Abstract BACKGROUND Minimally invasive lateral retroperitoneal (lateral-MIS) approaches to the spine involve traversing the lateral abdominal wall musculature and fascia. Incisional hernia is an uncommon approach-related complication. OBJECTIVE To review the incidence, treatment, and preventative measures of incisional hernia after lateral-MIS approaches. METHODS This is a retrospective review of cases performed by a single surgeon from 2011 to 2016. All patients who underwent lateral-MIS approaches at this institution were included. Patients with a postoperative diagnosis of lateral hernia on physical exam and corroborating advanced imaging findings were included in this study. Cases of flank bulge due to peripheral nerve injury were excluded. RESULTS Three-hundred three patients underwent lateral-MIS approaches to the spine. Three (1%) patients with incisional hernia were identified. Two patients presented with a clinically symptomatic incisional hernia, while 1 patient was diagnosed incidentally after a routine abdominal magnetic resonance imaging for an unrelated reason. No patients suffered bowel entrapment or strangulation. CONCLUSION Incisional hernia after lateral-MIS approaches is rare. Patients with incisional hernias may be susceptible to bowel incarceration and ischemia, though the incidence of this is probably low. Meticulous closure of the fascia is critical to avoiding this complication. Incisional hernia, XLIF, DLIF, OLIF, MIS-LIF, Complication ABBREVIATIONS ABBREVIATIONS ALIF anterior lumbar interbody fusion BMI body mass index CT computed tomography DLIF Direct Lateral Interbody Fusion LH lateral hernias LIH lateral incisional hernia MIS-LIF Minimally invasive surgery - lateral interbody fusion MRI magnetic resonance imaging. XLIF eXtreme Lateral Interbody Fusion Over the last 20 yr, the minimally invasive lateral retroperitoneal (lateral-MIS) approach has gained acceptance as a safe corridor to the lateral lumbar spine. Advantages of this approach include smaller incisions, shorter operative time, less blood loss, less postoperative back pain, and fewer wound issues as compared to traditional posterior approaches.1-5 This approach traverses the lateral abdominal wall en route to the retroperitoneal space. Once in the retroperitoneum, the spine can easily be accessed by either a transpsoas corridor (as with transpsoas lumbar interbody procedures, or MIS-LIF), or by developing a plane between the psoas and the great vessels that run ventral to the spine (as with prepsoas oblique lumbar interbody procedures, or OLIF). Wound closure after lateral-MIS exposure involves meticulous reapproximation and closure of all muscular and fascial planes violated during the approach. Failure to properly close the fascial layers can result in an incisional hernia. In this article, we review the incidence of incisional hernia after MIS lateral retroperitoneal exposure for lumbar interbody fusion (MIS-LIF), and discuss technical aspects to potentially prevent avoid this complication. METHODS A retrospective analysis of prospectively collected data from a single institution was performed from October 2011 to April 2016. IRB and patient consent was obtained prior to data collection. Patient identifiable protected health information was removed for the study. TABLE 1. Patient Characteristics of 3 Patients With Postoperative Incisional Hernia Case Sex Age BMI Diagnosis Surgery Location of hernia Symptoms Follow-up (mo) Hernia repair 1 F 45 32.7 Adult deformity L5/S1 ALIF, Left L2-L5 MIS-LIF, T10-Iliac Fusion Left L4 Pain and abdominal bulging 24 Yes 2 M 59 33.1 Lumbar spondylosis Left L2/3 MIS-LIF Left L4 Incidental on routine MRI for renal calculi 30 No 3 F 56 36.1 Lumbar spondylolisthesis Right L2/3, L3/4 MIS-LIF and percutaneous instrumentation Right L4 Abdominal bulging and borborygmi 12 No Case Sex Age BMI Diagnosis Surgery Location of hernia Symptoms Follow-up (mo) Hernia repair 1 F 45 32.7 Adult deformity L5/S1 ALIF, Left L2-L5 MIS-LIF, T10-Iliac Fusion Left L4 Pain and abdominal bulging 24 Yes 2 M 59 33.1 Lumbar spondylosis Left L2/3 MIS-LIF Left L4 Incidental on routine MRI for renal calculi 30 No 3 F 56 36.1 Lumbar spondylolisthesis Right L2/3, L3/4 MIS-LIF and percutaneous instrumentation Right L4 