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

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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).

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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

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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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A Ventral Hernia or abdominal wall hernia is an abnormal protrusion of the contents of the abdominal cavity or of preperitoneal fat through a defect or weakness in the abdominal wall.  The abdominal wall is the musculofibrous covering of the contents of the abdominal cavity.

A ventral hernia is a hernia of the abdominal wall excluding the inguinal area, the diaphragm and the pelvic area.  Abdominal wall hernias can be of congenital or acquired variety.  The latter can occur either spontaneously or after surgery. When they occur after surgery, they are called incisional hernias.  3-20% of laparotomy incisions develop ventral hernia.

Types of Ventral Hernia

Umbilical Hernia – This occurs at the umbilicus or the belly button when the intestine pushes through the umbilical ring.  It can be seen as a bulge at the area of the belly button.

Lumbar Hernia –  Lumbar hernia occurs when the bowel, omentum or preperitoneal fat herniates through a defect in the lumbar triangles.  This can be Right Lumbar Hernia or Left Lumbar Hernia

Hypogastric Hernia – This occurs in the hypogastric region.

Epigastric Hernia – An epigastric hernia occurs when the intestines protrudes through the abdominal wall muscles between the umbilicus and the chest.

Spigelian Hernia – A Spigelian hernia is a ventral hernia where the abdominal contents or peritoneum through the Spigelian fascia that is comprised of the transversus abdominis and the internal oblique aponeuroses.

Strangulated Hernia

When the intestinal tissue gets tightly caught as a bulge in the abdominal wall, then the condition is termed as strangulated ventral hernia. In this case the intestinal tissue cannot be pushed back and cuts the blood flow to the area causing the hernia contents to become ischemic due to compromised blood supply.  This requires emergency surgery.

Causes of Ventral Hernia

There are several factors that lead to the formation of ventral hernia and these include:

• Pregnancy
• Obesity
• Record of previous hernias
• Previous abdominal surgery
• Injuries to the bowel area
• Frequently lifting and pushing  of heavy objects
• Week scar tissues from previous abdominal surgery

Symptoms

Symptoms may last for weeks or months and includes:

• pain and discomfort in the abdominal area during prolonged walking, standing or lifting heavy objects
• outward bulging of skin or tissues in the abdominal area
• nausea
• vomiting
• Swelling in the bulged area

Diagnosing Ventral Hernia

The doctor performs a physical exam and asks about the symptoms. The doctor suggests various imaging test including ultrasound scan, CT scan or a MRI scan.

Ventral Hernia Repair

Ventral hernia repair is the second most common type of abdominal hernia operation (25.6% of all hernia repairs). It includes incisional hernia, epigastric hernia, umbilical hernia, lumbar hernia and spigelian hernia.

Laparoscopic Ventral Hernia Repair

Laparoscopic surgery is performing the hernia repair through keyhole incisions using a laparoscope.  A laparoscope is a thin long tube that has a camera attached to its end and enables the surgeon to view enlarged images of the cavity and the organs with a monitor attached.

Laparoscopic Ventral Hernia Repair requires much smaller incisions than open surgery; minimal abdominal wall tissue trauma, less hematoma and seroma; wound infection is four-fold less likely to occur in patients with laparoscopic repair.  Cosmetic benefit varies from case to case (lack of long scar vs. correction of abdominal bulge and apron). Length of hospital stay after laparoscopic ventral hernia repair is found to be shorter in the majority of cases.

Laparoscopic surgery has several advantages with a faster recovery time and minimal scars. Advantages of laparoscopic hernia removal include:

• Few small incisions
• Lowers chance of infection
• Less postoperative pain
• Reduced hospital stay
• Minimal scars
• Faster recovery time

When approaching the hernia with the traditional open technique, the fascial defect is ideally repaired with a prosthetic mesh placed in an onlay/subfascial position. However, the appropriate positioning of the mesh usually involves a large incision and a fair amount of dissection, often complicated by the patient’s body habitus. The laparoscopic approach to ventral hernia repair offers a minimally invasive technique to repair these hernias.

