A Novel Technique Using Mesh to Repair a Recurrent Large Indirect Inguinoscrotal Hernia

Abstract

Background: The positioning of a slit mesh around cord structures during laparoscopic transabdominal preperitoneal (TAPP) hernia repair rests the mesh better without kinks, thereby minimizing recurrences. However, studies also suggest that insufficient closure of the mesh slit may lead to recurrences. Aim: This report describes a novel technique using AbsorbaTacks (Covidien) to close the mesh slit and refashion an artificial ‘deep ring’ to minimize recurrence. Technique: We report the case of a fit 82-year-old Caucasian male presenting with a recurrent large right indirect inguinoscrotal hernia (8 x 8 × 7 cm with 4 × 4 cm deep inguinal ring). The patient underwent a TAPP repair with a background of unsuccessful open repair by another surgeon previously. Following mesh deployment, the mesh was lifted up by the cord structures, which was under tension due to a large defect. A slit was made in the inferomedial aspect of the mesh. This allowed it to be wrapped around the cord structures. The overlapped trouser flaps were then stapled together encircling the cord, by AbsorbaTacks to create a secure artificial ‘deep ring’. Edges of the mesh were also standardly affixed by AbsorbaTacks to the pectineal ligament and posterior abdominal wall. This creates a secure four-point fixation of the mesh scaffold to prevent ‘windsock’ effect, which happens when the mesh is pushed into the widened deep inguinal ring, leading to early recurrences. The peritoneal incision was also closed with AbsorbaTacks. Conclusion: No complications were registered during the early postoperative period. The patient had an uneventful recovery and was discharged within 20 hours with simple analgesia. No recurrence was reported during the 6 months follow-up period. Clinical significance: The anchoring of a slit mesh with tackers around the cord structures can be used to repair large recurrent inguinal hernias laparoscopically following an open repair. This technique potentially minimizes further recurrences. © Jaypee Brothers Medical Publishers. 2021.