Abdominal bulging and borborygmi 12 No View Large TABLE 1. Patient Characteristics of 3 Patients With Postoperative Incisional Hernia Case Sex Age BMI Diagnosis Surgery Location of hernia Symptoms Follow-up (mo) Hernia repair 1 F 45 32.7 Adult deformity L5/S1 ALIF, Left L2-L5 MIS-LIF, T10-Iliac Fusion Left L4 Pain and abdominal bulging 24 Yes 2 M 59 33.1 Lumbar spondylosis Left L2/3 MIS-LIF Left L4 Incidental on routine MRI for renal calculi 30 No 3 F 56 36.1 Lumbar spondylolisthesis Right L2/3, L3/4 MIS-LIF and percutaneous instrumentation Right L4 Abdominal bulging and borborygmi 12 No Case Sex Age BMI Diagnosis Surgery Location of hernia Symptoms Follow-up (mo) Hernia repair 1 F 45 32.7 Adult deformity L5/S1 ALIF, Left L2-L5 MIS-LIF, T10-Iliac Fusion Left L4 Pain and abdominal bulging 24 Yes 2 M 59 33.1 Lumbar spondylosis Left L2/3 MIS-LIF Left L4 Incidental on routine MRI for renal calculi 30 No 3 F 56 36.1 Lumbar spondylolisthesis Right L2/3, L3/4 MIS-LIF and percutaneous instrumentation Right L4 Abdominal bulging and borborygmi 12 No View Large All patients undergoing lateral-MIS approaches were included in this study. All patients underwent lateral-MIS approaches for MIS-LIF. The technique used for MIS-LIF at our institution has been described in previous studies.6 All surgeries were performed by the senior author. Patients with abdominal flank bulges postoperatively routinely underwent computed tomography (CT) of the abdomen. Those with the abdominal wall fascia in continuity were diagnosed with an abdominal pseudohernia, or flank wall musculature paresis caused by injury to the innervating peripheral nerves. Only patients with clinical and radiographic evidence of true incisional hernias were included in this study. RESULTS From October 2011 to April 2016, 303 patients underwent lateral retroperitoneal approaches for MIS-LIF. Three of 303 (0.99%) patients were noted to have incisional hernias within a 24-mo follow-up period. Patient characteristics are listed in Table 1. Two patients presented complaining of borborygmus and abdominal wall extrusion during valsalva. Patients were suspected to have abdominal hernias after palpation and reduction of the hernia on physical exam. Imaging was obtained to confirm the diagnosis and guide subsequent management. One additional patient was diagnosed with an incisional hernia incidentally after undergoing a routine abdominal magnetic resonance imaging (MRI) for an unrelated issue. One of the 3 patients required operative repair of the hernia. There was no bowel entrapment or strangulation. The patient underwent an uneventful repair of the hernia with the general surgery service and has not had recurrence of the hernia. Patient characteristics are listed in Table 1. Case 1 A 45 yr-old-female with progressive degenerative scoliosis underwent a staged L2-L5 MIS-LIF, L5/S1 anterior lumbar interbody fusion (ALIF), and T10—Ilium percutaneous instrumented fusion (Figure 1). Approximately 24 mo after surgery, the patient presented with a symptomatic incisional hernia at the site of her MIS-LIF. Though there was no evidence of strangulation or incarceration, the patient was bothered by the hernia and felt it limited her activity. She was referred to general surgery for primary repair. She underwent uneventful outpatient surgical herniorrhaphy. The repair was achieved in an open fascia, using nonabsorbable mesh placed in an underlay fashion. FIGURE 1. View largeDownload slide A, Coronal and B, axial CT demonstrating herniation of bowel through lateral fascial defect. FIGURE 1. View largeDownload slide A, Coronal and B, axial CT demonstrating herniation of bowel through lateral fascial defect. Case 2 A 59-yr-old male presented to clinic with chronic low back pain and bilateral lower extremity radiculopathy refractory to nonoperative therapy. MRI of the lumbar spine revealed spondylosis, decreased disk height, and foraminal stenosis at L2/3. He underwent L2-3 MIS-LIF without complications. Approximately 12 mo later, he underwent an abdominal MRI with contrast as part of a workup for a renal cyst. The MRI revealed an incidental incisional hernia without bowel entrapment. The patient declined operative repair as he was asymptomatic. Case 3 A 56-yr-old female with grade 2 