monthly focus

surgical intervention video

Minimally invasive surgery applied to hernia repair is expanding fast all over the world. Advantages of this technique include cosmetic benefits, faster recovery, less postoperative pain, and reduced indirect costs associated with a quicker return to normal activities. Despite this, these procedures could induce a long learning curve, due to the need for basic laparoscopic skills and the required knowledge of the preperitoneal space. Authors present the case of a young male patient with a right lateral hernia in whom a totally extraperitoneal (TEP) hernia repair was performed. In this video, key anatomical landmarks are demonstrated to facilitate the learning of the technique and the identification of every anatomical structure while performing the technique. The main objective of this video is to help less experienced surgeons understand the technique and orientation in the surgical field through the help of didactic drawings. 

Endoscopic totally extraperitoneal preperitoneal (TEP) inguinal hernia repair

Cure endoscopique d'une hernie inguinale totalement extrapéritonéale prépéritonéale (TEP)

Spigelian hernias are rare and only account for 0.1 to 2% of all ventral hernias. They are described as a protrusion of a peritoneal sac, organ, or preperitoneal adipose tissue through a congenital or acquired defect in the Spigelian aponeurosis, which is the part of the transversus abdominis aponeurosis that lies between the linea semilunaris laterally and the lateral edge of the rectus muscle medially. The risk of incarceration is increased in patients with a high BMI, age above 50 years, and in women. Given that this 79-year-old patient had all three factors, surgical treatment was selected, along with a laparoscopic transabdominal preperitoneal (TAPP) repair. Besides going for a laparoscopic approach known to decrease wound complications, extra care was taken to prevent a mesh bridge technique. By performing a primary fascial closure before placing a mesh, we were able to avoid higher rates of seroma, eventration (bulging), and patient dissatisfaction, all this, while allowing for a wider lateral mesh overlap that reduces the possibility of recurrence. 

Laparoscopic TAPP repair of a Spigelian hernia

Cure d'une hernie de Spiegel par voie d'abord laparoscopique transabdominale prépéritonéale 

This is the case of a 72-year-old man who had a previous traumatic right lumbar hernia initially approached by means of a laparoscopic intraperitoneal onlay mesh repair (IPOM) and its recurrence approached via an open onlay mesh repair. 

Lumbar incisional hernias are rare abdominal wall defects. According to the European Hernia Society classification for incisional abdominal wall hernias, the patient had a lateral L4 W2 hernia. This type of hernia is limited by the inguinal region inferiorly, the costal margin superiorly, the lateral margin of the rectus sheath medially, and the lumbar region laterally. Patients with such hernias typically seek medical assistance due to a lateral pathological bulge, which may be accompanied by discomfort or tenderness in the area. 

Due to their low incidence and the resulting lack of expertise in the treatment of this abdominal wall defect, surgical treatment poses a challenge. Laparoscopic approaches are technically feasible, safe, and may offer advantages over open repairs. In fact, they are associated with decreased blood loss, less postoperative pain, faster return of bowel function, shorter hospital stay, lower postoperative morbidity, and longer operative times. 

Surgical treatment was selected for the patient, along with a laparoscopic transabdominal preperitoneal (TAPP) repair, highlighting its advantages in a field where there is still no well-accepted standardized operative strategy. The repair of a recurrent hernia is a daunting task, even more so of a re-recurrent one. By choosing to perform a TAPP repair, we were able to prove that a laparoscopic redo repair is feasible even faced with weakened tissues and distorted anatomy. 



Laparoscopic TAPP repair of a complex lumbar hernia

Cure de hernie lombaire complexe par voie d'abord laparoscopique transabdominale prépéritonéale

Spigelian hernias are a rare type of abdominal hernias accounting for about 0.1% of cases. It occurs at any point of the semilunar line, at the crossing of the fibers of the transverse and oblique abdominal muscles on the lateral edge of the rectus abdominis muscle. However, it usually appears at the weak point located at the intersection between the semilunar line and the lateral end of the arcuate line of Douglas. Clinically, in Spigelian hernias, patients are either asymptomatic or they complain of slight abdominal discomfort. The neck of the hernia is usually narrow and is subsequently responsible for incarcerations and content strangulation. The clinical diagnosis of Spigelian hernias is difficult, most of the time requiring an abdominal CT-scan, which remains the key examination during the diagnosis of this hernia and its content. Treatment is surgical; there are different feasible approaches, i.e., direct, via herniorrhaphy or preperitoneal or preaponeurotic prosthetic placement; laparoscopic, using an intraperitoneal or preperitoneal mesh repair. Most authors use a laparoscopic approach, placing a preperitoneal mesh, with several postoperative benefits and comparable outcomes to the open approach.

Spigelian hernia: laparoscopic preperitoneal mesh repair

Hernie de Spiegel : cure laparoscopique avec pose de prothèse prépéritonéale

Incisional hernias are very common and might compromise 18 to 20% of patients after surgery. When associated with a rectus abdominis diastasis, the correction of both defects is mandatory to reduce recurrence. Laparoscopic surgery of the defects of the anterior abdominal wall is increasingly used. One of the novel techniques is the enhanced-view totally extraperitoneal known as eTEP, where a retromuscular space is created behind both rectus muscles making a connection of the left and right retrorectus spaces by dividing the medial edges of both posterior sheaths while preserving the linea alba. A mesh is placed in a sublay position without the need for fixation and a drain is left in this space, reminding of the conventional Rives-Stoppa technique, but with the benefits of minimally invasive surgery.

eTEP for incisional ventral hernia after right inguinal TAPP

video lecture

Anomalies atypiques de la paroi abdominale

In this authoritative lecture, Professor Salvador Morales-Conde, MD, PhD outlines the management of atypical abdominal wall defects including suprapubic, lumbar flank hernias, neuromuscularl lateral defects, subxiphoid, subcostal, parastomal hernias.

Atypical abdominal wall defects

Toxine botulique et reconstruction de la paroi abdominale

In this authoritative lecture, Professor Victor Radu, MD, PhD outlines Botulinum toxin and abdominal wall reconstruction (AWR).

Intramuscular botulinum toxin injection causes functional denervation by blocking neurotransmitter acetylcholine release resulting in flaccid paralysis and elongation of lateral abdominal wall muscles, increasing the rate of fascial closure during abdominal wall reconstruction, and decreasing recurrence rates. 

Dr. Radu, MD, PhD, FEBS-AWS has the following potential conflict of interest to disclose, receiving honoraria from Medtronic. However, Medtronic was never committed to the elaboration and running organization of this lecture. There is neither commercial publicity nor promotion in this lecture. Dr. Radu, MD, PhD, FEBS-AWS declares that he is fully committed to maintaining professional autonomy and independence in relation with the medical device Industry.

This lecture is aimed to promote education among its learners, and Dr. Radu, MD, PhD, FEBS-AWS declares that this lecture is fair, balanced, and free of commercial bias.