Bilateral Totally Extraperitoneal Research Articles

WP1.11 - Total Extra Peritoneal (TEP) Inguinal hernia repair is safe and feasible for recurrent inguinal hernia post Total Extra Peritoneal repair "TEP on TEP is possible”

Abstract This abstract share our experience in surgical management of recurrent inguinal hernia post total extra peritoneal (TEP) repair by utilizing the same approach TEP. Methods Two patients with recurrent inguinal hernia post TEP were consulted for laparoscopic VS open approach, and both opted for the laparoscopic approach, understanding the higher risk of conversion. Result The first case of 62y male with recurrent left inguinal hernia after bilateral TEP. The second case of 69y male with recurrent left inguinal hernia post lap TEP repair. Standard three lower midline ports technique, no balloon spacer was used. The first and most important step was developing the plane above the previous mesh. 20 ml of 1 % xylocaine and 1/200000 was instilled in the extra peritoneal space to minimize oozing. Separating the previous mesh from the inferior epigastric artery and posterior wall of rectus muscle, down into bony lard marks and cord structures was performed using suction and sharp dissection with minimal diathermy. All landmarks were exposed in the three zones, before utilizing anatomical mesh. Both patients stayed overnight and operation time was 84 and 90 minute respectively. Three months follow up showed no recurrence or significant pain. Conclusion To our knowledge, this is first study describe the use of TEP on TEP. It suggests that TEP should not be excluded in patients with previous posterior mesh repair, emphasizing the importance of proper consultation. The abstract calls for further cases and studies to assess the efficacy and safety of this approach.

195 Small bowel obstruction through peritoneal defect herniation after a totally extraperitoneal hernia repair- A unusual complication case series

Abstract The rates of major complications associated with totally extraperitoneal (TEP) inguinal hernia repair are reportedly low, and intra-abdominal complications are rare. However, here we present a case series with small bowel obstruction through herniation of the small bowel into the peritoneal defect after a TEP, which is a rare complication. The first case, a 71year old male two weeks post-TEP left inguinal hernia repair, presented with abdomen pain, vomiting, distension, and bowels not opened for three days with elevated inflammatory markers. Computed Tomography of the abdomen and pelvis (CTAP) demonstrated small bowel obstruction secondary to a loop of inflamed small bowel adherent to the anterior abdominal wall in the left inguinal region. During emergency diagnostic laparoscopy found to have a small bowel loop passing through a peritoneal defect just lateral to the medial umbilical ligament, converted to laparotomy, and small bowel resection was performed. In the second case, a 61-year-old male presented with similar complaints and elevated inflammatory markers two days post bilateral TEP. The CTAP showed dilated small bowel with a transition point in the left iliac fossa. Emergency diagnostic laparoscopy found a peritoneal defect on the left groin with small bowel herniation. The bowel-reduced back and the defect was closed with sutures. Small bowel obstruction due to a peritoneal defect after TEP is a rare but potentially fatal complication. Therefore, the clinician should have a low threshold for surgery, as it is unlikely to resolve with conservative treatment like the adhesional bowel obstruction.

OC-006 LAPAROSCOPIC TOTALLY EXTRA-PERITONEAL REPAIR OF BILATERAL INGUINAL HERNIAS WITH A LARGE SINGLE MESH: A SINGLE CENTER STUDY WITH MINIMUM 5 YEARS FOLLOW UP

Abstract Background Laparoscopic totally extraperitoneal (TEP) surgery with a single large mesh is currently the technique of choice for repair of bilateral inguinal hernias in our institution. Most surgeons use two meshes for the TEP repair. We present our experience with a single mesh repair. Material & Methods Records of all patients who had bilateral inguinal hernia and underwent bilateral laparoscopic TEP repair at our institution, 2010–2016, were retrospectively reviewed. We excluded patients who had a conversion to transabdominal intraperitoneal or open approach. Results A total of 470 patients were identified. The median age of patients was 56 (IQR 1–3; 41–66) years and median BMI was 25.9 (IQR 1–3; 23.1–28.1). 18.7% of the cohort (88 patients) had previous abdominal surgery and 39 patients (8.41%) had a recurrent inguinal hernia. Median length of operation was 63 (IQR1–3; 48–89) minutes. Operative complication were bleeding (0.4%) and bladder injury (0.2%). Post operative complications occurred in 32 patients; among the complications were seroma (2.6%), hematoma (2.1%), surgical site infection (0.4%) urinary retention (1.5%) and intestinal obstruction (0.2%). Median length of hospitalization was 1 day (IQR1–3; 1–2). After a median follow up of 102 months, 36 patients had a recurrence. 20 patients (4.3%) had a re-operation for recurrent inguinal hernia. Post-operative groin pain was present in 48 patients. Conclusion The use of a large single mesh is an effective and safe technique for TEP repair of bilateral inguinal hernias. The recurrence rate and prevalence of post-operative pain is consistent with the results reported by others.