L4/5 spondylolisthesis and L3/4 spondylosis underwent right L3-L5 MIS-LIF with percutaneous pedicle screw instrumentation, reduction of listhesis, and fusion. Her surgery was complicated by a right femoral nerve motor and sensory neuropathy that recovered within 1 yr. At her 1-yr follow-up, the patient noted a reducible incisional hernia. She denied any discomfort from the hernia and declined surgical repair. DISCUSSION Lateral Incisional Hernia Classification In 2009, the European Hernia Society provided a consensus classification system for primary and incisional abdominal wall hernias.7 Within this classification, lateral hernias (LH) are defined as primary or secondary fascial defects occurring within the area bounded by the costal margin, inguinal region, linea semilunaris, and the erector spinae.7,8 Hernias within this area are further divided into subcostal, flank, iliac, and lumbar zones. Table 2 describes the anatomical boundaries of the 4 zones of LH. The nomenclature of LH can be ambiguous however, as flank hernias have also been defined as hernias occurring between the costal margin and iliac crest,9 and hernias within this location have also been referred to as “transverse” hernias.10 Likewise lumbar hernias have been described as occurring between the erector spinae and external oblique, while they are bounded by the anterior axillary line medioventrally in the above classification. Broadly speaking, LH are distinguished from midline, paramedian, and spigelian hernias by their position outside of the rectal sheath. They occur primarily as congenital hernias of the superior (Grynfeltt) and inferior (Petit) lumbar triangles, or secondarily after trauma, infection, or surgery.11 TABLE 2. Anatomic Barriers of Lateral Hernias Based on the European Hernia Society Consensus Classification Superior Inferior Medial Lateral L1 (subcostal) Costal margin Horizontal line 3 cm above umbilicus Lateral margin of rectus sheath Anterior axillary line L2 (flank) Horizontal line 3 cm above umbilicus Horizontal line 3 cm below umbilicus Lateral margin of rectus sheath Anterior axillary line L3 (iliac) Horizontal line 3 cm below umbilicus Inguinal region Lateral margin of rectus sheath Anterior axillary line L4 (lumbar) Costal margin Iliac crest Anterior axillary line Erector spinae muscles Superior Inferior Medial Lateral L1 (subcostal) Costal margin Horizontal line 3 cm above umbilicus Lateral margin of rectus sheath Anterior axillary line L2 (flank) Horizontal line 3 cm above umbilicus Horizontal line 3 cm below umbilicus Lateral margin of rectus sheath Anterior axillary line L3 (iliac) Horizontal line 3 cm below umbilicus Inguinal region Lateral margin of rectus sheath Anterior axillary line L4 (lumbar) Costal margin Iliac crest Anterior axillary line Erector spinae muscles View Large TABLE 2. Anatomic Barriers of Lateral Hernias Based on the European Hernia Society Consensus Classification Superior Inferior Medial Lateral L1 (subcostal) Costal margin Horizontal line 3 cm above umbilicus Lateral margin of rectus sheath Anterior axillary line L2 (flank) Horizontal line 3 cm above umbilicus Horizontal line 3 cm below umbilicus Lateral margin of rectus sheath Anterior axillary line L3 (iliac) Horizontal line 3 cm below umbilicus Inguinal region Lateral margin of rectus sheath Anterior axillary line L4 (lumbar) Costal margin Iliac crest Anterior axillary line Erector spinae muscles Superior Inferior Medial Lateral L1 (subcostal) Costal margin Horizontal line 3 cm above umbilicus Lateral margin of rectus sheath Anterior axillary line L2 (flank) Horizontal line 3 cm above umbilicus Horizontal line 3 cm below umbilicus Lateral margin of rectus sheath Anterior axillary line L3 (iliac) Horizontal line 3 cm below umbilicus Inguinal region Lateral margin of rectus sheath Anterior axillary line L4 (lumbar) Costal margin Iliac crest Anterior axillary line Erector spinae muscles View Large Lateral incisional hernia (LIH) after lateral-MIS approaches for MIS-LIF typically occurs within the lumbar zone (L4; Figure 2). In contrast, miniopen approaches for retroperitoneal ALIF occur below the arcuate line between the linea alba and the linea semilunaris (lateral edge of the rectus sheath).12 These cases are susceptible to