Hybrid surgery is a procedure in which laparoscopic and open surgical steps are used for a better outcome to the patient. The aim of this study is to identify the factors that necessitated hybrid surgery in cases of hernia.

Materials and Methods:

It is a retrospective narrative study of 69 patients with hernia, who underwent hybrid surgery. Deciding factors and outcomes were analysed. Results: Of the 69 cases, 32 were open surgery followed by laparoscopy (OL)/open surgery followed by laparoscopy and then by open surgery again (OLO) and 37 were laparoscopy followed by open surgery (LO)/laparoscopy followed by open surgery and then by laparoscopy once more (LOL). Incorporating laparoscopic steps during open surgery helped in combining multiple surgeries, intra-abdominal adhesiolysis, etc., without enlarging the incision. Open surgical steps incorporated during laparoscopy, helped in reduction of irreducible hernia, darning of defects from outside, etc., Ventral hernia with apron and need for combining other surgeries had an association with OLO (P < 0.001). Inguinal hernia or ventral hernia without apron, irreducibility and need for omentectomy had an association with LO/LOL (P < 0.001). Factors having statistically significant association with sandwich repair were large defect size, multiple previous open surgeries, presence of precipitating factors and recurrent hernias.

Conclusion: Hybrid surgery offers definite benefits in select cases of hernias. Case-to-case planning is needed preoperatively and should be based on the difficulties anticipated. It will help the surgeon perform a safe procedure.

Keywords:

Hernia repair, hybrid, laparoscopy, laparoscopy followed by open surgery and then by laparoscopy once more, open surgery followed by laparoscopy and then by open surgery again

Introduction

Hernia is a very common disease which can be managed successfully with open surgery or laparoscopy. In a subgroup of patients, both open and laparoscopic surgical steps are combined for a desirable outcome.^[1] Such procedures are grouped under the umbrella term, ‘hybrid surgery’, for example, simultaneous laparoscopic cholecystectomy and open ventral hernia repair. A hybrid surgery where both laparoscopic and open surgical steps are applied for hernia repair alone is called a hybrid hernia repair.^[1] Hybrid surgery is not an on-table decision or laparoscopy converted to open because of difficulty or a complication. It is a pre-operative decision. In this article, we aim to bring to light our experience in this procedure.

Materials and Methods

It is a retrospective narrative study conducted amongst 69 patients with hernia, who underwent hybrid surgeries by our team during 2009–2019, at two centres. It accounted for 4.7% of the total hernia surgeries performed by us during the specified time period. The procedure was open first or lap first:^[1],[2] open surgery followed by laparoscopy (OL)/open surgery followed by laparoscopy and then by open surgery again (OLO) or laparoscopy followed by open surgery (LO)/laparoscopy followed by open surgery and then by laparoscopy once more (LOL). The rationales for doing hybrid surgery were analysed and grouped. Outcomes were assessed.

Definitions

Sandwich repair

The abdominal wall was augmented on the outer and inner aspect, with mesh on both sides or with mesh on one side and a fascial flap on the other.^[3]

Open-favoured adhesions

In case of adhesions, where open surgery is better and safer than laparoscopy, perform adhesiolysis completely.

Lap-favoured adhesions

In case of adhesions, where laparoscopy is preferable over open surgery due to ease of access, perform visualisation and adhesiolysis. More details are provided in [Table 1].

Table 1: Open-favoured adhesions and lap-favoured adhesions

Defect pattern (open-favoured or lap-favoured defects)

Just like adhesions, defects also are lap favoured or open favoured. The factors that decide defect pattern are (a) size of the defect, (b) number of defects and (c) nature of the surrounding muscles (muscle loss, papery thin muscles and divarication). In laparoscopy, a larger mesh can be kept. However, huge defects (ventral defects >8 cm^[1] and inguinal defects >4 cm) that need plication and darning are better closed through an open incision.^[4] In incisional hernia following renal transplant, some parts of the defect were better covered with a laparoscopically placed large mesh, while a portion over transplanted kidney was better covered with an open onlay mesh. In cases of bilateral inguinal hernia with a small umbilical defect <1 cm, inguinal defects can be better dealt with laparoscopically, while primary closure of the umbilicus, which is used as the primary trocar site, can be done by open technique.

Inclusion and exclusion criteria

All cases of hernias operated by our team using hybrid technique in the specified time period in the two centres were included. Hernia repairs with open technique alone or laparoscopy alone were excluded from the study.

Operative technique

Open surgery followed by laparoscopy

In some cases, there was difficulty in placing the initial trocar. It was due to multiple surgeries in the past resulting in intra-abdominal adhesions or because of obstructed hernia with abdominal distension. We opted for open technique first as trocar placement can be safer under vision. Cases with huge skin apron, badly scarred skin or presence of multiple healed sinuses also needed a skin incision initially. In such cases, although there was no difficulty in laparoscopic trocar placement, the position of trocars can be based on the skin loss and the hernial defect. Trocars placed under the skin flap had better cosmesis, and it did not leave any scar on the exposable area of the abdomen.

A skin incision was made preserving sufficient healthy skin to get a cover and, at the same time, to get a good cosmesis. Sac was opened, adhesiolysis was performed and contents were reduced. Once the peritoneal cavity was reached, the primary trocar was placed under vision or under hand guidance. Hernial defect was temporarily approximated with multiple Allis forceps or a 1-0 polypropylene suture. Then, laparoscopic working ports were placed and laparoscopic surgery was performed.

Laparoscopy helped in combining other surgeries like lysing lap-favoured adhesions, getting a better defect cover with a larger mesh, sandwich mesh repair, placing of mesh laparoscopically in cases where open mesh placement was not possible because of lengthy divarication, with papery thin muscles and very less subcutaneous fat, bridging the gap due to loss of muscle when a large abdominal wall mass was excised or in cases of healed sinuses, scar, colostomy reversal, etc., and reducing the length of incision for open surgery.

After laparoscopic steps are completed, some cases required final open steps. An onlay mesh placement for sandwich repair or darning from outside was performed. Some cases had an apron and required dermolipectomy and creation of neoumbilicus. The skin incisions were then closed. These come under OLO [Figure 1].

Figure 1: Presentation of open surgery followed by laparoscopy and open surgery again at last

Laparoscopy followed by open surgery

Initially, laparoscopic ports were placed. Dissection of hernia was done as much laparoscopically possible. After that, skin over the hernia was incised [Figure 2].

Figure 2: Initial Laparoscopy – Presentation of laparoscopy followed by open

The following steps were better done with open method, tackling of irreducibility and open-favoured adhesions, augmentation of defect closure with suturing or darning of the defect, division of cord structures, sandwich mesh repair, sublay mesh repair or transversus abdominis release, excision and removal of contents/tissues, like devascularised omentum, closure of defect in which the defect pattern favoured open method of repair and excision of the large redundant sac or scar to attain better cosmesis. In some cases, a laparoscopic mesh placement was done after the open procedure. Those cases were grouped under LOL [Figure 3]. Open mesh placement was onlay, sublay, preperitoneal or Lichtenstein’s with polypropylene meshes or partially absorbable meshes. Laparoscopic mesh placement was preperitoneal or intraperitoneal onlay mesh (IPOM) placement, performed using dual meshes or polypropylene meshes.

Figure 3: Presentation of laparoscopy followed by open surgery and again laparoscopy at last

Statistical analysis

Descriptive statistics were used to assess the baseline characteristics of the data. Qualitative variables such as gender, type of surgery, precipitating factors, recurrent hernias and apron were presented as frequency and percentages. Quantitative variables such as age and defect size were presented in mean and standard deviation. For the association of qualitative variables, either Chi-squared test or Fisher’s exact test (if cell values are <5 or zero) was used. Continuous variables were compared using Mann–Whitney U-test. A value of P < 0.05 was considered statistically significant. All data were entered in Microsoft Excel and analysed using SPSS version 20 (IBM SPSS Statistics, Software version 10.0, USA, 2020).

