David Ryan, MD, Ibrahim M Daoud, MD. St. Francis Hospital
Superior epigastric and subxiphoid hernias pose a difficult problem for repair. In an open repair the immobility of the tissues makes approximating the fascia difficult. In a laparoscopic repair, one often is unable to fix the superior or superior lateral aspect of the mesh to the abdominal wall as this can overlap the diaphragm, costal margin or pericardium. We describe a technique of fixating the mesh inferiorly with a standard tacking device and using a fibrin sealant to adhere the superior portion of the mesh.
Description of Methods:
Laparoscopic access to the abdomen is attainted with a midline 12mm trochar and 5mm trochars in each side of the abdomen. The falciform ligament is taken off the abdominal wall using a vessel sealing device. The herniating contents are then reduced completely into the abdomen. 5cm of tissue are cleared in all directions of the defect, as this is the overlap we seek. This typically includes freeing the left lateral segment of the liver. An appropriate mesh is elevated to the abdominal wall and tacked in place inferiorly and laterally up to the level that it is safe (the costal margin in our cases). A fibrin sealant is then placed on the anterior surface of the unsecured mesh and it is elevated to the abdominal wall.
Five hernias requiring this technique have been repaired since 2011. All involved had herniation of fat within the falciform ligament causing life limiting discomfort. Two of the defects abutted the xiphoid process and the hernia sac was adjacent to the pericardium. All patients have reported improvement from their preoperative symptoms and no recurrences have been note with the shortest follow up of six months.
This is a method that we have not seen formally described but we have found it successful in treating multiple difficult hernias. Although we do not propose a fibrin sealant to be equivalent to a tack or transfascial suture, we have found it to be successful in these particular cases where those options are not plausible. The position of the liver to maintain the mesh position on the abdominal wall likely has assisted in the success of the technique. Further study and follow up are essential to determine the long term success of this technique as well as if it may be applied to other areas that standard methods of fixation may not be safe. At this time, the authors have not applied the technique to other areas of the abdomen.