incisional hernia,13 though they are distinct from true LIH given their position medial to the linea semilunaris. This distinction is critical when considering surgical repair of these hernias. FIGURE 2. View largeDownload slide An anatomic diagram in the lateral position demonstrates the anatomic boundaries of the zones of lateral incisional hernias. In this rendition, the patient has an incisional hernia in the lumbar zone, as can be seen after MIS-lateral approaches. FIGURE 2. View largeDownload slide An anatomic diagram in the lateral position demonstrates the anatomic boundaries of the zones of lateral incisional hernias. In this rendition, the patient has an incisional hernia in the lumbar zone, as can be seen after MIS-lateral approaches. Incidence of LIH There is a paucity of literature regarding LIH.14 These defects can occur after renal surgery, vascular procedures, or iliac crest bone harvesting.9 In fact, the rate of LIH after urological surgery has been reported to be as high as 31%.15 Despite this, only 2 cases to date have been reported after lateral-MIS approaches (both for MIS-LIF).2,16 As such the incidence, risk factors, and optimal management of this complication are speculative. Reported risk factors for incisional hernia after ventral abdominal surgery include chronic obstructive pulmonary disease and a high body mass index (BMI),17 though it is unclear whether these risk factors are applicable to lateral access surgery or retroperitoneal approaches. The size of fasciotomy, duration of surgery, and location of fasciotomy may be risk factors for incisional hernia.18,19 Other potential risk factors such as female sex, diabetes, prior abdominal surgery, and choice of suture have not been shown to significantly increase rates of incisional hernia.20-23 The fasciotomy typically employed in lateral-MIS approaches to the retroperitoneum most closely approximates those used in laparoscopic approaches. The rate of incisional hernia after transperitoneal laparoscopic surgery has been reported to be between 0% and 5.2%.24 The rate of incisional hernia after laparoscopic peritoneal surgery may be lower than after retroperitoneal surgery, however, as retroperitoneal exposures have been suggested as a risk factor for incisional hernia. In a study by Takei et al,25 the incidence of incisional hernia following retroperitoneal laparoscopic nephrectomy was higher (8.7%) than the incidence for laparoscopic transperitoneal approaches (2.2%). This difference was attributed to the potential for higher pressures within the retroperitoneum, in addition to the weaker closure of fascia that is typical after retroperitoneal approaches. The risk of flank hernia and bulging following flank incisions for lateral nephrectomy has been estimated to be close to 50%.26 This includes incidences of “pseudohernia” however, where devascularization and denervation of the lateral abdominal wall musculature leads to weakness and subsequent bulging. The incidence of true incisional hernia in this cohort of patients was not reported, though it would be expected to be higher than MIS retroperitoneal approaches given the large size of fasciotomy used in radical nephrectomy. Anatomic Considerations The lateral-MIS approach affords surgeons a direct corridor to the lateral aspect of the lumbar spine. The lateral abdominal wall is composed of the external oblique, internal oblique, transversus muscle, and the transversalis fascia. The lateral abdominal wall is perfused by segmental arteries arising from the aorta, and innervated by ventral branches of the thoracic nerves, iliohypogastric, and ilioinguinal nerves. The neurovascular structures course between the internal oblique and the transversalis muscle.14 Entry into the retroperitoneum can be complicated by iatrogenic nerve injury during this dissection, leading to abdominal wall paresis, or pseudohernia.27 The incidence of devascularization and denervation after lateral-MIS retroperitoneal approaches is thought to be low, as the retroperitoneum is accessed by dissecting through the muscular layers without the use of sharp dissection or electrocautery, and bluntly entering the transversalis fascia. Once within the retroperitoneum, subsequent transpsoas and oblique exposures of the