Clinical characteristics and choice of laparoscopic surgical procedures for recurrent inguinal hernia

Abstract

Objective To summarize the clinical characteristics of recurrent inguinal hernia and investigate the choice of laparoscopic surgical procedures. Methods The clinical data of 330 patients with recurrent inguinal hernia (352 inguinal hernias) who underwent laparoscopic inguinal hernia repair (LIHR) at the Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine between January 2001 and December 2014 were retrospectively analyzed. The surgical procedures including transabdominal preperitoneal (TAPP) approach, total extraperitoneal (TEP) approach and intraperitoneal onlay mesh (IPOM) approach were selected and performed by doctors in the same team. Observed indicators included recurrent sites of previous surgery, repair methods, surgical procedures and clinical efficacies of this surgery. Patients were followed up by telephone interview and outpatient examination up to June 2015. The follow-up included the recurrence and postoperative complications.Measurement data with normal distribution were presented as±s, skew distribution data were described as M (range), and count data were analyzed using chi-square test. Results (1)Recurrent sites: of 352 recurrent inguinal hernias, 186 were detected in direct hernia region, 111 in indirect hernia region, 6 in femoral hernia region and 49 in compound hernia region. Among 125 recurrent inguinal hernias after suture repair, 44 were detected in direct hernia region, 48 in indirect hernia region, 2 in femoral hernia region and 31 in compound hernia region. Among 110 recurrent inguinal hernias after mesh-plug repair, 85 were detected in direct hernia region, 16 in indirect hernia region and 9 in compound hernia region. Among 61 recurrent inguinal hernias after patch repair, 37 were detected in direct hernia region, 16 in indirect hernia region, 3 in femoral hernia region and 5 in compound hernia region. Among 36 recurrent inguinal hernias after preperitoneal repair, 19 were detected in direct hernia region, 12 in indirect hernia region, 1 in femoral hernia region and 4 in compound hernia region. Among 14 recurrent inguinal hernias after high ligation of hernial sac, 1 was detected in direct hernia region and 13 in indirect hernia region. Six recurrent inguinal hernias after sclerosing agent injection were detected in indirect hernia region. Incidence of direct hernia in recurrent inguinal hernias was 52.84%(186/352), which was significantly different from 23.70%(998/4 211) in primary inguinal hernias (χ2=171.397, P<0.05). Incidence of direct hernia in recurrent inguinal hernias with implanted patches was 68.12%(141/207), which was significantly different from 31.03%(45/145) in primary inguinal hernias without implanted patches (χ2=47.052, P<0.05). (2)Repair methods: repairing myopectineal orifice was applied to recurrent inguinal hernias without implanted patches and after patch repair, with a ratio of fixed/unfixed patches of 82/124. Repairing myopectineal orifice or hernia defects was applied to recurrent inguinal hernias after mesh-plug repair and preperitoneal repair, with a ratio of fixed/unfixed patches of 133/13. There was significant difference in the ratio of fixed patch between the 2 repair methods (χ2=94.552, P<0.05). (3)Surgical procedures: of 352 recurrent inguinal hernias, 288 underwent TAPP approach, 50 underwent TEP approach and 14 underwent IPOM approach. TAPP approach and TEP approach were performed in 91 and 34 recurrent inguinal hernias after suture repair, TAPP approach and IPOM approach in 108 and 2 recurrent inguinal hernias after mesh-plug repair, TAPP approach and TEP approach in 46 and 15 recurrent inguinal hernias after patch repair, TAPP approach and IPOM approach in 24 and 12 after preperitoneal repair, TAPP approach and TEP approach in 13 and 1 recurrent inguinal hernias after high ligation of hernial sac and TAPP in 6 recurrent inguinal hernias after sclerosing agent injection. (4)Clinical efficacies: 330 patients underwent successfully laparoscopic surgery without conversion to open surgery and analgesics. The operation time, pain scores at postoperative day 1, the ratio of patients restoring unrestricted activities within 2 weeks and duration of postoperative hospital stay in 330 patients were (40±13)minutes (range, 15-100 minutes), 2.4±1.1 (range, 0.6-7.3), 99.70%(329/330) and (1.7±1.4)days (range, 1.0-9.0 days), respectively. Among 35 patients with complications, 1 patient with recurrent hernia after patch repair received reoperation of intestinal canal repair due to damnify of intestinal canal during TEP approach, other complications including 22 seroma, 8 urinary retention, 3 temporary nerve paresthesia and 1 paralytic ileus, and were cured by symptomatic treatment. All the patients were followed up for a median time of 58 months (range, 6-174 months). Conclusions Recurrent inguinal hernias are found frequently in the direct hernia region, with a higher ratio of direct hernias with implanted patches. According to intraoperative conditions, repairing myopectineal orifice or hernia defects can be selected during LIHR, and a choice of TAPP approach and TEP approach depends on previous surgical approach, gap of implanted patches and doctors' experiences. IPOM approach can be served as an alternative for TAPP approach. Key words: Inguinal hernia, recurrent; Therapy; Laparoscopy