Results

Amongst 69 patients with hernia who underwent hybrid surgeries, 42 (61%) cases were ventral hernia repairs, 22 (32%) were inguinal hernia repairs and 5 (7%) were combined ventral and inguinal hernia repairs. The age ranged from 4 to 85 years, with an average of 48.30 ± 15.77 years. There were 34 males and 35 females. M: F was 3:11 for ventral hernia and 21:1 for inguinal hernia (P < 0.001). Sixty-eight (98.55%) patients complained of abdominal swelling. Sagging of the abdomen or apron was complained of by 29 (42.03%) patients. Pain was complained by 21 (30.43%) patients. Ulceration of skin was seen in one case.

The body mass index varied from 16 to 42 kg/m² and the average body mass index was 26.53 ± 5.23 kg/m². Out of the 69 cases, 2 (2.90%) were underweight, 28 (40.58%) were normal weight and 26 (37.68%) were pre-obese. Thirteen cases (18.84%) were obese (obesity class I – 9 cases, obesity class II – 2 cases and obesity class III – 2 cases). Other precipitating factors were lower urinary tract symptoms (LUTS) in 9 (13.0%) cases, respiratory illness in 6 (8.69%) cases and constipation in 1 case. LUTS were more with inguinal hernia (P = 0.001). Chronic respiratory illness also was more with inguinal hernia, and obesity was more with ventral hernia, but these were not significant (P = 0.237 and P = 0.114, respectively). Precipitating factors were absent in 43 (62.32%) cases.

Thirty-two patients had a history of previous abdominal surgeries. Thirty cases had undergone open surgeries, of which 12 had 1 open surgery, 15 had 2 open surgeries and 3 had 3 or more abdominal surgeries. Six cases had undergone laparoscopic surgeries, of which five had one laparoscopic surgery and one patient had two laparoscopic surgeries. Four patients had both open and laparoscopic surgeries. Thirteen (18.84%) cases were recurrent hernias: 1 lap recurrence and 12 open recurrences. Of these 12 open recurrences, 9 were first recurrence, 2 were second recurrence and 1 was third recurrence.

Twenty-five (36.23%) patients had other surgeries combined along with hernia repair. Such cases included nine cholecystectomies, nine tubal ligations, three sleeve gastrectomies, two appendectomies, two total laparoscopic hysterectomies, two ovarian cystectomies, one excision of appendices epiploicae and one orchidectomy for undescended testis.

Of the 69 cases, 32 (46.38%) were OL/OLO and 37 (53.62%) were LO/LOL. Of OL/OLO, all 32 cases were OLO. Of LO/LOL, 8 cases were LO and 29 were LOL.

The defect size varied from 1 to 13 cm (mean: 4.47 ± 3.20 cm) for ventral defects and 0.5–8 cm (mean: 3.88 ± 1.88 cm) for inguinal defects. Defect size and need for darning for defect closure were associated with both types of hybrid surgeries (defect size: ventral: P = 0.024, inguinal: P = 0.022 and darning: P = 0.013). Defect size was an important factor in deciding sandwich repair also. In ventral hernia, the average defect size was 9.60 ± 2.30 cm in the sandwich group while 3.93 ± 2.72 cm in the non-sandwich group which is found to be significant (P = 0.003). In inguinal hernia, the average defect size was 4.83 ± 0.753 cm in the sandwich group while 3.71 ± 1.90 cm in the non-sandwich group (P = 0.167). Ten (14.5%) cases had sandwich repair. Types of sandwich repair performed were open onlay + laparoscopic IPOM in three cases, open onlay + laparoscopic preperitoneal repair in one case, open onlay + open sublay in one case and open fascial flap + open sublay in one case for ventral hernias, open Lichtenstein’s repair + laparoscopic preperitoneal repair in two cases and open Lichtenstein’s repair + open preperitoneal repair in two cases for inguinal hernias. The frequency and correlation of factors necessitating hybrid surgery are given in [Table 2] and [Table 3], respectively.

Table 2: Frequency table of factors deciding hybrid surgery

Table 3: Factors deciding hybrid surgery, correlation with type of surgery and sandwich

The duration of post-operative hospital stay varied from 1 to 7 days, with an average of 2.66 ± 1.19 days. Two patients had extended hospital stay due to immediate post-operative complications. One had severe cough followed by haematoma scrotum, necessitating exploration. The other had paralytic ileus for 2 days, which was managed conservatively. At the time of 1-month follow-up, two patients were found to have seroma and one patient had delayed wound healing. No complications were observed at the follow-up assessment at 1 year. The follow-up varied from 1 to 10 years, with an average of 5.21 ± 3.16 years.

Discussion

Laparoscopic surgery has definite advantages over open surgeries. Literature describes lesser morbidity (in terms of sepsis and pain) and mortality and shorter hospital stay with laparoscopy. It also has a lesser chance of seroma and wound-related issues and lesser mesh-related issues. Patients are more satisfied because of earlier return to work. A larger mesh can be placed.^{[1],[4],[5],[6]} In select cases, open surgery surpassed laparoscopy, when associated with large defects, unsightly scars or aprons and massive adhesions.^[1],[4] Some cases needed open surgical steps along with laparoscopic steps. These cases accounted for 4.7% of total hernia cases operated by us. Other studies show the incidence around 10%.^[1]

In open-first technique (OL/OLO), the open surgery was performed initially for one of these reasons; apron: in cases of ventral hernia with a large apron, we raised the flap and placed the trocars. This avoided scars in the umbilical and supraumbilical regions.^[7] Association of apron and OLO was found to be statistically significant, dense adhesions expected at the site of laparoscopic entry: in patients with history of enterocutaneous fistulas, three or more laparotomies, post-operative wound site infections and mesh rejection; dense adhesions need to be expected.^[1],[7],[8] Incision was made over the hernia to reduce the contents, and trocars were placed under direct vision. This group comprised 16 (23.19%) cases in this study and badly scarred skin or presence of multiple healed sinuses.^[7],[8] In four cases, we opted for excision of the scar first, as trocar placement could be planned based on the skin loss and the hernial defect. In cases of obstructed hernias, abdominal distension may make the primary trocar placement unsafe. Incision needs to be made over the hernia and contents to be reduced after ensuring bowel vascularity. Trocars are placed under direct vision. We did not have such cases in this series. Combining laparoscopy helped in combining other surgeries, adhesiolysis (lap-favoured adhesions) and mesh sandwich repair and reducing the length of incision of open surgery. Adhesiolysis and reduction of open incision, when laparoscopy is combined with open surgery, is discussed in other studies.^[7],[9] These are in addition to the already known advantages of laparoscopy.

In lap-first technique (LO/LOL), we noticed that combination of open method was helpful in tackling open-favoured adhesions. Laparoscopic mesh was augmented by the following open methods: defect closure from outside, darning, fascial flap, component separation or sandwich mesh. Examination of contents, removal of contents or tissues which were excised and excision of redundant sac were also better carried out in an open manner. During hernia repair, the following procedures were also done when necessitated: omentectomy, fat excision, orchidectomy for undescended testis, subcutaneous peritoneal cyst excision and prolene sinus excision. Adhesiolysis and augmentation of repair were reported in other studies also.^[7],[8]

Ventral hernia with an apron and a need for combining other surgeries was significantly associated with OLO. Ventral hernia without an apron, but having irreducibility, need for omentectomy and need for darning for defect closure, was significantly associated with LO. Inguinal hernia with irreducibility and need for omentectomy was significantly associated with LOL. Large defects needed darning from outside for defect closure by hybrid method. Factors such as large redundant sac, obesity, multiple previous abdominal surgeries, recurrent hernias and presence of multiple precipitating factors were also noticed in hybrid surgery, but the association was not statistically significant (P > 0.05).

