Tricks - Laparoscopic Epigastric Herniorrhaphy

The following video is being translated into English on behalf of Dr. Abello. Laparoscopic, pediatric, epigastric hernia repair. This is a 5-year-old girl with swelling and tenderness in the epigastric region that has not been able to be reduced for 6 months. We decided on a microlaparoscopic approach with a 3 millimeter umbilical port and another 23 millimeter percutaneous instruments placed in the left anterior axillary line. With finger pressure on the abdominal wall hernia bulge, we identified the hernia site laparoscopically. Dissecting with the Maryland dissector and the Hook cautery, the peritoneum was opened and the fatty tissue was removed. The hernia ring was exposed. Suturing with interrupted percutaneous 3O PDS suture. Avoids the non-cosmetic incision and scar in the epigastric region. With 2 separated points, we finished the hernia repair. OK. So, uh, can the faculty hear me now? Yes, OK, good. So this, this, this begs the question, is there a role for laparoscopy? Does it make sense to do laparoscopy for epigastric hernia repairs? Uh, Doctor Vanderzee, let me open it up to you. I think it's, uh, a very nice option. Um, if you, uh, have, you have those, uh, special combined optics where you have, uh, the, the optic and a working channel, where you could even, uh, only use the umbilicus for, for entrance and then to mobilize the, uh, the fatty tissue, and then use an endoclose or what has been used here, just percutaneously, make a, a, a 2 incision. Put in the suture, bring it out from the other side and and tie it subcutaneously. So it's, it's a very nice technique. Anyone here, uh, want to make a comment, Sharif? It's, it's a nice technique. I'm just curious about the type of hernia because maybe I missed something on the video, but it looked like when the video started, it looked like there was some momentum or something protruding. Through the defect, and that's not usually an epigastric hernia. An epigastric hernia just has preperitoneal fat. It's extraperitoneal. So, you know, it didn't look to me like that was a, a true epigastric hernia. It looked like a full thickness hernia. And the other point is, um, I just, you know, working on the anterior abdominal wall through the umbilicus, even just to take something down is, is difficult because you just don't have the angle that you need. So it looks easy on the video, but I just wonder how. How easy that really is. Yeah, so, uh, go ahead. An epigastric hernia with no, no, go ahead, stop the video. I don't know why it's playing. Yeah, hello, sorry. Oh, Deb, are you there? Oh, that was Deb. Go ahead, Deb. So he said, uh, that the, um, epigastric hernia was indeed an epigastric hernia. It just had a lot of fat. It was not omentum, right? And, and I interpreted that too, Sharif, that. You know, he's almost took down a little bit of the falsi form and then from the inside opened up that space, went in and it was pulling down preperitoneal fat. I think he was pulling it down into the abdomen, but that was, it was living up. Uh, in the hernia space. So that's how I interpret it. Am I, does anyone else interpret that differently? I think that he was the trick maybe was the finger pressure on the outside he was pressing, yes, which pushed it in. I think it's a neat technique. And for the teenage girl that has an unsightly epigastric hernia, I think it's something to bear in mind. Let me, let me ask the audience a question. Do you all routinely, will you always fix an epigastric hernia? Jeff says no. OK. I, I do, uh, Todd, because it's interesting. I've seen some of these patients who have not wanted repair, actually, over the years, increase in size to a very significant hernia. Um, you know, I've seen kids who are 34 years old and had the, the usual little nodule, and then they come back at 10. Um, and just have a huge amount of preperitoneal fat and a bigger defect. So I think their natural history is to enlarge, and when you fix them when they're small, it really is a pretty minor procedure. So I'm gonna bring this to Bob, but Sharif, I, I've been waiting for someone to tell me that, uh, because I always stutter when I talk to the families. I go, well, you know, you're, if it's asymptomatic, I'm trading, I mean, I think there's a likelihood you'll get some pain and discomfort from there. The only thing I can think of is that maybe into adulthood it becomes larger, especially if it's a female, and after pregnancy it could enlarge, and then you're using mesh versus just a primary closure, but