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TRANSPERITONEAL PREPERITONEAL LAPAROSCOPIC LUMBAR INCISIONAL HERNIORRHAPHY
0022-5347/01/1664-1267/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 166, 1267–1269, October 2001 Printed in U.S.A.
TRANSPERITONEAL PREPERITONEAL LAPAROSCOPIC LUMBAR INCISIONAL HERNIORRHAPHY BIJAN SHEKARRIZ, TULIO M. GRAZIOTTIN, SHAHRAM GHOLAMI, HSUEH-FU LU, HIROFUMI YAMADA, QUAN-YANG DUH AND MARSHALL L. STOLLER* From the Departments of Urology and Surgery, School of Medicine, University of California-San Francisco, San Francisco, California
ABSTRACT
Purpose: Flank incisions may be associated with flank hernias, which may be complicated by incarceration and strangulation. Furthermore, they may be the cause of significant patient dissatisfaction with the surgical outcome. To avoid an open surgical procedure with its associated morbidity for hernia repair we describe a novel laparoscopic technique for repairing flank hernias with minimal morbidity and an excellent outcome. Materials and Methods: Three cases of flank hernia were managed by the transperitoneal preperitoneal laparoscopic approach using polypropylene mesh to repair the fascial defect. An initial transperitoneal approach helps to identify the limits of the hernia. A 2 to 3 cm. margin of overlying peritoneum is incised around the hernia margin. It is important not to dissect overlying bowel. The mesh is placed behind the peritoneal envelope and secured with hernia staples. Results: All cases were managed successfully via laparoscopy. There were no intraoperative or postoperative complications. At a mean followup of 12 months cosmesis has been excellent and there have been no recurrences. Conclusions: We describe a minimally invasive, versatile technique for laparoscopic repair of flank incisional hernias with excellent functional and cosmetic results. This approach avoids the significant morbidity associated with open repair of incisional flank hernias. KEY WORDS: hernia, inguinal; laparoscopy; polypropylene; groin
Lumbar hernia is an uncommon condition that may be anatomically divided into superior and inferior hernias. More than 90% of patients present with protrusion of the abdominal contents through the superior lumbar triangle (Grynfeltt’s hernia). The remaining cases involve an inferior hernia through the inferior lumbar triangle (Petit’s hernia).1 Furthermore, based on the etiology these hernias may be classified as congenital or acquired.2, 3 Acquired hernias are multifactorial, and a previous flank incision and flank trauma are common etiologies.4, 5 Incisional hernia after the flank and lumbar approaches are rare, including small neck hernias and large protrusions on the posterolateral aspect of the abdominal wall. Patients may be asymptomatic or present with pain and abdominal discomfort. A 25% risk of incarceration and 8% risk of strangulation have been reported.6 Therefore, repair is indicated at diagnosis. In addition, many patients request repair for cosmetic reasons. Open surgical repair of a flank incisional hernia may be difficult due to the lack of adequate tissue for coverage and the need for extensive dissection.5 This approach requires a large incision and may result in significant postoperative morbidity. Recently a laparoscopic approach for lumbar hernia repair has been reported with good short-term results and decreased morbidity.6 –9 For the last 3 years we have applied a modified technique for the laparoscopic repair of incisional lumbar hernia. We describe our experience with 3 cases of laparoscopic transabdominal preperitoneal repair of incisional flank hernias using a polypropylene mesh as an alternative to the open surgical approach. We reviewed the literature and discuss the technical advantages. From 1998 to 2000, 3 patients with a
lumbar incisional hernia underwent laparoscopic transperitoneal preperitoneal repair. CASE HISTORIES
Case 1: A 49-year-old woman with a history of diabetes and chronic renal failure requiring hemodialysis underwent left flank nephrectomy in 1989 for renal stone disease. Subsequently a left flank incisional hernia developed and the patient presented with pain. Physical examination demonstrated a large fascial defect with intestinal contents protruding from the hernia. Computerized tomography (CT) confirmed herniation of the colon and spleen through the fascial defect. Case 2: A 52-year-old man with obesity, and a history of alcoholism and the traumatic fracture of 5 ribs and the clavicle had a flank hernia 2 years after the trauma. It was repaired using an open procedure. However, hernia recurred 10 months later due to wound infection. CT showed a 9.5 cm. hernia sac (fig. 1). Case 3: A 44 year-old man with a condrosarcoma of the left 11th rib underwent rib resection. Three years postoperatively a mass was noted at the incision site, consistent with a flank hernia. SURGICAL TECHNIQUE