Sandwich mesh repair was done in cases where higher chance of recurrence was expected. These included cases with large defects (ventral defects >8 cm and inguinal defects >4 cm), multiple previous open surgeries, presence of precipitating factors and recurrent hernias. It is in accordance with the general recommendations based on the literature review.^[3]

Two features of the defect need to be assessed: defect size and defect pattern. Defect size as a criterion for decision-making for ventral hernia is discussed in the literature^[10],[11] and in our study. Another important factor which we felt worth considering was the pattern of the defect importantly observed in nine cases.

There are various studies comparing laparoscopy and hybrid surgery. Post operative seroma, protrusion of mesh, complex adhesiolysis and pain scores were lesser in the hybrid group.^{[2],[7],[11],[12]} Hybrid repair also reduces recurrence rates.^[13] In our study, although comparison with laparoscopy alone or open alone was not available, outcomes were good and no major untoward incident was noted.

Practical difficulties

The most commonly encountered difficulty was lack of space either due to gas leak or restriction following darning in abdominoplasty. When laparoscopy was done after making an open incision, air leak happened. Allis forceps were applied, approximating the defect to reduce this problem. In some cases, we need to switch between laparoscopy and open surgery multiple times. Hence, wall closure was deferred till the completion of all other steps. For the same reason, mesh placement was done towards the end of the procedure. In cases of abdominoplasty, when plication was done initially, we had difficulty in mesh placement due to crumbled fascia. If plication was done after the laparoscopic placement of mesh, it led to crumbling of mesh. In both the methods, difficulties need to be anticipated and procedure to be done with a case-to-case assessment.

Conclusion

Hybrid surgery offers definite benefits in select cases of hernias. Hybrid surgery was performed in patients having ventral hernias with apron, lax abdomen, irreducibility, large defect or when there was a need to combine other surgeries. Inguinal hernias with irreducibility or large defects were tackled with hybrid surgeries to have better results. Case-to-case planning is needed preoperatively and should be based on the difficulties anticipated. It will help the surgeon in performing an excellent procedure and give a better outcome to the patient.

Acknowledgements

We are thankful to Mr. Subin Thomas for language editing and grammar corrections, Ms. Anithadevi T S for the data analysis and Mr. Dipin Prakash and Mr. Maneesh for data entry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

The post Hybrid surgery in hernias: Our experience appeared first on Dr. R. Padmakumar.

Patient Selection for TAPP Inguinal Hernia Repair

Difficult cases:

• Indirect hernial sacs are closely applied to the cord structures and are more often complete, making dissection difficult.
• Left-sided hernias are more difficult to dissect than the right-sided ones for a beginner.
• Recurrent hernias and irreducible hernias.
• Obese patients.

Direct or small indirect primary hernias in lean and thin subjects are the best during learning curve.

Anesthesia

General anesthesia

Skin Preparation

No studies are there assessing preparation for hernia surgery, but as with other surgical procedures, there is no difference in surgical site infections (SSI) in preparation and no preparation group. In
our centre, we prepare skin of all male patients before surgery.

Catheterization of the patient

The patient is asked to pass urine just before shifting him to the operation theater. Predisposing factors for an injury are a full bladder or a previous exposure of the retropubic space, particularly after prostate interventions, irradiation, or in case of huge or recurrent hernias (16). If the patient has any of these factors, Foley’s indwelling catheter is placed prior to surgery. It may be removed the next morning.

Antibiotic prophylaxis

Hernia repair is considered a clean surgery (infection rate <2%). With age >75 years, obesity, urinary catheter, recurrent hernia, diabetes, immunosuppressant/ corticosteroid usage, and malignancy, infection rate rises to 14%(17). In endoscopic repair, antibiotic prophylaxis does not significantly reduce the number of wound infections- level 2B evidence. In the presence of risk factors for wound infection based on patient factors (recurrence, advanced age, immunosuppressive conditions) or surgical factors (expected long operating times, use of drains), the use of antibiotic prophylaxis should be considered – Grade C recommendation. But in our center, preoperative prophylactic antibiotics are administered (ceftriaxone & sulbactam at induction and tobramycin two hours prior) for all.

After induction of anesthesia, irreducible hernial contents, if any, are reduced if possible before painting & draping is commenced.

The patient lies supine with both arms tucked by the side, to make room for the surgeon and his assistant to stand at shoulder level. The monitor is positioned at the foot end of the patient. The operating surgeon stands on the side opposite to hernia. The assistant, who holds the camera, stands on the side of hernia or behind the surgeon. The scrub nurse positions herself to the left of the patient, to the left of the surgeon.

Pneumoperitoneum and placement of ports

Open umbilical or Palmer’s point entry: Direct open entry with blunt trocar is as safe as Veress needle entry, level 1B evidence.

A vertical umbilical incision is made. The abdominal wall is lifted up and stabilized with one hand and the 10-mm blunt trocar is directed towards the hollow of the pelvis. A 0 degree telescope attached to the camera is introduced and the entry point inspected. The head end of the table is kept 20-300 low to facilitate movement of the bowel away from the operative field. The groin area is then visualized. Two 5-mm ports are placed as working ports for the right and left hand of the surgeon, one on each side, at the level of umbilicus in the midclavicular line. These ports should be placed under vision to prevent injury to the inferior epigastric vessels and underlying bowel. The telescope is now changed to 30 degrees for better view.

The hernia defect is inspected and the type of hernia (direct or indirect) is confirmed by the position of defect in relation to the inferior epigastric vessels and cord structures. The spermatic vessels will be seen laterally and the vas deferens medially and they meet at the internal ring (round ligament instead of vas deferens in female). This forms an inverted V. The inferior epigastric vessels (IEV) can be seen coursing upwards from this point. A direct hernia is medial to the IEV. An indirect hernia is lateral to the IEV.

Fig.3.3- TAPP Inguinal Hernia Repair – Anatomical landmarks, right side, indirect defect

Fig. 3.4 – TAPP Inguinal Hernia Repair – Direct hernia, left side.

All the anatomical landmarks normally seen before peritoneal reflection are identified. These include the median umbilical ligament in the midline, the medial umbilical ligaments on each side and the lateral umbilical ligaments. Contents of the hernial sac, if any, are reduced with the help of atraumatic bowel forceps. In case of irreducible hernias, the bowel contents need to be handled with care. In case of omentum, it may be reduced or excised and removed via 2-cm scrotal incision.

Operative Steps

Step 1– Incising the peritoneum

The peritoneal incision is begun at a point that is midway between the groin crease and the umbilicus, generally about 4-5 cm above all the defects. It may be worth marking the line of proposed peritoneal cut using an energy source so as to avoid coming closer to the defect later.  Incision on the peritoneum is made from medial to lateral i.e. from right side to the left on the left side and from left side to right on the right side. Scissors, monopolar hook, or harmonic scalpel can be used for the dissection. It extends from the medial umbilical ligament to the paracolic gutter. Extending it medially beyond the medial umbilical ligament may increase the chances of injury to the urinary bladder, particularly if the urinary bladder is not empty especially if the peritoneal cut is not placed towards umbilicus.

Step 2 – Raising the peritoneal flap

The correct plane of dissection of the peritoneal flap from the transversus muscle is anterior to the preperitoneal fascia through the loose areolar tissue, i.e. in the space of Bogros. The flap is raised by both blunt and sharp dissection. Generally, the plane is avascular, but any small vessel is carefully cauterized before division.