I don't even know if that was true, so I'm glad to hear that you actually have seen them get bigger. I'm seeing Jeff wants to say something. Yeah, whoa, whoa, I wouldn't, I wouldn't say that they all get bigger. I think there's a huge number out there that just remain totally asymptomatic and a small size, and I educate the parents. And tell them that we're here. Uh, if it gets bigger or becomes symptomatic, come back, but I've never known one to be. Really a health concern, uh, a great deal. Yeah, some have a bit of pain and so forth, but they're not like, uh, like inguinal hernias. So I think the majority actually live quite happily inside the confines of a very small defect, and they live life normally. I am a little bit more aggressive in girls just because of the issue with pregnancy. I've anecdotally known several women with epigastric hernias to have significant pain at the time of pregnancy. Um, I, I tend to repair the inferior ones, not the one that was described here in this video through a peri umbilical incision, just moving my then skin incision up so that you can do it without the falderal of laparoscopy, but I think this is a very nice technique for the, for the higher ones. Yeah, Dr.lo agrees with you. He, he does not repair all asymptomatic hernias, but he does repair them in female patients because of that concern that you spoke of. Interesting. This is, this is a great discussion, and I will tell you that the one time I get scared is because I know an adult, when I was doing adult residency, we did have. Some pretty big ones that I remember putting mesh around them. So I wondered if they started off as the small ones. And so Jeff, to answer your question, I hear what you're saying, and I, I don't repair most, but I always walk away after I leave them in the clinic wondering did I do this child justice? Is this kid gonna come back as an adult needing mesh that I could have fixed now with two stitches? Um, so I don't know, and, and I don't know if anyone else wants to make a comment uh regarding the laparoscopy. I just had a a change in heart because I want to give credit, so Oliver Munster presented the same technique at IPEG in, in Beijing a few months ago last spring. And I was thinking you're, you're making, you're putting 3 incisions or 2 incisions or 1 even. Instead of this one, but, but you're hiding it in the umbilicus. So, you know, the scars do grow and if they're 3 years old and it's this big, it'll be twice as big when they're older. So I guess from a cosmetic standpoint, uh, you are hiding the scar in the umbilicus. And then Kathy, I have a question for you. I get nervous about the ones that are inferior but not right above the umbilicus and you, you make that commitment to do that maybe a supra umbilical or whatever. And if you can't reach it, you're in trouble because now, uh, you know, now you have to make two incisions. So has that ever happened? Do you have a rule like how high up you think you can reach pliable, you know, epigastric? I've never had to make two incisions. I remember when Jack Langer, when I first came into practice, Jack said, Listen, I'm doing these pyloric stenosis operations through this perambilical incision, and it's much more aesthetically pleasing. And so basically to do that operation on a big pyloric, you need to get halfway up to the xiphoid process, so Um, fair enough. That, that initial operation helped me be more aggressive with the supraumbilical semicircular peri umbilical incision. I can basically get a long ways up there. The, the, the, the one that's shown here, however, that probably I wouldn't have even tried that, but I do like this idea of the laparoscopic technique and putting the incisions on the side down below as opposed to right in the, uh, midline. Just a quick follow-up comment. I don't know if anybody has, uh, has seen this, but I've had over the years, at least half a dozen patients with hernias about 1 centimeter or 1 centimeter a half above the umbilicus that were not epigastric hernias. They actually were true full thickness abdominal wall hernias with a sac, and, and those were not epigastric hernias. So, um, you know, they may be misdiagnosed as epigastric hernias, but they actually were full thickness defects with it, just like an umbilical hernia, except they were not in the umbilicus. And I've seen several of these now. I know they're not really described in the books, but they should be agree, agree, agree, and sometimes there's like Swiss cheese. You can find a few of them actually. So I want