The patient was placed in the modified flank position with the ipsilateral kidney elevated 60 degrees, the kidney rest elevated and the bed flexed. Pneumoperitoneum was established using a Veress needle placed subcostally in the midclavicular line at the lateral edge of the abdominal rectus musculature. An expandable mesh sleeve trocar was then inserted. A blunt fascial dilator back loaded with a laparoscopic port was passed through the lumen of the mesh sleeve. The remaining ports were placed based on hernia location (fig. 2). Four 10 mm. ports were used. After the abdominal
Accepted for publication May 25, 2001. * Requests for reprints: Department of Urology, U-575, University of California-San Francisco, San Francisco, California 94143-0738. 1267
1268
TRANSPERITONEAL LUMBAR INCISIONAL HERNIORRHAPHY
cavity was entered omental adhesions were dissected free, exposing the hernia defect (fig. 3, A). An additional 2 to 3 cm. margin of overlying peritoneum was dissected around the edge of the hernia. The peritoneal envelope was pushed away from the hernia defect. Polypropylene mesh was fashioned according to the size of the defect and secured over the defect behind the peritoneal envelope using staples with a 3 cm. margin remaining along the hernia edges (fig. 3, B). A 5 mm. titanium stapling device was used. Mesh size was 10 to 15 cm. to cover beyond the edges of the fascial defects. The mesh was stapled behind the peritoneal envelope to the posterior abdominal wall muscles. The peritoneum was then brought
up over the mesh and secured with staples to reapproximate the initial peritoneal incision (fig. 3, C). RESULTS
Laparoscopic transperitoneal preperitoneal repair of lumbar incisional hernia was successful in all patients. The table lists operative data. Using polypropylene mesh enabled complete coverage of the hernia beyond the boundaries of the defect. No perioperative complications developed and blood loss was minimal. Mean operative time was 138 minutes (range 120 to 150). Two patients were discharged home on postoperative day 1. One patient on chronic hemodialysis was discharged home after dialysis on postoperative day 3. All patients returned to normal activity within 2 to 4 weeks. At a mean followup of 1 year (range 1 to 3) no hernia recurrence was noted and cosmesis was excellent. DISCUSSION
FIG. 1. CT shows posterior abdominal wall fascial defect with abdominal contents protruding.
FIG. 2. With patient in right lateral decubitus position initial 3 trocars are placed. Port configuration may be adjusted based on defect site.
Lumbar hernia is related to acquired spontaneous, incisional or traumatic and congenital disease.3–5, 10 Flank and lumbar incisions are rarely associated with hernias compared with inguinal and midline incisions due to the strong muscular anatomy. However, the superior lumbar or Grynfeltt’s triangle bounded by the 12th rib, internal oblique muscle and erector spinae muscle is a fragile region and the site of most lumbar incisional hernias. Although lumbar incisional hernias are uncommon in healthy individuals, several factors may contribute to development. Predisposing factors include advanced patient age, chronic debilitation, nutritional depletion, obesity, pulmonary conditions with cough, previous wound infection and postoperative sepsis.5 Lumbar hernias may present as small or large protrusions. An intraoperative risk factor is injury to the subcostal nerve during flank incision, which may result in atrophy of the ipsilateral abdominal wall muscles that manifests as laxity and in severe cases protrusion of the abdominal contents through the flank as a large hernia.5 The diagnosis may be made clinically in the majority of cases. However, CT is recommended before surgical repair.5, 7 This study may detect small or additional hernias and it is also important for defining the boundaries of the defect before planned surgery. Several techniques have been described for the open repair of lumbar hernia. No consensus exists on the best surgical approach. A reason for the controversy is the relative rarity of this condition, limiting the number of procedures performed by a single surgeon or at a single center. For example, in a recent review of superior lumbar hernia cases at a large university hospital only 4 were identified in a 20-year period.11 Simple primary closure has also been described. However, it is not adequate or possible in many cases due to fascial attenuation and bony hernia boundaries.7 A common approach has been the placement of various rotational and onlay fascial flaps with bony fixation for se-
FIG. 3. Transperitoneal laparoscopic view of lumbar hernia. A, before dissection. B, positioning of polypropylene mesh behind peritoneum to cover 3 to 4 cm. beyond defect margins. C, completed repair with additional peritoneal coverage.