Care should be taken to avoid injury to the inferior epigastric vessels (IEV) while raising the peritoneum medial to the internal ring. These vessels should always be left attached to the muscle and should never be included in the flap. Otherwise, they may come in the way of dissection and may get injured. The plane of dissection is easier on the medial side and blunt dissection is sufficient since the areolar tissue is loose and the peritoneum is not adhered to the rectus muscle. On the medial side, continued caudal dissection will identify the shiny Cooper’s ligament and the pubic bone. Laterally, the peritoneum is slightly adhered to the transversus muscle, and sharp dissection may be required. Take care not to get into the plane of muscles.

In case of local omental or intestinal adhesions to the peritoneum of the groin, it is not recommended to perform adhesiolysis in general, unless it obstructs the view. In sliding hernias or even irreducible hernias, neither adhesiolysis nor reduction is mandatory, but the straightforward preperitoneal dissection should be performed. This facilitates the mobilization of hernia content within the sac and helps to avoid intestinal injury.

Step 3 – Dissection of medial peritoneum and direct sac

Dissection is continued medially to the pubic symphysis to visualize the cave of Retzius. The medial dissection should go across the midline to the opposite side, up to opposite IEV; so that the mesh can be placed with a good overlap over the defect. A direct defect is encountered medially above the iliopubic tract. The direct sac can be easily pulled inside along with essentially thinned out fascia transversalis identified by its glistening appearance and belongs to the parietal wall, i.e., pseudosac. With sharp and blunt dissection, sac is separated from pseudosac (a push pull technique).  In case of large direct hernias, after reducing the sac, the dome of the pseudosac can be fixed to the rectus muscle over the pubic bone with a few tacks to prevent postoperative seroma formation and also helps to have a base for the mesh, Level 2B evidence (18).

Step 4 – Lateral dissection

After the medial dissection, the flap is raised lateral to the internal ring till the anterior superior iliac spine is reached and it is carried posteriorly over the psoas muscle. Care is taken during this dissection to avoid injury to the nerves overlying the psoas muscle namely lateral cutaneous nerve of the thigh laterally and the femoral branch of the genitofemoral nerve medially.

Retroperitoneal area lateral to the cord structures on the left side. The lateral cutaneous nerve of the thigh (1) and the femoral branch of the genitofemoral nerve (2) can be seen coursing on the psoas muscle (3). Both the nerves enter the thigh below the iliopubic tract (4).

The post TAPP INGUINAL HERNIA REPAIR appeared first on Dr. R. Padmakumar.

Ramakrishnapillai Padmakumar1, Aravind Balakrishnan2, Madhukara Pai3, Kevin J Chiramel4, Farish Shams5, Premna Subin6

Abstract

Aim and objective: To show the advantage of endoscopic approach for lateral ectopic thyroid removal.

Background: Ectopic thyroid tissue lateral to midline is very rare. Because of its unusual location, lateral ectopic thyroid gland can cause diagnostic difficulties when diseased.

Case description: Here we are presenting a case of a male patient with submandibular ectopic thyroid tissue with multinodular goiter and absent thyroid tissue in normal anatomic site. He underwent endoscopic-assisted total thyroidectomy (endoscopic thyroidectomy). This technique for ectopic thyroid removal has not been reported in the literature so far.

Conclusion: Endoscopic approach for removal of the diseased gland will allow for a magnified view of the adjoining structures and better cosmesis for the patient.

Clinical significance: Lateral ectopic thyroid should be in differential diagnosis of lateral neck swelling.

Keywords: Ectopic thyroid, Endoscopic, Endoscopic thyroidectomy, Minimal access surgery, Submandibular region, Endoscopic Ectopic Thyroidectomy.

Background

Ectopic thyroid tissue usually occurs in the midline and that too most commonly in cervical region (lingual 90%).1–4 Its prevalence is approximately 1/100,000 to 1/300,000.5 The remaining ectopic thyroid glands (10%) can be found in infrahyoid, submandibular, prelaryngeal, mediastinum, esophagus, heart, diaphragm, and parapharyngeal regions. In most of the cases, the ectopic thyroid gland will be the only functioning gland. Ectopic thyroid tissue lateral to midline is very rare. These lateral ectopic thyroid tissues when diseased may lead to difficulty in diagnosis due to its unexpected location. Here we are going to present a case of a male patient with submandibular ectopic thyroid tissue with multinodular goiter and absent normal tissue in normal anatomic site. He underwent endoscopic-assisted total thyroidectomy. This technique for ectopic thyroid removal has not been reported in literature so far.

Case Description

A 58-year-old male patient presented to our department with complaints of a swelling in the upper neck on left submandibular region for about 6 months.

It was associated with rapid increase in size. There were no other associated symptoms. On examination, a 5 × 3 cm painless swelling was noted in the left submandibular region. The lump was soft in consistency. Thyroid tissue was not palpable in the normal anatomical location (Fig. 1).

Ultrasonography revealed a well-circumscribed heterogeneously hyperechoic nodule in the left submandibular region with absent thyroid gland in the thyroid bed—possibly ectopic thyroid nodule. Fine-needle aspiration biopsy of the swelling was taken which revealed colloid goiter. Thyroid scintigraphy revealed an area of increased radionuclide uptake in the submandibular region and no radionuclide uptake was seen in the neck in the thyroid bed.

Preoperative thyroid hormones and biochemical tests were normal. As gland was enlarging rapidly in size, endoscopic-assisted complete removal of ectopic thyroid tissues was done under general anesthesia. Initially, the gland was approached from left axillary breast ports. We dissected the gland from the surrounding tissues by endoscopic method. For retrieval of specimen, we put a small skin incision in the submandibular region and the specimen was removed in toto (Fig. 2). This helped in significantly minimizing the scar in cervical region.

Postoperative period was uneventful, and he was discharged on third postoperative day. Thyroxine 100 μg was started, as there was no other functioning thyroid gland. Histopathology report showed
features consistent with multinodular colloid goiter.

Fig. 1: Extended neck showing submandibular ectopic thyroid gland

Fig. 2 – Ectopic thyroid in relation with surrounding structures

Discussion

Ectopic thyroid in the submandibular region was first described by Helidonis et al.6 They speculated that the ectopic thyroid has a parahyoid location and because of its dimension resembled a submandibular gland anomaly. Abnormalities of thyroid gland during embryologic development and migration may result in ectopic thyroid gland. Normally, migration of the thyroid gland is from the foramen cecum to the pretracheal position.7 In addition to normal migration pathway of the thyroid gland, ectopic thyroid tissue can be seen even in mediastinal, intracardiac, gastrointestinal, and intraperitoneal locations.4,8,9 Ectopic thyroid tissue is mostly (90%) localized in sublingual position.

Asymptomatic ectopic thyroid tissue may become symptomatic, particularly in the adolescence and pregnancy period due to increase in thyroid-stimulating hormone level and due to thyroid tissue hyperplasia.10,11 All diseases that involve thyroid tissue in its normal location can also involve ectopic thyroid tissue. The differential diagnosis should include thyroglossal duct cyst, hyperplastic lymphoid tissue, lymphangioma, fibroma, lipoma, dermoid cyst, squamous cell carcinoma, minor salivary gland tumor, lymphoma, and vascular tumors.12,13

Ultrasonography (USG), scintigraphy, computerized tomographic scan (CT), and magnetic resonance imaging (MRI) are the methods that can be used in the diagnosis. Thyroid scintigraphy is a sensitive and specific method in determining that thyroid gland is not in its normal location.13 USG and CT are beneficial in the diagnosis but have low sensitivity and specificity. In MRI, ectopic tissue is observed to be iso- or hyperintense compared to muscles. 13 In addition to imaging of the normal thyroid tissue, thyroid
scintigraphy is also important to show the functions of the lingual thyroid tissue. In our case, we performed USG followed by FNAC and then thyroid scintigraphy was performed for confirmation of our diagnosis. All the surgeries performed for lateral ectopic thyroid so far has been by open method. We performed an endoscopic assisted total thyroidectomy which has not been reported in literature so far. Endoscopic approach for removal of the diseased thyroid gland will give a magnified view of the adjoining structures and better cosmesis for the patient.

