Endoscopic-assisted linea alba reconstruction
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Patients with symptomatic umbilical, trocar, and/or epigastric hernias and concomitant rectus abdominis diastasis represent a growing clinical problem. The optimal management of this complex hernia situation is the subject of debate in the literature. This paper reports the early results of an innovative surgical technique aimed at managing this hernia situation.
Endoscopic-assisted linea alba reconstruction (ELAR) with mesh augmentation is a surgical technique long known in the literature for its good outcome for incisional hernia repair (myofascial release, overlapping herniorrhaphy, Gibson’s operation, shoelace repair, anterior rectus sheath repair, dynamic patch plasty) via a small access route. The early results for 140 patients are presented here.
Two patients (1.4%) developed postoperative complications requiring redo surgery. These were two cases of diffuse secondary bleeding without an identifiable bleeding source, in one patient with liver cirrhosis and portal hypertension and in another patient receiving treatment with platelet aggregation inhibitors. All other complications were successively managed with conservative treatment. After 1 year, two of 30 patients reported occasional pain, including pain at rest in one patient.
The ELAR technique with mesh augmentation is an innovative, minimally invasive surgical procedure for treatment of patients with a complex abdominal wall hernia comprising symptomatic umbilical, trocar, and/or epigastric hernias with concomitant rectus abdominis diastasis.
KeywordsRectus abdominis diastasis Umbilical hernia Epigastric hernia Trocar hernia Mesh augmentation Complications
Rectus abdominis diastasis (RAD) describes a condition in which the two rectus muscles are separated by an abnormally wide distance of more than 2 cm . When a patient with RAD raises his or her head and begins to sit up, the increase in intra-abdominal pressure as the two rectus muscles contract can result in a diffuse fusiform bulge . Patients with RAD typically are middle-aged and older men with central obesity, or small, fit women who have carried a large fetus or twins to term . Rectus abdominis diastasis is often seen in umbilical and/or epigastric hernia (45%) . Patients with small umbilical and/or epigastric hernia with concomitant RAD, who underwent suture repair, had a significantly higher recurrence rate (31.2% vs. 8.3%; p < 0.001) . The authors concluded that umbilical and/or epigastric hernias, regardless of size, with concomitant RAD require mesh repair owing to unacceptably higher recurrence rates . In full-extend RAD instead of a stable linea alba only a very thin membrane extends longitudinally from the xiphoid process to the subumbilical area, also extending laterally on both sides by several centimeters lateral to the midline. Accordingly, anatomic reconstruction with mesh augmentation is needed for effective repair and to prevent recurrence of not only the umbilical or epigastric hernia but also of RAD.
If RAD is symptomatic or associated with midline hernias (umbilical, trocar and/or epigastric), corrective surgery of all pathologies at the same time could represent the most recommended approach .
Owing to missing data, it was not possible in a systematic review to find any clear evidence of the superiority of an endoscopic or open technique for the treatment of RAD with concomitant umbilical and/or epigastric hernia .
The spectrum of surgical procedures ranges from the open sublay technique through open myofascial release with and without mesh to laparo-endoscopic techniques . Furthermore, there are innovative techniques such as the EMILOS and MILOS operations [6, 7].
Another alternative is the endoscopic-assisted linea alba reconstruction (ELAR), which is a hybrid technique . However, this surgical technique is not new but is based on the long-established method reported on with good results in the literature under various names such as “myofascial release” , “overlapping herniorrhaphy”, “onlay prosthesis” [9, 10], “shoelace repair” , “Gibson’s operation” [12, 13], “modified shoelace repair” , “anterior rectus sheath repair” , ”dynamic patch plasty” , and “autodermal hernioplasty”, as described by Rehn . A common feature of all these techniques is that the anterior layer of the rectus sheath is exposed from the xiphoid process to the subumbilical area and then incised. Next, the medial segments of the anterior layer of both rectus sheaths are sutured together at the midline for reconstruction of a new linea alba. This also closes the defects caused by ventral and incisional hernias. Then the resultant defect in the anterior layer of the rectus sheath is repaired by suturing a mesh for augmentation of the anatomic reconstruction.