TRANSPERITONEAL LUMBAR INCISIONAL HERNIORRHAPHY Surgical data on laparoscopic flank hernia repair Pt. — Age No.
Mesh Size (cm.)
Operative Time (mins.)
1 — 49
7.3 ⫻ 15
150
2 — 52 10 ⫻ 10 3 — 44 12 ⫻ 12 There were no complications.
145 120
Analgesic Requirement Oral, intravenous Oral Oral
Hospital Stay (days) 3 1 1
cure coverage of the defect.12 Furthermore, applying synthetic material, such as polypropylene mesh, with muscle flaps in sandwich fashion has also been reported.5 A difficulty in open extraperitoneal repair of flank hernia is that the bony boundaries of these hernias, including the iliac crest and/or 12th rib, may make adequate fixation of the synthetic material difficult.7 Fixation of the synthetic mesh to the iliac crest for inferior hernias and to the 12th rib for superior hernias has been advocated.5 However, regardless of the technique the open surgical approach is associated with significant morbidity and long convalescence related to extensive surgical dissection. To overcome this problem a laparoscopic approach to lumbar hernia repair has recently been presented.6 –9 Burick and Parascandola reported the initial case of a traumatic lumbar hernia explored and repaired via laparoscopy.9 Bickel et al described laparoscopic repair of an acquired superior triangle lumbar hernia in a morbidly obese patient.8 The transperitoneal approach was used and polypropylene mesh was applied to cover the hernia defect. Heniford et al reported a technique for laparoscopic repair of a lumbar hernia using the transabdominal approach.6 Polypropylene mesh was placed intraperitoneally to cover the fascial defect. As in open techniques, the mesh was secured to the iliac crest for inferior hernias. An orthopedic drill was used to create a hole, through which a polypropylene suture was passed and secured to the mesh. For superior hernias a suture was tied around the 12th rib for mesh fixation. Furthermore, transabdominal sutures were placed using a suture passer to secure the mesh externally to the abdominal wall. Arca et al recently reviewed their experience with this technique in 7 patients.7 Mean operative time was 144 minutes (range 80 to 325). No conversion to open repair was required. Postoperatively morbidity was minimal and 4 patients were discharged home within 24 hours after surgery. In 1 case an abscess developed postoperatively above the mesh, requiring mesh removal 2 weeks later. Similarly in our experience laparoscopic correction of flank incisional hernia has been successful. In our technique positioning the mesh preperitoneally is advantageous. The mesh may be fixed with staples without the need for additional bone anchoring. Peritoneal coverage over the mesh provides additional security and decreases the risk of postoperative adhesions between the mesh and bowel. The weight of the intraperitoneal contents is an additional support to maintain the mesh in correct position in the early postoperative period.