Conclusion

Lateral ectopic thyroid tissue is a very rare condition of which most common site is in submandibular location. Endoscopic approach for removal of the diseased ectopic gland has not been reported earlier. The procedure is very safe and gives a much better cosmetic outcome.

References

1. Zieren J, Paul M, Scharfenberg M, et al. Submandibular ectopic thyroid gland. J Craniofac Surg 2006;17(6):1194–1198. DOI: 10.1097/01. scs.0000246502.69688.60.
2. Choi JY, Kim JH. A case of an ectopic thyroid gland at the lateral neck masquerading as a metastatic papillary thyroid carcinoma. J Korean Med Sci 2008;23(3):548–550. DOI: 10.3346/jkms.2008.23.3.548.
3. Huang TS, Chen HY. Dual thyroid ectopia with a normally located pretracheal thyroid gland: case report and literature review. Head Neck 2007;29(9):885–888. DOI: 10.1002/hed.20604.
4. Aköz T, Erdogan B, Ayhan M, et al. Ectopic submandibular thyroid tissue. Rev Laryngol Otol Rhinol (Bord) 1998;119(5):323–325.
5. Akanmu IN, Adewale OM. Lateral cervical ectopic thyroid masses with eutopic multinodular goiter: an unusual presentation. Hormones (Athens) 2009;8(2):150–153. DOI: 10.14310/horm.2002.1232.
6. Helidonis E, Dokianakis G, Papazoglou G, et al. Ectopic thyroid gland in the submandibular region. J Laryngol Otol 1980;94(2):219–224. DOI: 10.1017/S0022215100088708.
7. Yılmaz MS, Aytürk S, Güven M, et al. Submandibular ectopic thyroid with normally located thyroid gland. Kulak Burun Bogaz Ihtisas Derg 2014;24(1):50–53. DOI: 10.5606/kbbihtisas.2014.41713.
8. Feller KU, Mavros A, Gaertner HJ. Ectopic submandibular thyroid tissue with a coexisting active and normally located thyroid gland: case report and review of literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90(5):618–623. DOI: 10.1067/moe.2000.108804.
9. Kanaya H, Tanigaito Y, Shyono N, et al. A rare case of ectopic, normally functioning thyroid tissue presenting as a left submandibular mass. Nippon Jibiinkoka Gakkai Kaiho 2005;108(9):850–853. DOI: 10.3950/jibiinkoka.108.850.
10. Kurukahveciŏglu S, Arslan H, Kocatürk S, et al. Ectopic thyroid gland at infrahyoid localization: case report. Kulak Burun Bogaz Ihtis Derg 2007;15(2):87–90.
11. Bersaneti JA, Silva RDP, Ramos RRN, et al. Ectopic thyroid presenting as a submandibular mass. Head and Neck Pathology 2011;5(1):63–66. DOI: 10.1007/s12105-010-0209-z.
12. Prado H, Prado A, Castillo B. Lateral ectopic thyroid: a case diagnosed preoperatively. Ear, Nose Throat J 2012;91(4):E14–E18. DOI: 10.1177/014556131209100417.
13. Çeliker M, Çeliker FB, Turan A, et al. Submandibular lateral ectopic thyroid tissue: ultrasonography, computed tomography, and scintigraphic findings. Case Rep Otolaryngol 2015;2015:769604. DOI:
    10.1155/2015/769604.

1–4Department of General and Laparoscopic Surgery, VPS Lakeshore Hospital and Keyhole Clinic, Kochi, Kerala, India

5,6Department of Laparoscopic Surgery, Verwandeln Institute, Kochi, Kerala, India

Corresponding Author:

Ramakrishnapillai Padmakumar,
Department of General and Laparoscopic Surgery,
VPS Lakeshore Hospital and Keyhole Clinic, Kochi, Kerala, India,
Phone: +91 9447230370, e-mail: drrpadmakumar@gmail.com

How to cite this article:
Padmakumar R, Balakrishnan A, Pai M, et al. Endoscopic Ectopic Thyroidectomy. World J Lap Surg 2020;13(3): 136–137.

Source of support: Nil
Conflict of interest: None

The post Endoscopic Ectopic Thyroidectomy appeared first on Dr. R. Padmakumar.

Padmakumar R, Chiramel KJ, Pai M, Shams F, Subin P. Management of polycythemia vera by endoscopic parathyroidectomy. J Appl Hematol [serial online] 2020 [cited 2020 Nov 20];11:204-7.

Available from: https://www.jahjournal.org/text.asp?2020/11/4/204/300771

Contents

1. Abtract
2. Introduction
3. Case Report
4. Outcome
5. Discussion
6. Conclusion
7. References

Abstract

Polycythemia vera (PV) is a hemotologic disease. Majority of persons with Polycythemia vera, essential thrombocythemia and primary myelofibrosis show the Janus kinase (JAK) 2 gene– which is needed for the normal development of blood cells. Polycythemia vera is generally controlled with medication: hydroxyurea or pipobroman. Phlebotomy is the mainstay of therapy for PV. Association between hyperparathyroidism and PV has been very sparingly considered. Primary hyperparathyroidism may produce a growth factor, which induces pancytosis, especially in the presence of high levels of ionized calcium. It is found that parathyroid hormone levels (PTH) could influence hemopoiesis through a direct action on hemopoietic precursors. A 52-year-old female presented with complaints of fever associated with headache and generalized weakness.

On evaluation, her hemoglobin value was found to be high (Hb– 18.8 g/dl) with leukocytosis. She was evaluated for polycythemia vera, which showed JAK-2 mutation positivity. She was started on Enteric Coated Aspirin. She was managed initially with twice-weekly venesection to keep packed cell volume <45. It was observed that she was having very high PTH– 569.9 pg/ml and low Vitamin D levels– 8.41 mg/ml. She underwent a Technetium 99M Sestamibi Scan (TcMIBI), which showed a large adenoma involving the left inferior parathyroid gland. She was taken up for endoscopic parathyroid removal through the left axillo-breast approach. Intraoperatively, PTH value had dropped from 569.9 pg/ml to 62 pg/ml. Hemoglobin level decreased to normalcy by the 2^nd week of surgery without any medication or venesection.

Patients with polycythemia vera must be screened for hyperparathyroidism. Early treatment of hyperparathyroidism by parathyroid removal will take care of polycythemia vera as well. Endoscopic parathyroidectomy is very feasible, safe, and well accepted by patients.

Keywords: Hyperparathyroidism, Janus kinase-2 mutation, parathyroid adenoma endoscopic parathyroidectomy, polycythemia vera

Introduction

Polycythemia vera (PV) is a hemotologic disease. In Polycythemia vera, hyperviscosity results from the increased red cell count. The associated increase in white cells and platelets can lead to headache, fatigue, and other symptoms. Thrombus formation of artery or vein may also be a feature. Majority of persons with PV, essential thrombocythemia (ET) and primary myelofibrosis show Janus kinase (JAK) 2 gene, which is needed for the normal development of blood cells. The presence of JAK-2 distinguishes the above disorders from other myeloproliferative disorders (MPD). Hence, it avoids the use of chemotherapeutic agents currently employed in the treatment of MPD.^[1] The identification of JAK-2 and increased RBC are the two significant components of making a diagnosis of PV. Ninety-five percent of Polycythemia vera cases show JAK-2 V617F. Other JAK–2 mutations located in axon 12 can be detected in 2%–5% of cases. JAK-2 V617F mutation-positive patients respond well to treatment compared to mutation-negative patients.

