Prevention and treatment of peritoneal laceration in the laparoscopic totally extraperitoneal hernia repair during learning curve

Abstract

Objective To explore the causes and managements of peritoneal laceration in the laparoscopic totally extraperitoneal (TEP) hernia repair during learning curve. Methods The retrospective cross-sectional study was conducted. The clinical data of 120 patients with inguinal hernia who underwent laparoscopic TEP hernia repair in the Third Affiliated Hospital of Anhui Medical University (98 patients) and Anhui Provincial Hospital (22 patients) during surgeons′ learning curve between February 2012 and January 2017 were collected. Patients underwent laparoscopic TEP hernia repair, meshes were intraoperatively placed and then fixed by medical glue. Observation indicators: (1) intraoperative situations: surgical procedure, operation time, using of mesh, intra-operative peritoneal laceration; (2) postoperative situations: time to anal exsufflation, time for fluid diet intake, occurrence of complications, duration of hospital stay; (3) follow-up: number of patients receiving follow-up, follow-up time, recurrence of hernia during follow-up, pain in inguinal region, intestinal adhesion and obstruction induced abdominal pain, incisional infection. Follow-up using outpatient examination and telephone interview within 10 days postoperatively and using telephone interview at 10 days postoperatively was performed to detect the recurrence of inguinal hernia, pain in inguinal region, intestinal adhesion and obstruction induced abdominal pain and incisional infection up to May 2017. Measurement data with normal distribution were represented as ±s. Results (1) Intraoperative situations: of 120 patients, 112 underwent laparoscopic TEP hernia repair, 5 converted to laparoscopic transabdominal preperitoneal hernia repair and 3 converted to open surgery due to adhesion between hernial sac and surrounding tissues induced bleeding of separation. Total operation time of 120 patients was (71±13)minutes, including (63±7)minutes in 106 patients with unilateral hernia and (79±11)minutes in 14 patients with bilateral hernia. All the patients used intraoperatively meshes of 10.0 cm×15.0 cm and 16.0 cm×10.8 cm. Forty-eight patients had intraoperative peritoneal laceration, peritoneal laceration occurred for reconstruction of preperitoneal space in 10 patients, separation of anterolateral preperitoneal space in 11 patients and improperly operating equipment or hernial sac in 27 patients. Of 48 patients with peritoneal laceration, 40 continued to finish operation through acupuncturing into the abdominal cavity for exsufflation and then received peritoneal suture and repair, including 5 with recurrence of indirect inguinal hernia (receiving tissue repair) undergoing peritoneal repair through opening hernial sac, and 8 intraoperatively converted to other or open surgery. (2) Postoperative situations: time to anal exsufflation and time for fluid diet intake in 120 patients were (18±4)hours and (15±6)hours. Of 120 patients, 14 had postoperative complications, scrotal emphysema of 6 patients disappeared in 24 hours and inguinal and scrotal seroma of 8 patients disappeared after puncture treatment. All the patients were discharged from hospital in 2 days postoperatively. (3) Follow-up: 112 of 120 patients were followed up for 3-65 months, with a median time of 31 months. During follow-up, there was no occurrence of recurrence of hernia, pain in inguinal region, intestinal adhesion and obstruction induced abdominal pain and incisional infection. Conclusion During surgeons′ learning curve, identifying anatomy of the groin clearly, a right way to treat the hernia sac and broken peritoneum in the operation can ensure the smooth completion of the laparoscopic TEP hernia repair. Key words: Hernia, inguinal; Peritoneal laceration; Laparoscopy