The surgery is initiated by administering a dose of anesthesia to relax the patient and to reduce the pain and discomfort caused by the condition. The surgeon makes a small incision in the abdominal wall and inserts a laparoscope to view the internal abdominal cavity and associated organs. A laparoscope is a thin long tube that has a camera attached to its end and enables the surgeon to view enlarged images of the cavity and the organs with a monitor attached. After investigation, the surgeon makes few more incisions to insert hernia repair tools and the bulged tissues are pushed back and placed in position. Later a mesh is placed in the weak spot of the abdominal wall to prevent the possibility of reoccurrence of hernia. Later the incisions are closed and sutured.

After the surgery, meditations are administrated to reduce pain and discomfort from the surgery. The patient can leave the hospital in a day or two and are instructed not to do any heavy tasks like weight lifting. Diet rich in fiber content and adequate fluid intakes is instructed.

Videos Related to Hernia

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Obturator Hernia – Symptoms

Symptoms of Obturator hernia include:

• Bowel obstruction
• Abdominal bloating
• Pain
• Constipation
• Nausea
• Vomiting

Causes of Obturator Hernia

Aging can cause loosening of muscle mass and fatty tissue and the intestine enters the obturator canal. Multiple child birth and obesity can also cause obturator hernia. It can be diagnosed by imaging tests like CT scan, ultrasound scan or MRI scan of the abdomen.

Treatment

Obturator hernia can be treated with Laparoscopic surgery. The surgery is initiated by administering a dose of anesthesia to relax the patient and to reduce the pain and discomfort. The surgeon then makes a small incision in the abdominal wall and inserts a laparoscope to view inside of the abdominal cavity and associated organs. The surgeon makes few more incisions to insert two more instruments and the bulged tissues are pushed back and placed in position. Later a mesh is placed in the weak spot of the abdominal wall to prevent the possibility of reoccurrence of hernia. Later the incisions are closed with self dissolving sutures.

After the surgery, medications are administrated to reduce pain and discomfort of the surgery. The patient can leave the hospital in a day or two and resume normal life in a week’s time.

Advantages of laparoscopic hernia surgery include:

• Small incisions
• Lowers chance of infection
• Less postoperative pain
• Reduced hospital stay
• Minimal scars
• Faster recovery time

Hernia – Other Types

Videos Related to Hernia

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Symptoms of Femoral Hernia

• Sudden groin and abdominal pain
• Nausea
• Vomiting

Diagnosing Femoral Hernia

Femoral hernia causes pain in the abdominal area. The doctor suggests various tests to diagnose its presence including ultrasound scan or CT scan.  The hernia can get complicated when they gets strangulated or obstructed causing extreme pain while lifting heavy objects or during bowel movements.

• Hernia obstruction –The bulged tissues gets stuck in the femoral canal resulting in excessive pain, nausea and vomiting.
• Hernia strangulation –The strangulated hernia causes restriction of blood flow to the area and gets trapped in the femoral canal. The condition requires emergency surgery to restore the blood supply to the area.

Causes

There are many factors that lead to the formation including:

• excess strain during bowel movement
• constipation
• heavy weight lifting
• obesity
• Chronic cough

Treatment

The surgery is initiated by administering a dose of anesthesia to relax the patient and to reduce the pain and discomfort caused by the condition. The surgeon makes a small incision in the abdominal wall and inserts a laparoscope to view the internal abdominal cavity and associated organs. A laparoscope is a thin long tube that has a camera attached to its end and enables the surgeon to view enlarged images of the cavity and the organs with a monitor attached. After investigation, the surgeon makes few more incisions to insert hernia repair tools and the bulged tissues are pushed back and placed in position. Later a mesh is placed in the femoral canal to prevent the possibility of reoccurrence of hernia in the canal. Later the incisions are closed and sutured. The surgery takes around 45 minutes to one hour to complete. After the surgery, meditations are administrated to reduce pain and discomfort from the surgery. The patient can leave the hospital in a day or two and are instructed not to do any heavy tasks like weight lifting. Diet rich in fiber content and adequate fluid intakes is instructed. The laparoscopic surgery has several advantages with a faster recovery time and minimal scars.

Femoral Hernia vs Inguinal Hernia

Both Femoral Hernia and Inguinal Hernia occurs at the groin area.  However, there are key differences in both these hernias.

Compared to Inguinal hernia, femoral hernias carry a higher risk of leading to strangulation.  Strangulation in hernia is life threatening as it cut off the supply of blood.

Other types of hernia

• Inguinal hernia
• Hiatal hernia
• Ventral Hernia
• Obturator Hernia
• Umbilical hernia
• Incisional hernia

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