spine carry their own respective risks of neurovascular injury. Discussion of these risks is beyond the scope of this manuscript. Diagnosis and Treatment of Lumbar Hernias Ninety percent of lumbar hernias are nonacute, whereas 9% to 10% of lumbar hernias present in acute fashion manifesting with symptoms of bowel or urinary obstruction.28 As the natural evolution of lumbar hernias is steady growth in size and symptomology, most surgeons believe that LIH should be repaired in all patients, except those at high risk.28 CT scan is considered the modality of choice in the diagnosis and preoperative planning of LIH, as it delineates both anatomy and content.11 Size and location of the hernia, previous abdominal or retroperitoneal surgeries, and comorbid conditions influence the technique used to repair LIH. Multiple methods of repairing LIH have been described including the use of musculo-aponeurotic rotation flaps using either the gluteus or latissimus dorsi muscles, and the use of nonabsorbable mesh using transabdominal or extraperitoneal approaches.11,29-31 There is no consensus regarding the superiority of 1 method over another. Laparoscopic hernia repair is associated with the lower morbidity rate, shorter length of stay, lower consumption of analgesics, and earlier return to normal activity without associated increase in cost.31 Principles of adequate hernia repair such as overlap of mesh >5 cm on either side of the defect and adequate fixation to tissues should be utilized. In addition, it is important to preserve the nerves that course through retroperitoneal planes to prevent postoperative sensory symptoms or pseudohernia. The abdominal mesh is typically placed between the peritoneum and transversalis fascia. It can be placed between the internal and external obliques to avoid the neurovascular structures that course between the internal and transverse layers, though this is not done routinely within the lumbar zone.14 Preventing Lateral Hernias From a Technique Standpoint A meticulous surgical technique is critical to minimizing the risk of LIH after lateral-MIS approaches. Full thickness closure of the transversalis fascia and muscle layers reduces the risk of postoperative incisional hernia. However, the traversing nerves can be entrapped with blind sutures, leading to pseudohernia formation. Because of the small incisions used in lateral-MIS approaches, reapproximation of each individual layer can be challenging. In obese patients where visualization is limited, a layer-by-layer closure is not recommended. When operating near the iliac crest, leaving a small fascial cuff attached to the crest facilitates closure at the end of surgery. Fasciotomies in direct contact with bone are otherwise difficult to close. Lastly, unbreaking the table prior to closure allows a tension-free closure and better approximation of tissue. Running or interrupted sutures may be used provided no residual fascial defects are left that would facilitate herniation of the peritoneal contents. While our group no longer uses the 2-incision technique for retroperitoneal exposure, additional fasciotomies (especially in the vicinity of the primary surgical fasciotomy) would likely lead to an increased incidence of hernia. In patients with a normal body habitus, our technique for closure involves direct approximation of the transversalis fascia with interrupted sutures. The internal and external oblique muscles can be approximated with loose interrupted sutures, but this is not typically necessary unless there is a very large muscular defect (for example with multilevel exposures). Approximation of the external and internal obliques carries the risk of entrapping and strangulating peripheral nerves that traverse between these layers, and as such we do not routinely do this. The external oblique fascia can usually be clearly delineated for closure. We avoid using monopolar electrocautery during the initial dissection in favor of muscle dilation and sharp opening of fascial layers, to minimize nerve injury and facilitate closure. If the layers of fascia cannot be clearly demarcated (such as in morbidly obese patients, in whom there is a deep operative corridor), we favor full thickness closure, acknowledging the potential for