to, you know, the question, yeah, I think, go ahead, go ahead, Kathy. Sorry, yeah, well, actually, no, I think I agree with Sharif. I had a few also that is just 1 centimeter or above like what we call a supraumbilical hernia, which is not an umbilical hernia, and these were managed by the supraincisional umbilical hernia incision that you can hide it through the umbilicus ulna, so that was. Fine, but in older kids, like, you know, for example, one year and above that they have, they come to you with this epigastric hernia, I think it's very hard to reach to that level if it's really in the midline. Most of them it's like in the midway between the xiphoid and the and the umbilicus, so it's very hard to reach it through the umbilical or supraumbilical incision. So but why are you repairing a kid? Who's a year and a half years old with an asymptomatic epigastric hernia, they're not, it's not going to cause a problem. Our anesthetists are loath to actually anesthetize for a truly elective, truly elective operation for a kid who's less than age 5. I mean, there are some soft reports about cognitive problems with general anesthesia. So I'd just leave these kids alone when they're in school, think about repairing them. Yeah, so, um, what I do actually go ahead, Sua, to answer his, uh, comment, then we'll go to Sharif. Sorry, um, most of the parents when they come to me actually they want the hernia to be fixed, and I just want them, you know, this is maybe not necessary, and, um, it's just cosmetically, but most of them, they say it bothers them. They, they got pain. So, um, I, I know sometimes if you just leave them may, may not do anything, but I don't know for. Long run, like, you know, what they are above the adolescents or adults, what's going to happen to it. So if they're persistent and it's symptomatic, I'll fix them, OK? And Sharif, I was just going to make the point that I think this is a gap in our knowledge. I mean, we still, we have, it's not just epigastric hernias. I mean you can look at hydroceles and other things. Where we don't really know still what is the optimal time to repair them. Most of us repair a hydro seals somewhere between 1 year and 2, but not why, why not leave them until 3 or 4 or 5? I mean, we don't really know. I think one of the points is Um, most of us feel that toddlers tend to recover and, you know, the morbidity of the operation is much less than if you have a 6 or a 7 year old who's going to associate the hospital stay, whether there's a lot of psychological components, missing school, etc. So that's one rationale for doing it when you identify it, but I agree, I don't think you need to push to, to fix it. If the parents would rather not, then that's fine. Uh, a comment about the laparoscopic approach. I've always imagined because I've never seen one. That it would be hard to see the defect laparoscopically. My question exactly if it's truly an epiplocele, which is really why I think what we're sort of talking about, I mean, that's, it's preperitoneal fat, um, and those you wonder, uh, do you really, is there something in the abdomen for those? And the annoyance is that preperitoneal fat, particularly if it's innervated or whatever, that's annoying to people, and I wonder, you know, is it hard to find. That little epiplocele and I think so, so Doctor Abeo used the finger pressure test to identify where it is, but I talked to the adult surgeons and they said they have to, you have to take down the falciform to really see it and take off the peritoneum and then open the perineum, which he said in the video he does. He opens up the peritoneum, pushes with his finger, and then he sees that fat poking through that Jeff was pointing out, and, uh, so I think this was a. Isn't that funny? We had the biggest discussion on epigastric hernias. Someday somebody, somebody's gonna get an adhesion to that peritoneal defect and develop a bowel obstruction from this, which you wouldn't get if you did it, just do a little incision. Yeah, that's a good point. Uh, anyone want to make any last comments on this? All right, I see we have a lot of discussion and I apologize. I, I, uh, can't I haven't been answering all of the, uh, comments, so we always invite you to call your questions in if you wanna, uh, make a point and we'll try to get to your questions. Let's take a, uh, a brief 10 minute break. All the faculty, please stay on. Please keep your cameras on. We're gonna come back with, um, uh, a lot of really great, uh, cool innovative tricks, uh, in about 10 minutes. See you soon.