1269
Postoperatively lifting restrictions are similar to those after routine open surgery. All patients had good functional and cosmetic results. Therefore, this approach is preferable to open surgery since it requires less tissue dissection. Another advantage of the laparoscopic approach is superior visualization of the hernia boundaries under pneumoperitoneum, so that unrecognized small preoperative defects may be included in repair. In the study of Heniford et al a 3 cm. superior defect that was not detected by CT was identified by laparoscopy and repaired simultaneously.6 The transperitoneal approach may also be advantageous over the usual open flank approach via the previous incision, which requires dissection through a previous operative field in previously operated and scarred retroperitoneal tissue. Many patients have not undergone previous transperitoneal procedures, making adequate exposure easier via the transperitoneal approach. CONCLUSIONS
Laparoscopic transperitoneal preperitoneal repair of a lumbar incisional hernia simplifies the operative procedure in these challenging cases and may be superior to open approaches in terms of associated morbidity and convalescence. Although long-term followup is necessary for assessing the efficacy of this procedure, we believe that the laparoscopic approach should be the primary mode of treatment for repairing lumbar incisional hernia. REFERENCES
1. Geis, W. T. and Saletta, J. D.: Lumbar hernia. In: Hernias, 3rd ed. Edited by L. M. Nyhus and R. E. Condon. Philadelphia: J. B. Lippincott, p. 401, 1989 2. Wakhlu, A. and Wakhlu, A. K.: Congenital lumbar hernia. Pediatr Surg Int, 16: 146, 2000 3. Fakhry, S. M. and Azizkhan, R. G.: Observations and current operative management of congenital lumbar hernias during infancy. Surg Gynecol Obstet, 172: 475, 1991 4. Esposito, T. J. and Fedorak, I.: Traumatic lumbar hernia: case report and literature review. J Trauma, 37: 123, 1994 5. Sutherland, R. S. and Gerow, R. R.: Hernia after dorsal incision into lumbar region: a case report and review of pathogenesis and treatment. J Urol, 153: 382, 1995 6. Heniford, B. T., Iannitti, D. A. and Gagner, M.: Laparoscopic inferior and superior lumbar hernia repair. Arch Surg, 132: 1141, 1997 7. Arca, M. J., Heniford, B. T., Pokorny, R. et al: Laparoscopic repair of lumbar hernias. J Am Coll Surg, 187: 147, 1998 8. Bickel, A., Haj, M. and Eitan, A.: Laparoscopic management of lumbar hernia. Surg Endosc, 11: 1129, 1997 9. Burick, A. J. and Parascandola, S. A.: Laparoscopic repair of a traumatic lumbar hernia: a case report. J Laparoendosc Surg, 6: 259, 1996 10. Pul, M., Pul, N. and Gurses, N.: Congenital lumbar (GrynfeltLesshaft) hernia. Eur J Pediatr Surg, 1: 115, 1991 11. Alves, A., Jr., Maximiano, L., Fujimura, I. et al: Grynfelt hernia. Arq Gastroenterol, 33: 32, 1996 12. Bolkier, M., Moskovitz, B., Ginesin, Y. et al: An operation for incisional lumbar hernia. Eur Urol, 20: 52, 1991
Vol. 166, 1267–1269, October 2001 Printed in U.S.A.
TRANSPERITONEAL PREPERITONEAL LAPAROSCOPIC LUMBAR INCISIONAL HERNIORRHAPHY BIJAN SHEKARRIZ, TULIO M. GRAZIOTTIN, SHAHRAM GHOLAMI, HSUEH-FU LU, HIROFUMI YAMADA, QUAN-YANG DUH AND MARSHALL L. STOLLER* From the Departments of Urology and Surgery, School of Medicine, University of California-San Francisco, San Francisco, California
ABSTRACT
Purpose: Flank incisions may be associated with flank hernias, which may be complicated by incarceration and strangulation. Furthermore, they may be the cause of significant patient dissatisfaction with the surgical outcome. To avoid an open surgical procedure with its associated morbidity for hernia repair we describe a novel laparoscopic technique for repairing flank hernias with minimal morbidity and an excellent outcome. Materials and Methods: Three cases of flank hernia were managed by the transperitoneal preperitoneal laparoscopic approach using polypropylene mesh to repair the fascial defect. An initial transperitoneal approach helps to identify the limits of the hernia. A 2 to 3 cm. margin of overlying peritoneum is incised around the hernia margin. It is important not to dissect overlying bowel. The mesh is placed behind the peritoneal envelope and secured with hernia staples. Results: All cases were managed successfully via laparoscopy. There were no intraoperative or postoperative complications. At a mean followup of 12 months cosmesis has been excellent and there have been no recurrences. Conclusions: We describe a minimally invasive, versatile technique for laparoscopic repair of flank incisional hernias with excellent functional and cosmetic results. This approach avoids the significant morbidity associated with open repair of incisional flank hernias. KEY WORDS: hernia, inguinal; laparoscopy; polypropylene; groin