Outcomes of Endoscopic Totally Extraperitoneal (TEP) repair of clinically occult inguinal hernia diagnosed with ultrasonography.

Inguinal hernias generally present with groin lump and pain. Although inguinal hernias can be diagnosed clinically in most cases, patients without a groin lump pose a considerable diagnostic challenge. The first-line diagnostic imaging tool in these cases is ultrasound (US) and the recommended surgical procedure is laparoscopic-endoscopic repair. This retrospective study aims at evaluating postoperative results and complication rates of TEP technique in patients with occult contralateral hernias diagnosed with US in comparison to patients with clinically diagnosed hernias. A retrospective study was conducted to evaluate the outcomes of TEP procedure in patients with radiologically diagnosed occult contralateral hernias in comparison to patients with clinically diagnosed hernias. All hernias included in this study were repaired by TEP technique and secured with an extraperitoneal mesh. Demographic data, patient characteristics and perioperative information were obtained by reviewing medical records. A total number of 109 patients were enrolled in the study. The majority of patients were male and the mean age was 48.9 ± 14.6 years. In 56 cases, hernias were repaired unilaterally, while the remaining 53 were repaired bilaterally. Right-sided hernias were more common than left-sided hernias. The morbidity rate was 7.1% in unilateral repairs and 3.8% in bilateral repairs. The recurrence rate was 3.6% for unilateral repairs and 5.7% for bilateral repair. Some studies report that the incidence of clinical contralateral inguinal hernias identified after primary unilateral surgery is approximately 10%. If these contralateral hernias were diagnosed prior to the primary surgery, the risk of performing another operation could be avoided. Laparoscopic surgery enables bilateral hernia repair without any additional incisions, presenting similar morbidity rates when compared to unilateral repair. There was no significant difference between unilateral and bilateral TEP repair in terms of intraoperative and postoperative surgical complications. These results suggest that laparoscopic inguinal hernia repair is a safe and effective surgical technique for both unilateral and bilateral procedures. In order to prevent second operation, all patients with suspected inguinal hernia should undergo an US examination before surgery.

A study of contralateral occult inguinal hernia in adult male patients undergoing total extraperitoneal herniorraphy.

Background:The incidence of contralateral occult hernia (COH) varies from 4.2% to 57.5%. Total extraperitoneal (TEP) gives us opportunity to visualize contralateral groin for occult hernia and its simultaneous repair. Ultrasonography (USG) helps to diagnose occult hernia preoperatively with detection rate of 96.6% with specificity 84.4%.Objective:The aims of this study were to identify the incidence of contralateral occult inguinal hernia in clinically diagnosed unilateral inguinal hernia patients using USG as diagnostic modality and to compare the clinical outcomes of unilateral TEP vs. bilateral TEP with respect to pain, duration of hospital stay, time for return to normal work, and postoperative complications.Setting and Design:This was a prospective observational, single-center study.Materials and Methods:A total of 30 male patients were included in the study who was having clinically diagnosed unilateral hernia. All patients were assessed by USG for contralateral occult inguinal hernia.Results:Incidence of COH was 10%, two (6.7%) had indirect defect, and 1 (3.3%) had direct defect. Two (6.7%) patients underwent bilateral TEP and 28 (93.3%) underwent unilateral TEP. No significant difference was observed in terms of mean duration of hospital stay, duration of surgery, and visual analog scale score for pain in both unilateral and bilateral TEP. The mean for resuming daily work in unilateral TEP was 4.86 ± 0.833 days and in bilateral TEP the mean was 7.50 ± 0.70 days and this showed statistically significant difference (P < 0.001).Conclusion:Patients with COH should be counselled for synchronous repair as there is no significant difference in clinical outcomes of unilateral and bilateral TEP. On the basis of this pilot study, it can be concluded that preoperative USG is mandatory for diagnosis and simultaneous management of preexisting contralateral hernia.

