Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia

Abstract

I congratulate Bittner and colleagues for presenting this most valuable document on reviewed guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [1]. However, two closely related topics on the handling of a large direct sac and the risk of seroma formation need further explanation. I believe that part of their statements and recommendations lacks precision and therefore could be misleading. Page 2,793 of their article states: ‘‘level 2B: In large direct hernias, inversion and fixation of the extended fascia transversalis to Cooper’s ligament may reduce the frequency of occurrence of serohematoma.’’ The following page also has this recommendation: ‘‘Level 1B: The use of fibrin sealant (FS) for mesh fixation during bilateral TEP leads to a significant reduction of analgesic consumption but is associated with an increased incidence of postoperative seroma.’’ Although findings have shown that FS significantly reduces the incidence and volume of seroma formation after axillary dissection [2], the main reason for using it in TEP repair of inguinal hernia is that it offers an alternative to stapled fixation due to its adhesive property [3], thus avoiding tacker-related complications. These complications comprise not only potential vascular or nerve injury but also chronic pubalgia when the staple is placed in Cooper’s ligament [4]. Moreover, by offering the unique possibility of gluing the mesh inferiorly at the level of the triangles of doom and pain, FS reduces even further the risk of recurrence in expert hands [5]. In a personal series of[650 TEP inguinal hernia repairs using FS, only six early hernia recurrences were recorded, all in the initial phase of the study and most likely related to technical imperfection. Preliminary results of this approach have already been published elsewhere [6]. The authors mentioned the famous prospective study of Lau [7], which demonstrated a significantly higher incidence of seroma in the FS group than in the mechanical stapling group. I must clarify that the vast majority of his patients presented with a direct defect, and as clearly explained in his article, ‘‘FS was used to affix the mesh onto the Cooper’s ligament and pelvic floor, instead of applying it for sealing the potential space of the hernial cavity.’’ Yes, inversion and staple fixation of the lax fascia transversalis to Cooper’s ligament reduces the incidence of seroma formation, but this procedure can be favorably replaced by a much cheaper, safer, and more reliable alternative using a simple pre-tied suture (Endoloop Ligature of PDS II; Ethicon Endo-Surgery, Inc., CA), as initially presented at the 2010 Annual Scientific Congress of the Royal Australasian College of Surgeons in Perth [8]. The technique consists of inverting the extended fascia transversalis with a forceps while tying up an Endoloop at its base to leave a completely ‘‘flattened’’ fascia (Fig. 1). A prospective series of 250 patients had 76 repairs of direct inguinal hernias performed using the aforementioned technique, and only one patient (1.3 %) experienced a symptomatic groin seroma. In this case, the direct hernia defect was quite complex, multiloculated, and associated with an incisional hernia from a previous lower midline C. R. Berney (&) Department of Surgery, Bankstown-Lidcombe Hospital, University of New South Wales, 68 Eldridge Road, Bankstown, NSW 2200, Australia e-mail: berneycr@hotmail.com