pseudohernia. Limitations This study is limited by its retrospective nature. While the rate of incisional hernia in this cohort is low (with a lower rate of surgical revision), the true incidence is almost certainly underestimated. Hernias can present in a delayed fashion, and it is possible that more patients will present in long-term follow-up (follow-up for this cohort of patients ranged from 1 to 5 yr). Abdominal wall paresis due to peripheral nerve injury during exposure (pseudohernia) was excluded from this study. The incidence of pseudohernia after lateral-MIS surgery was previously reported by our group in 2011, with 10 out of 568 patients treated at four institutions suffering from abdominal wall paresis.27 This complication unfortunately has no treatment and is associated with patient morbidity. It is critical to distinguish pseudohernia from true incisional hernia. CONCLUSION Incisional hernia after MIS retroperitoneal approach is a rare technical complication. Meticulous surgical closure of the transversalis fascia and the external oblique fascia minimizes the risk of incisional hernia. Full thickness sutures that incorporate all traversed fascial layers may be necessary in some patients; however, this technique carries the risk of nerve entrapment and subsequent pseudohernia. Patients with signs or symptoms of incisional hernia should be evaluated urgently with advanced imaging (CT or MRI) and be referred for consultation to a general surgeon. Patients with evidence of an acute abdomen or strangulated bowel should be referred to the emergency room for urgent evaluation. Disclosures Dr Uribe is a consultant for and has direct stock ownership in Nuvasive. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Dakwar E , Cardona RF , Smith DA , Uribe JS . Early outcomes and safety of the minimally invasive, lateral retroperitoneal transpsoas approach for adult degenerative scoliosis . Neurosurg Focus . 2010 ; 28 ( 3 ): E8 . Google Scholar CrossRef Search ADS PubMed 2. Caputo AM , Michael KW , Chapman TM et al. Extreme lateral interbody fusion for the treatment of adult degenerative scoliosis . J Clin Neurosci . 2013 ; 20 ( 11 ): 1558 - 1563 . Google Scholar CrossRef Search ADS PubMed 3. Ozgur BM , Aryan HE , Pimenta L , Taylor WR . Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion . Spine J . 2006 ; 6 ( 4 ): 435 - 443 . Google Scholar CrossRef Search ADS PubMed 4. Wang MY , Mummaneni P V . Minimally invasive surgery for thoracolumbar spinal deformity: initial clinical experience with clinical and radiographic outcomes . Neurosurg Focus . 2010 ; 28 ( 3 ): E9 . Google Scholar CrossRef Search ADS PubMed 5. Park Y , Ha JW . Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach . Spine . 2007 ; 32 ( 5 ): 537 - 543 . Google Scholar CrossRef Search ADS PubMed 6. Le TV , Uribe JS . 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Dakwar E , Le TV , Baaj AA et al. Abdominal wall paresis as a complication of minimally invasive lateral transpsoas interbody fusion . Neurosurg Focus . 2011 ; 31 ( 4 ): E18 . Google Scholar CrossRef Search ADS PubMed 28. Moreno-Egea A , Baena EG , Calle MC , Martínez JAT , Albasini JLA . Controversies in the current management of lumbar hernias . Arch Surg . 2007 ; 142 ( 1 ): 82 - 88 . Google Scholar CrossRef Search ADS PubMed 29. Moreno-Egea A , Girela E , Parlorio E , Aguayo-Albasini JL . Controversias en el manejo actual de las hernias traumáticas de pared abdominal . Cir Esp . 2007 ; 82 ( 5 ): 260 - 267 . Google Scholar CrossRef Search ADS PubMed 30. Mismar A , Al-Ardah M , Albsoul N , Younes N . Underlay mesh repair for spontaneous lumbar hernia . Int Surg Case Rep . 2013 ; 4 ( 6 ): 534 - 536 . Google Scholar CrossRef Search ADS 31. Tobias-Machado M , Rincon FJ , Lasmar MT , Zambon JP , Juliano R V , Laparoscopic surgery for treatment of incisional lumbar hernia . Int Braz J Urol . 2005 ; 31 ( 4 ): 309 - 314 . Google Scholar CrossRef Search ADS PubMed Acknowledgments The authors would like to thank Puya Alikhani, MD and Sananth Sivakanthan, MD for their contributions to this manuscript. Copyright © 2018 by the Congress of Neurological Surgeons
Operative Neurosurgery – Oxford University Press
Published: Apr 27, 2018
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