapubic ventral hernias. Bendavid11 reported the Shouldice Clinic experience repairing parapubic hernias via an open technique in seven patients. All of his patients presented with a denuded pubis lacking fascia. He approached the defect preperitoneally through the space of Retzius, and placed a polypropylene mesh anchored to the pubis and Cooper’s ligaments inferiorly, and full-thickness abdominal wall sutures superiorly. Although recurrence was not reported, his results were favorable after a 5 to 48 month follow-up with no infections or seromas. Hirasa17 reported the first laparoscopic experience with the repair of suprapubic hernias. They employed a composite mesh with a 2 to 3 cm overlap, fixated only with spiral tacks and no transabdominal sutures in seven patients. After a 4 to 9 month follow up in six of the patients, one hernia (14.3%) recurred at 8 months as a result of the mesh pulling off of the abdominal wall. There is some evidence to support the use of full-thickness transabdominal sutures to ensure adequate mesh fixation.2,7,8 Another important aspect of ventral hernia repair is an adequate overlap of mesh from the edge of the hernia defect.2,7 Obtaining adequate overlap to provide the necessary surface area for mesh-host tissue integration is difficult to achieve in hernias occurring just above the pubic bone. We develop a peritoneal flap inferiorly similar to the dissection plane for

26 laparoscopic, transabdominal, preperitoneal, inguinal hernia repair to identify the critical pelvic structures, and allow for the safe placement of fixation constructs directly to Cooper’s ligaments and the pubic bone. We believe this represents the strongest tissue of the pelvis, holding suture well enough to rely on them almost exclusively for the inferior fixation of the mesh. The two recurrences reported in our series occurred in the first nine patients (5.5% overall recurrence rate).19 The recurrences occurred just above the pubis before we began to employ full-thickness, transabdominal sutures incorporating the periosteum of the pubis. After this modification, no recurrences have been documented. This underscores the importance of adequate mesh fixation with sutures to the strong bony or ligamentous structures as opposed to the attenuated muscle at the hernia’s border. Although technically demanding, the LRSPH is technically feasible, safe, and results in a low recurrence rate. It can be performed with low morbidity in very large and recurrent hernias. Transabdominal suture fixation to the bony and ligamentous structures yields a durable hernia repair.

A.M. Carbonell
6. Stoppa RE: The treatment of complicated groin and incisional hernias. World J Surg 13:545-554, 1989 7. Koehler RH, Voeller G: Recurrences in laparoscopic incisional hernia repairs: A personal series and review of the literature. JSLS 3:293-304, 1999 8. LeBlanc KA: The critical technical aspects of laparoscopic repair of ventral and incisional hernias. Am Surg 67:809-812, 2001 9. Joels CS, Matthews BD, Kercher KW, et al: Evaluation of adhesion formation, mesh fixation strength, and hydroxyproline content after intraabdominal placement of polytetrafluoroethylene mesh secured using titanium spiral tacks, nitinol anchors, and polypropylene suture or polyglactin 910 suture. Surg Endosc 19:780-785, 2005 10. van’t Riet M, de Vos van Steenwijk PJ, Kleinrensink GJ, et al: Tensile strength of mesh fixation methods in laparoscopic incisional hernia repair. Surg Endosc 16:1713-1716, 2002 11. Bendavid R: Incisional parapubic hernias. Surgery 108:898-901, 1990 12. Lobel RW, Sand PK: Incisional hernia after suprapubic catheterization. Obstet Gynecol 89(Pt 2):844-846, 1997 13. Losanoff JE, Richman BW, Jones JW: Parapubic hernia: Case report and review of the literature. Hernia 6:82-85, 2002 14. Norris JP, Flanigan RC, Pickleman J: Parapubic hernia following radical retropubic prostatectomy. Urology 44:922-923, 1994 15. el Mairy AB: A new procedure for the repair of suprapubic incisional hernia. J Med Liban 27:713-718, 1974 16. Carbonell AM, Kercher KW, Matthews BD, et al: The laparoscopic repair of suprapubic ventral hernias. Surg Endosc 19:174-177, 2005 17. Hirasa T, Pickleman J, Shayani V: Laparoscopic repair of parapubic hernia. Arch Surg 136:1314-1317, 2001 18. Matuszewski M, Stanek A, Maruszak H, Krajka K: Laparoscopic treatment of parapubic postprostatectomy hernia. Eur Urol 36:418-420, 1999 19. Huang CS, Huang CC, Lien HH: Prolene hernia system compared with mesh plug technique: A prospective study of short- to mid-term outcomes in primary groin hernia repair. Hernia 9:167-171, 2005 20. Pfannenstiel H: Ueber die vortheile des suprasymphysaren fascienquerschnitts fur die gynakologischen koliotomien. Samml Klin Vortr 268: 1735-1756, 1900 21. Luijendijk RW, Jeekel J, Storm RK, et al: The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment. Ann Surg 225:365-369, 1997 22. Griffiths DA: A reappraisal of the Pfannenstiel incision. Br J Urol 48: 469-474, 1976

References
1. Burger JW, Luijendijk RW, Hop WC, et al: Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578-583, 2004; discussion 583-585 2. Heniford BT, Park A, Ramshaw BJ, Voeller G: Laparoscopic repair of ventral hernias: Nine years’ experience with 850 consecutive hernias. Ann Surg 238:391-399, 2003; discussion 399-400 3. DeMaria EJ, Moss JM, Sugerman HJ: Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Prospective comparison to open prefascial polypropylene mesh repair. Surg Endosc 14:326-329, 2000 4. Park A, Birch DW, Lovrics P: Laparoscopic and open incisional hernia repair: A comparison study. Surgery 124:816-821, 1998; discussion 821-822 5. Ramshaw BJ, Esartia P, Schwab J, et al: Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg 65:827-831, 1999; discussion 831-832

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