Lumbar hernia is an uncommon condition that may be anatomically divided into superior and inferior hernias. More than 90% of patients present with protrusion of the abdominal contents through the superior lumbar triangle (Grynfeltt’s hernia). The remaining cases involve an inferior hernia through the inferior lumbar triangle (Petit’s hernia).1 Furthermore, based on the etiology these hernias may be classified as congenital or acquired.2, 3 Acquired hernias are multifactorial, and a previous flank incision and flank trauma are common etiologies.4, 5 Incisional hernia after the flank and lumbar approaches are rare, including small neck hernias and large protrusions on the posterolateral aspect of the abdominal wall. Patients may be asymptomatic or present with pain and abdominal discomfort. A 25% risk of incarceration and 8% risk of strangulation have been reported.6 Therefore, repair is indicated at diagnosis. In addition, many patients request repair for cosmetic reasons. Open surgical repair of a flank incisional hernia may be difficult due to the lack of adequate tissue for coverage and the need for extensive dissection.5 This approach requires a large incision and may result in significant postoperative morbidity. Recently a laparoscopic approach for lumbar hernia repair has been reported with good short-term results and decreased morbidity.6 –9 For the last 3 years we have applied a modified technique for the laparoscopic repair of incisional lumbar hernia. We describe our experience with 3 cases of laparoscopic transabdominal preperitoneal repair of incisional flank hernias using a polypropylene mesh as an alternative to the open surgical approach. We reviewed the literature and discuss the technical advantages. From 1998 to 2000, 3 patients with a
lumbar incisional hernia underwent laparoscopic transperitoneal preperitoneal repair. CASE HISTORIES
Case 1: A 49-year-old woman with a history of diabetes and chronic renal failure requiring hemodialysis underwent left flank nephrectomy in 1989 for renal stone disease. Subsequently a left flank incisional hernia developed and the patient presented with pain. Physical examination demonstrated a large fascial defect with intestinal contents protruding from the hernia. Computerized tomography (CT) confirmed herniation of the colon and spleen through the fascial defect. Case 2: A 52-year-old man with obesity, and a history of alcoholism and the traumatic fracture of 5 ribs and the clavicle had a flank hernia 2 years after the trauma. It was repaired using an open procedure. However, hernia recurred 10 months later due to wound infection. CT showed a 9.5 cm. hernia sac (fig. 1). Case 3: A 44 year-old man with a condrosarcoma of the left 11th rib underwent rib resection. Three years postoperatively a mass was noted at the incision site, consistent with a flank hernia. SURGICAL TECHNIQUE
The patient was placed in the modified flank position with the ipsilateral kidney elevated 60 degrees, the kidney rest elevated and the bed flexed. Pneumoperitoneum was established using a Veress needle placed subcostally in the midclavicular line at the lateral edge of the abdominal rectus musculature. An expandable mesh sleeve trocar was then inserted. A blunt fascial dilator back loaded with a laparoscopic port was passed through the lumen of the mesh sleeve. The remaining ports were placed based on hernia location (fig. 2). Four 10 mm. ports were used. After the abdominal
Accepted for publication May 25, 2001. * Requests for reprints: Department of Urology, U-575, University of California-San Francisco, San Francisco, California 94143-0738. 1267
1268
TRANSPERITONEAL LUMBAR INCISIONAL HERNIORRHAPHY
cavity was entered omental adhesions were dissected free, exposing the hernia defect (fig. 3, A). An additional 2 to 3 cm. margin of overlying peritoneum was dissected around the edge of the hernia. The peritoneal envelope was pushed away from the hernia defect. Polypropylene mesh was fashioned according to the size of the defect and secured over the defect behind the peritoneal envelope using staples with a 3 cm. margin remaining along the hernia edges (fig. 3, B). A 5 mm. titanium stapling device was used. Mesh size was 10 to 15 cm. to cover beyond the edges of the fascial defects. The mesh was stapled behind the peritoneal envelope to the posterior abdominal wall muscles. The peritoneum was then brought
up over the mesh and secured with staples to reapproximate the initial peritoneal incision (fig. 3, C). RESULTS
Laparoscopic transperitoneal preperitoneal repair of lumbar incisional hernia was successful in all patients. The table lists operative data. Using polypropylene mesh enabled complete coverage of the hernia beyond the boundaries of the defect. No perioperative complications developed and blood loss was minimal. Mean operative time was 138 minutes (range 120 to 150). Two patients were discharged home on postoperative day 1. One patient on chronic hemodialysis was discharged home after dialysis on postoperative day 3. All patients returned to normal activity within 2 to 4 weeks. At a mean followup of 1 year (range 1 to 3) no hernia recurrence was noted and cosmesis was excellent. DISCUSSION
FIG. 1. CT shows posterior abdominal wall fascial defect with abdominal contents protruding.