The authors have reported good to very good results on using this technique for incisional hernia. It should therefore also be suitable for anatomic reconstruction of the abdominal wall in association with umbilical, trocar, and/or epigastric hernias and concomitant RAD. With the addition of video-endoscopic equipment, this operative procedure was further developed to a hybrid technique to optimize the results obtained with as small as possible an access route . The operative technique and early results of the ELAR operation are presented here.
Between 15 June 2015 and 1 January 2017, a total of 140 patients were operated on with this technique. These were 90 men and 50 women. All patients signed an informed consent. As the described operation technique was performed for many years via larger incision in our hospital and results are reported in many publications in the literature, approval by an ethics committee was not necessary.
The mean age was 54.7 years with range of 25–85 years. The indications were RAD with symptomatic umbilical hernias (n = 17), epigastric hernias (n = 8), umbilical and epigastric hernias (n = 75), and incisional hernias (n = 40), which were mainly trocar hernias resulting from periumbilical insertion of a 10-mm trocar during laparoscopic operation. The patients had a mean body mass index (BMI) of 29.9 with range of 18–50. The mean defect length was 8.6 cm (range: 3–15 cm) and the defect width, 5.9 cm (range: 4–11 cm).
The mean operating time was 116 min (range: 62–209 min). The meshes used had a mean length of 18.7 cm (range: 13–28 cm) and mean width of 9.1 cm (range: 5–15 cm). The mean hospital stay was 4.5 days (range: 2–18 days). Two patients experienced postoperative secondary bleeding requiring redo surgery (1.4%). In each case this involved diffuse secondary bleeding without an identifiable bleeding source, in one patient with liver cirrhosis and portal hypertension and in another patient receiving treatment with platelet aggregation inhibitors. Nine patients (6.4%) developed discrete impaired wound healing or discrete necrosis adjacent to the incision; they all responded to conservative treatment. In all, 125 of the 140 patients who had undergone surgery already attended the scheduled follow-up review 30 days after the operation. At that time two patients (1.6%) still showed evidence of discrete impaired wound healing, which was further treated by us. Six patients (4.8%) had a seroma of no clinical significance and which required no treatment. Twenty-six patients (20.8%) still reported intermittent pain in the region of the mesh margins. Only seven patients continued to take painkillers (5.6%).
Thirty patients have already attended their 1‑year follow-up examination. There was no evidence of seroma, impaired wound healing, or recurrence. Two patients still reported occasional pain, including pain at rest in one patient.
Symptomatic RAD is a relatively common change in the abdominal wall, which has no pathological significance. However, any concomitant development of umbilical hernias, epigastric hernias, and trocar hernias often leads to symptomatic RAD. This then raises the question of optimal reconstruction for management of this complex hernia situation. Open operations via large access routes find little acceptance among patients. With this constellation of findings, endoscopic techniques have their limitations since endoscopic repair of RAD-mediated bulging is difficult. Alternative techniques include the MILOS and EMILOS innovations [6, 7]. And as a further innovative technique, the ELAR operation with its early results are described here . It embodies a technique long described under various names in the literature for incisional hernia repair via a relatively small access route. The advantage bestowed by this technique is that it restores the abdominal wall anatomy through the use of autologous tissue and additional mesh augmentation for stabilization of the reconstruction. This technique eliminates RAD, which was the underlying cause of the abdominal wall defects. It also restores the functions of the rectus muscles that are able to resume such functions as stabilizers of the trunk only when they are positioned adjacent to the new linea alba. The early postoperative results up to 30 days revealed a complication-related redo surgery rate of only 1.4%. All other postoperative complications responded to conservative treatment. Likewise, the initial findings after 1 year, albeit only available so far for a relatively small number of patients, demonstrated encouragingly low recurrence and pain rates. Naturally, these findings must be confirmed on the basis of a larger number of cases and further studies.
Endoscopic-assisted linea alba reconstruction (ELAR) is a promising operative technique, in particular for the patient group with RAD and concomitant umbilical, trocar, and epigastric hernias since it can be implemented via a relatively small open access route, thus reducing the complication rate. This is confirmed by the results presented here. However, further studies with a greater number of cases and longer follow-up are needed before final assessment of this surgical technique can be made.
Conflict of interest
F. Köckerling, M.D. Botsinis, C. Rohde, W. Reinpold, and C. Schug-Pass declare that they have no competing interests.
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