Phlebotomy is the mainstay of therapy for PV. It is done with the aim of keeping the packed cell volume (PCV) <45% in males and 42% in females. It is done with the aim of reducing problems associated with erythrocytosis. The administration of aspirin is advised to reduce ocular migraine and microvascular complications.

High calcium level in polycythemia vera is generally believed to have a link with malignancies such as renal cell carcinoma. High red cell volume can also be induced by chronic lung disease, stenosis of the renal artery, hydronephrosis, chronic smoking, and hepatocellular carcinoma. The link of hyperparathyroidism to polycythemia vera is generally not thought off. There is some functional relationship between parathyroid hormone levels (PTH), osteoblastic and osteoclastic activity as well as hematopoiesis.

Primary hyperparathyroidism generally results from an adenoma, hyperplasia, or carcinoma of parathyroid glands; that may require surgical intervention. The classical biological signs of hyperparathyroidism are hypercalcemia, hypophosphatemia, increased PTH in blood, and increased cyclic adenosine monophosphate urinary elimination. The parathyroid tumor may produce a growth factor which induces pancytosis, especially in the presence of ionized hypercalcemia. Hemopoietic precursors may be directly influenced by PTH, resulting in hemopoiesis. Moderate levels of PTH can induce hematopoiesis but maybe inhibitory at a high concentration. We are presenting a case of polycythemia vera associated with primary hyperparathyroidism due to parathyroid adenoma.

Case Report

A 52-year-old postmenopausal female presented with complaints of fever associated with headache and generalized weakness. She was on treatment for systemic hypertension with telmisartan, chlorthalidone, and nifedipine. On evaluation, her hemoglobin value was found to be high (Hb– 18.8 g/dl) with neutrophilic leukocytosis and mild lymphocytosis. Peripheral smear showed normocytic normochromic blood picture with erythrocytosis. The Serum iron level was 65 mcg/dL. She was evaluated for polycythemia, which showed JAK-2 mutation positivity. She was started on enteric coated aspirin.

Elevated uric acid (10.2 mg/dL) and calcium (13.53 mg/dL) were initially taken as part of polycythemia. But when it increased to 13 and 14.9, respectively, she was evaluated in detail for any parathyroid pathology. It was observed that she was having very high PTH– 569.9 pg/ml and low Vitamin D levels (25-OH Vit. D)– 8.41 mg/ml.

She did not have any bone pain or features of stone diseases. She underwent a Technetium 99M Sestamibi Scan (TcMIBI) double phase parathyroid scintigraphy, which showed large adenoma involving the left inferior parathyroid gland, later confirmed with ultrasound. USG abdomen was unremarkable.

She was managed initially with twice-weekly venesection of 350 ml to 400 ml to keep PCV <45. She was then referred to our department to proceed with endoscopic parathyroidectomy. She was taken up for endoscopic parathyroid removal through the left axillo-breast approach under general anesthesia.

The procedure of endoscopic parathyroidectomy through axillo-breast approach is performed in the following manner. A 10-mm trocar was placed on the anterior axillary fold to introduce the telescope. In the beginning, the telescope aids in dissecting the space. Later, it shows the structure with magnification and delineation. Two working ports of 5 mm were placed in the subplatysmal area. This will expose the sternocleidomastoid and sternohyoid muscles.

The plain medial to the sternocleidomastoid (lateral to the strap muscles) was opened to expose the left lower lobe of the thyroid and the nearby parathyroid adenoma. A large left inferior parathyroid gland adenoma was identified. By blunt dissection, the parathyroid adenoma was mobilized, safeguarding the recurrent laryngeal nerve. The parathyroid vessels were sealed and divided using ultrasonic device. The gland was placed in a custom made endobag and removed in toto through the 10-mm trocar. The drainage tube was placed, and subcuticular closure was performed [Figure 1]. The parathyroidectomy specimen was given for histopathological assessment. Intraoperatively, PTH value had dropped from 569.9 pg/ml to 62 pg/ml. Her course in the hospital was uncomplicated.

Figure 1: Incisions for Endoscopic Parathyroidectomy on left side

HPE revealed a 3.5 cm × 3 cm × 2 cm parathyroid adenoma weighing 5 g. It had mitosis <1/10 HPF. The capsule was intact, and there was no capsular invasion [Figure 2].

Figure 2: Low power view showing perivascular arrangement of tumor cells

Outcome

Her wounds healed well with minimal scarring and the symptoms at the presentation– headache and weakness disappeared. Hemoglobin level decreased to normalcy by the 2^nd week of surgery. Antihypertensives were reduced to single drug– Telmisartan (compared to three drugs preoperatively). Six months following surgery, the PTH value is 28 pg/mL, serum calcium is 9.1 mg/dL, and Hb is 14.3 g/dL. She is continuing the enteric-coated Aspirin– 75 mg once daily.

Discussion

Chronic myeloproliferative neoplasms (CMPNs) are diseases of clonal multipotent stem cells. The four classical subgroups are: chronic myeloid leukemia, primary myelofibrosis (PMF), PV, and ET. Almost all patients having PV, 60%–65% of patients with ET have JAK2 V617F point mutation. JAK2 mutations cause hypersensitivity in hematopoietic progenitor cells towards growth factors and other cytokines. JAK2 V617F mutation-positive PV and ET patients had lower vitamin D levels.^[6] Other than the effects on calcium-phosphate metabolism and bone balance, Vitamin D has an impact on cell proliferation, differentiation and cell adhesion as well as proliferation and apoptosis of tumor cells. In a study on patients with CMPNs, it was observed that there was a high prevalence of Vitamin D deficiency in patients with PV and ET– more so with PV. Vitamin D deficiency was observed in our patient also.

It has been described that PTH may induce hemopoiesis by a direct action on hemopoietic precursors– at a low concentration. It may be inhibitory at a high concentration. In our patient, we found that she had very high PTH but still had erythropoiesis. An article in the Journal of Endocrinology and Metabolism has mentioned about parathyroid adenoma being a risk factor for PV.^[7] Weinstein, in his study, has mentioned that reduction in calcium level in the postoperative period was associated with remission of PV. When the hypercalcemia recurred at a later time, it was again accompanied by pancytosis.^[8] In 4 out of 5 cases, parathyroidectomy resulted in complete and stable remission of PV even without any treatment.^[5] Godeau et al. also reported a case of PV with primary hyperparathyroidism, which responded successfully with the removal of parathyroid adenoma.^[9]

In a case reported in the International Journal of Haemotology, the patient had a JAK-2 status negative and they observed only transient (<1 year) control of PV following parathyroidectomy.^[4] George M Rogers has observed that PTH increases ferric chloride Fe 59 incorporation into erythrocytes of polycythemic mice. He also stated that PTH might increase erythropoiesis not only in pathological situations but also may play a role in the regulation of normal erythropoiesis.^[10]

Multiple endocrine neoplasias (MEN) I and II will have multiple adenomas or hyperplasia of the parathyroid glands. Parathyroid tumor, along with pancreatic and pituitary tumors, is the typical pattern of MEN1. The lesions in MEN-2A are pheochromocytoma, medullary carcinoma thyroid, parathyroid adenoma, or hyperplasia. In addition to the components of MEN-2A; MEN-2B will have oral and submucosal tumors. Detailed evaluation to look for these lesions is essential once a parathyroid adenoma is encountered. We also evaluated our patients fully and excluded MEN.

