Comment to: First laparoscopic totally extraperitoneal repair of Laugier’s hernia: a case report. Ates M, Dirican A, Kose E, Isik B, Yilmaz S. Hernia 2013; 17:121–123

Abstract

I read with interest the recent case report of Ates et al. [1] regarding laparoscopic totally extraperitoneal (TEP) repair of Laugier’s hernia and would like to take this opportunity to add few comments. The authors made a very important remark that ‘the surgeon should be alert to the possibility of an atypical femoral hernia when examining patients with inguinal hernias’ and this statement is even more relevant in female patients who carry a significantly higher risk of having a synchronous femoral [2], or less commonly obturator hernia. In a personal prospectively maintained database on 582 patients undergoing TEP repairs for inguinal hernias, out of 540 male patients who had 763 repairs an obturator hernia was incidentally identified in only 3 explored groins (0.4 %), whereas the same combined anomaly was found in 5 out of 52 inguinal hernia repairs (9.6 %) in the remaining 42 female patients. In comparison, I only came across two patients initially consented for a TEP repair of bilateral inguinal hernias that were incidentally found to have an associated Laugier’s hernia at time of surgery. Both repairs were completed laparoscopically and a photographic representation of the first case can be seen in a recently published article [3]. This reinforces the increasing observation that a laparoscopic approach may offer further advantages over traditional inguinal herniorrhaphy as it can also allow simultaneous repair of occult contralateral inguinal [4], synchronous femoral [5] or obturator [6] hernias. It is therefore extremely important to possess a thorough anatomical knowledge of the pelvis and groin regions as viewed through the laparoscope, but also to systematically and carefully expose all potential hernial defects such as the obturator foramen and femoral canal. This only comes at the cost of quite a steep learning curve [7] that will eventually allow the surgeon to master every aspect of this challenging procedure [8]. Once a synchronous groin/pelvic hernia has been identified, it may also become quite convenient to be familiar with few extra technical tricks that could be of significant value for a successful clinical outcome. I would like to illustrate this with the presentation of my second patient, at the time 54 years of age, who was incidentally diagnosed with multiple groin defects. During a standard TEP approach and following reduction of bilateral indirect inguinal hernia sacs and right femoral hernia, a synchronous previously undiagnosed smaller left-sided femoral hernia was identified along with the presence of an additional, quite distinct and substantial defect that had formed through the lacunar ligament on the right side (Laugier’s hernia). The Laugier’s hernia was reduced (Fig. 1a, b) and remaining defect closed using the previously described Endoloop technique (Fig. 1c) [9] in order to minimize the risk of postoperative seroma formation. Similarly, the right femoral canal was plugged using a small size prosthetic mesh (Perfix Plug, Bard, Warwick, RI, USA) that was simply glued in place using fibrin sealant [TISSEEL (Fibrin Sealant), Baxter, Deerfield, IL, USA] (Fig. 1d). Finally, two anatomical meshes of polyester with lateral slit (Parietex Anatomical Mesh 15 9 10 cm, TECT 1510 ADP2, Covidien, Mansfield, MA, USA) were used to cover all defects and also fixed with fibrin sealant as This comment refers to the article available at 10.1007/s10029-011-0820-2.