FIG. 2. With patient in right lateral decubitus position initial 3 trocars are placed. Port configuration may be adjusted based on defect site.
Lumbar hernia is related to acquired spontaneous, incisional or traumatic and congenital disease.3–5, 10 Flank and lumbar incisions are rarely associated with hernias compared with inguinal and midline incisions due to the strong muscular anatomy. However, the superior lumbar or Grynfeltt’s triangle bounded by the 12th rib, internal oblique muscle and erector spinae muscle is a fragile region and the site of most lumbar incisional hernias. Although lumbar incisional hernias are uncommon in healthy individuals, several factors may contribute to development. Predisposing factors include advanced patient age, chronic debilitation, nutritional depletion, obesity, pulmonary conditions with cough, previous wound infection and postoperative sepsis.5 Lumbar hernias may present as small or large protrusions. An intraoperative risk factor is injury to the subcostal nerve during flank incision, which may result in atrophy of the ipsilateral abdominal wall muscles that manifests as laxity and in severe cases protrusion of the abdominal contents through the flank as a large hernia.5 The diagnosis may be made clinically in the majority of cases. However, CT is recommended before surgical repair.5, 7 This study may detect small or additional hernias and it is also important for defining the boundaries of the defect before planned surgery. Several techniques have been described for the open repair of lumbar hernia. No consensus exists on the best surgical approach. A reason for the controversy is the relative rarity of this condition, limiting the number of procedures performed by a single surgeon or at a single center. For example, in a recent review of superior lumbar hernia cases at a large university hospital only 4 were identified in a 20-year period.11 Simple primary closure has also been described. However, it is not adequate or possible in many cases due to fascial attenuation and bony hernia boundaries.7 A common approach has been the placement of various rotational and onlay fascial flaps with bony fixation for se-
FIG. 3. Transperitoneal laparoscopic view of lumbar hernia. A, before dissection. B, positioning of polypropylene mesh behind peritoneum to cover 3 to 4 cm. beyond defect margins. C, completed repair with additional peritoneal coverage.
TRANSPERITONEAL LUMBAR INCISIONAL HERNIORRHAPHY Surgical data on laparoscopic flank hernia repair Pt. — Age No.
Mesh Size (cm.)
Operative Time (mins.)
1 — 49
7.3 ⫻ 15
150
2 — 52 10 ⫻ 10 3 — 44 12 ⫻ 12 There were no complications.
145 120
Analgesic Requirement Oral, intravenous Oral Oral
Hospital Stay (days) 3 1 1
cure coverage of the defect.12 Furthermore, applying synthetic material, such as polypropylene mesh, with muscle flaps in sandwich fashion has also been reported.5 A difficulty in open extraperitoneal repair of flank hernia is that the bony boundaries of these hernias, including the iliac crest and/or 12th rib, may make adequate fixation of the synthetic material difficult.7 Fixation of the synthetic mesh to the iliac crest for inferior hernias and to the 12th rib for superior hernias has been advocated.5 However, regardless of the technique the open surgical approach is associated with significant morbidity and long convalescence related to extensive surgical dissection. To overcome this problem a laparoscopic approach to lumbar hernia repair has recently been presented.6 –9 Burick and Parascandola reported the initial case of a traumatic lumbar hernia explored and repaired via laparoscopy.9 Bickel et al described laparoscopic repair of an acquired superior triangle lumbar hernia in a morbidly obese patient.8 The transperitoneal approach was used and polypropylene mesh was applied to cover the hernia defect. Heniford et al reported a technique for laparoscopic repair of a lumbar hernia using the transabdominal approach.6 Polypropylene mesh was placed intraperitoneally to cover the fascial defect. As in open techniques, the mesh was secured to the iliac crest for inferior hernias. An orthopedic drill was used to create a hole, through which a polypropylene suture was passed and secured to the mesh. For superior hernias a suture was tied around the 12th rib for mesh fixation. Furthermore, transabdominal sutures were placed using a suture passer to secure the mesh externally to the abdominal wall. Arca et al recently reviewed their experience with this technique in 7 patients.7 Mean operative time was 144 minutes (range 80 to 325). No conversion to open repair was required. Postoperatively morbidity was minimal and 4 patients were discharged home within 24 hours after surgery. In 1 case an abscess developed postoperatively above the mesh, requiring mesh removal 2 weeks later. Similarly in our experience laparoscopic correction of flank incisional hernia has been successful. In our technique positioning the mesh preperitoneally is advantageous. The mesh may be fixed with staples without the need for additional bone anchoring. Peritoneal coverage over the mesh provides additional security and decreases the risk of postoperative adhesions between the mesh and bowel. The weight of the intraperitoneal contents is an additional support to maintain the mesh in correct position in the early postoperative period.