The surgical results of our patients were excellent is in terms of resolution of PV and hyperparathyroidism. As we proceeded with endoscopic parathyroidectomy the patient was very comfortable and could get excellent cosmetic outcomes without any neck scars. It also encouraged the patient to undergo the procedure at an early stage. It will also motivate her to undergo another procedure in case other parathyroids go in for hyperplasia or adenoma later.

Conclusion

Patients with polycythemia vera must be screened for hyperparathyroidism. Early treatment of hyperparathyroidism by parathyroid removal will take care of polycythemia as well. Endoscopic parathyroidectomy is very feasible, safe, and well accepted by patients.

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

Nil.

Conflicts of interest

There are no conflicts of interest.

References

Zhan H, Spivak JL. The diagnosis and management of polycythemia vera, essential thrombocythemia and primary myelofibrosis in the JAK2V617F era. Clin Adv Hematol Oncol 2009;7:334-42.

Kiladjian JJ. The spectrum of JAK2-positive myeloproliferative neoplasms. Hematology Am Soc Hematol Educ Program 2012;2012:561-6.

Bae EH, Kim HS, Kim MJ, Kang YU, Kim YH, Kim CS, et al. Hypercalcemia in a patient with polycythemia vera. Chonnam Med J. 2012 ;48:128-9. doi: 10.4068/cmj.2012.48.2.128. Epub 2012 Aug 24. PMID: 22977755; PMCID: PMC3434793

Kulaylat AN, Jung EE, Saunders BD. The role of parathyroidectomy in JAK2 mutation negative polycythemia vera. Int J Hematol 2014;100:615-8

Boivin P, Bernard JF. Polycythaemia and hyperparathyroidism: A fortuitous association? Eur J Haematol 1992;49:153-5.

Yikilmaz AŞ, Akinci S, Bakanay ŞM, Dilek İ. Vitamin D Deficiency and Janus kinase 2 V617F Mutation Status in Essential Thrombocythemia and Polycythemia Vera. Malays J Med Sci. 2020 ;27:70-7. doi:10.21315/mjms2020.27.1.7. Epub 2020 Feb 27. PMID: 32158346; PMCID: PMC7053540

Fallah M, Kharazmi E, Sundquist J, Hemminki K. Nonendocrine cancers associated with benign and malignant parathyroid tumors. J Clin Endocrinol Metab 2011;96:E1108-14

Weinstein RS. Parathyroid carcinoma associated with polycythemia vera. Bone 1991;12:237-9

Godeau P, Bletry O, Brochard C, Hussonois C. Polycythemia vera and primary hyperparathyroidism. Arch Intern Med. 1981 ;141:951-3. PMID: 7235821

Rodgers GM. Hyperparathyroidism associated with polycythemia. Arch Intern Med 1982;142:951-3

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Abstract

Laparoscopic inguinal anatomy detail is different from that is necessary for open hernia surgery. ‘PK Band’ is a condensation of areolar tissue lateral to inferior epigastric vessels on either side. It extends fromarcuate line to apex of triangle of doom. It is more condensed and prominent in the upper part. ‘PK Band’ is more prominent in males and tall structured individuals. It is an important land mark during laparoscopic inguinal dissection in both TEP (total extra peritoneal) and TAPP (trans abdominal preperitoneal) methods. Lateral blunt dissection in the preperitoneal plane will definitely be restricted by this band. Forcing the scope laterally will cause tear of the peritoneum at that level. Muscle injury may also be caused by blunt dissection. Division of this band during laparoscopic hernia repair connects the space of Bogros with space of Retzius. This provides sufficient space necessary for proper placement of mesh and hence significantly reduce recurrence.

Keywords : ‘PKBand’ . Laparoscopy . Inguinal Hernia . TAPP . TEP . Facia Condensation

Watch Video Presentation in YouTube

Conflict of Interest

None

Introduction

This is an observational information where we attempt to explain the anatomical importance and clinical significance of “PK Band” which is a fibrous band encountered while performing cases of laparoscopic inguinal hernia repair. During our 20 years of experience in performing over 6000 cases of laparoscopic hernia repairs, we made this observation. Identification of this structure is necessary for proper dissection and comfortable placement of mesh during laparoscopic inguinal hernia surgery.

Background

Nyhus et al. (in 1991) [1] have mentioned about transversalis fascia analogues [2, 3]. In the endoabdominal fascial sac, there are several locations of condensation of the fascia, which are continuous with and integrated to the sac itself.

These condensations, termed as transversalis fascia analogues, are found at points of insertion of various muscles or at points where aponeurotic structures are attached to the fascial sac. The five important fascial analogues are transversalis fascial sling, transversus abdominis aponeurotic arch, the iliopubic tract, iliopectineal ligament, and the interfoveolar ligament.

There is mention of medial boundary of Bogros space as a condensed area lateral to inferior epigastric vessel [4]. Also, there is mention of lateral boundary of Retzius space as condensation of tissue lateral to inferior epigastric vessel. But the surgical importance of this thickened area was not evaluated or described probably because it may not be important in open hernia surgery.

Location of the ‘PK Band’

The “PK band” is a condensation of the loose areolar tissue between the space of Bogros and the space of Retzius. It lies lateral to the inferior epigastric artery bilaterally. It extends from the arcuate line to the apex of the triangle of doom. It is more condensed and prominent in the upper part.

Prevalence of PK Band

It is seen in all patients. More prominent in males, tall statured and in well-built individuals.

Significance in Laparoscopic Hernia Repair

1. In totally extraperitoneal (TEP) repair

For surgeons, the lateral blunt dissection in the preperitoneal plane will definitely be restricted by this band. Forcing the scope laterally will cause tear of the peritoneum at that level. Extraperitoneal space is lost and the operating surgeon will not be able to complete a good lateral dissection. The procedure may have to be converted to intraperitoneal approach or open surgery due to air leak into the general peritoneal cavity. Many surgeons limit the lateral dissection to this band and place the mesh improperly. The principle behind mesh placement is that it should be placed equidistant laterally and medially to the inferior epigastric artery so that it adequately covers the indirect and direct hernial defects. Mesh placed without lateral dissection will not be covering the indirect hernia defect. Mesh folding can occur and it may lead to recurrence of hernia [5]. To prevent all these lapses during surgery and to avoid unnecessary delay and difficulty in dissection, the surgeon should divide “PK Band.”

2. In transabdominal preperitoneal (TAPP) repair

While dissecting in the loose areolar plane for placement of mesh, “PK band” is the landmark which is encountered lateral to the inferior epigastric artery. There is loose areolar tissue on either side of this band. In order to complete lateral dissection for smooth placement of mesh, it is imperative that just as in TEP the surgeon divides “PK Band.” If not identified, there is strong possibility for either peritoneal tear or injury to the muscles, and mesh placement will be improper leading to recurrence of hernia.

Conclusion

“PK Band” acts as an important anatomical landmark in both TAPP and TEP. Its division is necessary in proper completion of lateral dissection and proper placement of mesh.

References

1. Nyhus LM, KleinMS, Rogers FB, et al. (1991) Current problems in surgery. 28(6):407–450. doi: https://doi.org/10.1016/0011-38
2. MemonMA, Quinn THet al (1999) J Laparoendosc Adv Surg Techn 9(3):267–272. https://doi.org/10.1089/lap.1999.9.267
3. Annibali R., Fitzgibbons R.J. (1995) Laparoscopic Anatomy of the Abdominal Wall. In: Phillips E.H., Rosenthal R.J. (eds) Operative Strategies in Laparoscopic Surgery. Springer, Berlin, Heidelberg
4. Ansari MM, et al. (2017) Retzius and Bogros spaces: a prospective laparoscopic study and current perspectives.Ann IntMedDental Res 3(5)
5. Choy C, Shapiro K, Patel S et al (2004) Surg Endosc 18:523. https://doi.org/10.1007/s00464-003-8183-0

Author information

Affiliations

1. Department of General & Laparoscopic Surgery, VPS Lakeshore Hospital, Kochi, India
   • Padmakumar Ramakrishnapillai
   • , Sandeep Gupta
   • , Madhukara Pai
   • , Aravind Balakrishnan
   • , Kevin J Chiramel
   •  & Premna Subin
2. VSM Hospital, Mavelikkara, India
   • Farish Shams
3. Verwandeln Institute, Kochi, Kerala, 682306, India
   • Subin Thomas

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After the peritoneum is dissected away, six additional structures need to be identified. They are

1. Pubic crest (Lighthouse sign),
2. Iliopubic tract,
3. Cooper’s ligament,
4. Femoral canal
5. Obturator nerve and
6. Internal inguinal/ spermatic ring

Pubic Crest:

It helps in getting orientation. Beware of small veins overlying. If they bleed entire vision gets spoiled.