1269
Postoperatively lifting restrictions are similar to those after routine open surgery. All patients had good functional and cosmetic results. Therefore, this approach is preferable to open surgery since it requires less tissue dissection. Another advantage of the laparoscopic approach is superior visualization of the hernia boundaries under pneumoperitoneum, so that unrecognized small preoperative defects may be included in repair. In the study of Heniford et al a 3 cm. superior defect that was not detected by CT was identified by laparoscopy and repaired simultaneously.6 The transperitoneal approach may also be advantageous over the usual open flank approach via the previous incision, which requires dissection through a previous operative field in previously operated and scarred retroperitoneal tissue. Many patients have not undergone previous transperitoneal procedures, making adequate exposure easier via the transperitoneal approach. CONCLUSIONS
Laparoscopic transperitoneal preperitoneal repair of a lumbar incisional hernia simplifies the operative procedure in these challenging cases and may be superior to open approaches in terms of associated morbidity and convalescence. Although long-term followup is necessary for assessing the efficacy of this procedure, we believe that the laparoscopic approach should be the primary mode of treatment for repairing lumbar incisional hernia. REFERENCES
1. Geis, W. T. and Saletta, J. D.: Lumbar hernia. In: Hernias, 3rd ed. Edited by L. M. Nyhus and R. E. Condon. Philadelphia: J. B. Lippincott, p. 401, 1989 2. Wakhlu, A. and Wakhlu, A. K.: Congenital lumbar hernia. Pediatr Surg Int, 16: 146, 2000 3. Fakhry, S. M. and Azizkhan, R. G.: Observations and current operative management of congenital lumbar hernias during infancy. Surg Gynecol Obstet, 172: 475, 1991 4. Esposito, T. J. and Fedorak, I.: Traumatic lumbar hernia: case report and literature review. J Trauma, 37: 123, 1994 5. Sutherland, R. S. and Gerow, R. R.: Hernia after dorsal incision into lumbar region: a case report and review of pathogenesis and treatment. J Urol, 153: 382, 1995 6. Heniford, B. T., Iannitti, D. A. and Gagner, M.: Laparoscopic inferior and superior lumbar hernia repair. Arch Surg, 132: 1141, 1997 7. Arca, M. J., Heniford, B. T., Pokorny, R. et al: Laparoscopic repair of lumbar hernias. J Am Coll Surg, 187: 147, 1998 8. Bickel, A., Haj, M. and Eitan, A.: Laparoscopic management of lumbar hernia. Surg Endosc, 11: 1129, 1997 9. Burick, A. J. and Parascandola, S. A.: Laparoscopic repair of a traumatic lumbar hernia: a case report. J Laparoendosc Surg, 6: 259, 1996 10. Pul, M., Pul, N. and Gurses, N.: Congenital lumbar (GrynfeltLesshaft) hernia. Eur J Pediatr Surg, 1: 115, 1991 11. Alves, A., Jr., Maximiano, L., Fujimura, I. et al: Grynfelt hernia. Arq Gastroenterol, 33: 32, 1996 12. Bolkier, M., Moskovitz, B., Ginesin, Y. et al: An operation for incisional lumbar hernia. Eur Urol, 20: 52, 1991