Iliopubic Tract:

The iliopubic tract is a thick fibrous white tract which runs from the superior pubic ramus to the anterior superior iliac spine.

• The iliopubic tract separates the inguinal region from the femoral canal.
• Sutures or tacks should never be placed below the level of the iliopubic tract laterally

Cooper’s Ligament:

This ligament is a condensation of the transversalis fascia and periosteum located lateral to the pubic symphysis. It is densely adherent to the pubic ramus and joins the iliopubic tract and lacunar ligaments at their medial insertions. This ligament is used to anchor the mesh in huge direct hernias.

Mobilizing adipose tissue around the Cooper’s ligament can injure an aberrant obturator artery, which might course over it. Injury to this vessel results in distressing bleeding. This unfortunate morbidity has resulted in the naming of this vessel Corona mortis (crown of death).

Femoral Canal:

It denotes the potential site of origin of a femoral hernia. The canal lies posterior to the iliopubic tract.

Obturator Nerve:

It courses in the lateral pelvic wall. Mesh placement should extend up to that region. It helps to take care of obturator hernias, especially in elderly.

Internal Inguinal Ring:

Denotes the site of origin of an indirect inguinal hernia. The most reliable indicator of the internal ring is the junction of the testicular vessels and the
spermatic cord in a male and entry of round ligament in a female.

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With the introduction of the laparoscope into the abdomen, five important landmarks can be identified in the infra-umbilical region.

1. Inferior epigastric vessels
2. Medial umbilical ligament
3. Spermatic vessels
4. Vas deferens
5. Trapezoid of disaster

Inferior epigastric vessels

The inferior epigastric artery is prominently visualized during laparoscopic preperitoneal dissection of groin hernia.

1. It forms the lateral border of the Hesselbach’s triangle.
2. It demarcates between direct and indirect inguinal hernia.
3. It leads us to iliac vessels and apex of triangle of doom.
4. Bleeding due to its injury can occur during dissection.

Medial umbilical ligament

Urinary bladder lies medial to the medial umbilical ligament.

Spermatic vessels

It forms the lateral border of the ‘triangle of doom’ and the medial
border of the ‘triangle of pain’.

Vas deferens

Forms the medial border of the ‘triangle of doom’ and ‘quadrangle
of disaster’

‘Trapezoid of Disaster’ (Labeled by Seid)

Lying beneath the peritoneum and transversalis fascia are the external iliac artery and vein and nerves- triangle of pain + triangle of doom

Dissection should be done with care in this area. No tacks should be placed in this area.

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Transversalis Fascia (of Gallaudet)

This fascia is a two layered structure (bilaminar). The anterior layer is adherent to the rectus abdominis muscle. The posterior layer lies in between the anterior layer and the peritoneum. It divides this space into an anterior (vascular space) and a posterior (Space of Bogros). Medially it is continuous with the space of Retzius. One should work in the space of Bogros to prevent unnecessory oozing.

Prevesical space of Retzius

The preperitoneal space that lies deep to the supravesical fossa and the medial umbilical fossa is the prevesical space of Retzius (Described in 1858, by Swedish anatomist Anders Retzius). This space contains loose connective tissue and fat.

Important structures in this space are:

Arteries

1. External iliac artery
2. Inferior epigastric artery and its branches

Veins

1. External iliac vein
2. Inferior epigastric veins
3. Deep venous circulation

Nerves

1. Lateral femoral cutaneous nerve
2. Genitofemoral nerve
3. Femoral nerve
4. Ilioinguinal nerve
5. Iliohypogastric nerve
6. Lymphatics and lymph nodes

Pubic branches:

-The inferior epigastric artery gives rise to anterior pubic artery, which accompanied with the iliopubic vein crosses the superior pubic ramus. In 25-30% of individuals, the anterior pubic branch is large and can replace the obturator artery. This large arterial branch (Aberrant obturator artery) can partially encircle the neck of a hernia sac and be injured in a femoral hernia repair. It could also be injured while dissecting on to the Cooper’s ligament. So the whole anastomotic ring is known as the – ‘Corona Mortis’ (circle of death) (10).

Deep venous circulation of the preperitoneal space (Bendavid): –

The venous circle/ deep venous circulation of Bendavid(11) is located at the subinguinal space of Bogros. It is a network of deep inferior epigastric, rectusial, suprapubic and retropubic veins. These are important because damage to these vessels is easy and usually leads to haematoma formation.

Nerves in the inguinal region: –

The following three nerves are at risk for injury during dissection-

1. Lateral femoral cutaneous nerve
2. Femoral branch of genitofemoral nerve
3. Obturator nerve

The following nerves are usually not at risk during dissection, but can be injured if excessive pressure is applied during mesh fixation.

1. Ilioinguinal nerve
2. Iliohypogastric nerve
3. Genital branch of genitofemoral nerve

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The ‘Myopectineal Orifice of Fruchaud’

All groin (inguinofemoral) hernias originate in a single weak area called the myopectineal orifice. This oval, funnel-like, ‘potential’ orifice formed by the following structures, makes the ‘myopectineal orifice of Fruchaud’.
-Henry Fruchaud

Boundaries

• Superiorly Internal oblique and transversus abdominis muscles.
• Inferiorly Superior pubic ramus.
• Medially Rectus muscle sheath.

The Peritoneal Landmarks

Median Umbilical Ligament:

This ligament ascends in the median plane from the apex of the bladder to the umbilicus. It represents the obliterated allantoic duct and its lower part is the site of the rare urachal cyst.

Medial Umbilical Ligament

This ligament represents the obliterated umbilical artery on each side and can be traced down to the internal iliac artery.

Lateral Umbilical Ligament

It is the ridge of peritoneum, which is raised by the inferior epigastric vessels.

These ligaments delineate the infraumbilical fossae

The Infraumbilical Fossae

These fossae are important for surgeons-

1. Delineate the sites of groin herniation.
2. An important landmark for orientation during hernia repairs.

Supravesical fossae:

The infraumbilical area between the median and medial umbilical
ligaments. This is the site for the origin of the supravesical hernia.

Medial Umbilical fossae:

The infraumbilical area between the medial and lateral umbilical
ligaments. This is the site for the origin of the femoral and direct inguinal hernia.

Lateral Umbilical fossae:

The infraumbilical area lateral to the lateral umbilical ligament. This is
the site for the origin of the indirect inguinal hernia.

Hesselbach’s Triangle (by Franz Caspar Hesselbach)

It is the site for direct hernia

Iliopubic Tract

The iliopubic tract is a thickened lateral extension of the transversalis fascia, which runs from the superior pubic ramus to the iliopectineal arch and the anterior superior iliac spine. It is intimately associated with the inguinal ligament. It is anterior to the Cooper’s ligament and posterior to the inguinal ligament. The iliopubic tract separates the internal ring from the femoral canal. It is visualized as a fibrous (white) tract.

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