Recurrence after totally extraperitoneal (TEP) inguinal hernia repair: the role of physical examination and ultrasound.

Physical examination (PE) combined with ultrasound (US) is recommended to confirm a recurrent hernia. However, the evidence is rather weak. The aim of this study was to evaluate PE and appraise the added value of US in alleged recurrent inguinal hernias after totally extraperitoneal (TEP) inguinal hernia repair. All adult patients who were re-operated for suspicion of a recurrent hernia after a primary unilateral or bilateral TEP between 2006 and 2017 were identified and investigated retrospectively. Patient characteristics, PE, additional imaging and intra-operative findings were registered. PE outcomes were compared with intra-operative findings to calculate the positive predictive value (PPV) of PE. In case of clinical doubt, the added value of US was evaluated by comparing US findings with the intra-operative findings. A total of 130 patients were re-operated for suspicion of 137 recurrent hernias. In 75 patients, US was performed. PE was positive for an inguinal hernia in 101 groins (73.7%), negative in 30 (21.9%) and inconclusive in 6 (4.4%). PE matched the operative findings in 75.2%. The PPV of diagnosing a recurrent hernia (or lipoma) on PE was 97%. In case of clinical doubt (n = 36), positive US matched the operative findings in 20 cases (87.0%). US does not necessarily need to be incorporated in the standard diagnostic workup of a recurrent inguinal hernia. After PE alone, a recurrent hernia (or lipoma) can be diagnosed with a PPV of 97%. Only in case of clinical doubt, US has additional value.

What happens after no contralateral exploration in total extraperitoneal (TEP) herniorrhaphy of clinical unilateral inguinal hernias?

While performing unilateral TEP herniorrhaphy, controversy still exists about whether to do contralateral exploration or not. Routine contralateral exploration has been proposed to prevent metachronous contralateral hernias by the repair of incidental contralateral occult hernias. Some surgeons have even proposed to do prophylactic bilateral TEP herniorrhaphy for unilateral hernia patients. To evaluate the appropriateness of not doing contralateral exploration in unilateral TEP herniorrhaphy, we reviewed our experiences under our practice of no contralateral exploration and we also reviewed other published literature. A total of 305 patients who underwent 313 TEP herniorrhaphies for inguinal hernias by a single surgeon during August 2012-July 2016 at Chia-Yi Christian Hospital were enrolled in this retrospective study. Demographic, perioperative and follow-up data were obtained for analysis and review. Of the 305 patients, 261 patients had unilateral TEP herniorrhaphy and 44 patients had bilateral TEP herniorrhaphy. The mean operation time for the unilateral TEP herniorrhaphy group was 59.8min, and for the bilateral TEP herniorrhaphy group it was 85.2min (p<0.001). Seven of 261 (2.7%) patients had metachronous contralateral hernia after unilateral TEP herniorrhaphy. There were no statistically significant differences in any of the outcome variables when comparing the sequential and simultaneous primary bilateral TEP herniorrhaphies. Without routine contralateral exploration, the incidence of metachronous contralateral hernia was 2.7% (7/261) in unilateral hernia patients. This is acceptable as metachronous hernia also occurred in 3.2% of patients with negative contralateral exploration according to our literature review. Sequential and simultaneous bilateral primary TEP herniorrhaphy outcomes were similar. We conclude that no exploration for the other groin is a justified decision for unilateral inguinal hernia patients.

Bilateral endoscopic totally extraperitoneal (TEP) inguinal hernia repair does not impair male fertility.

Endoscopic totally extraperitoneal (TEP) hernia repair with polypropylene mesh has become a well-established technique. However, since the mesh is placed in close contact with the spermatic cord, mesh-induced inflammation may affect its structures, possibly resulting in impaired fertility. The aim of this observational prospective cohort study was to assess fertility after bilateral endoscopic TEP inguinal hernia repair in male patients. Fifty-seven male patients (22-60years old) with primary, reducible, bilateral inguinal hernias underwent elective bilateral endoscopic TEP hernia repair with use of polypropylene mesh. The primary outcome was testicular perfusion; secondary outcomes were testicular volume, endocrinological status, and semen quality. All patients were assessed preoperatively and 6months postoperatively. Follow-up was completed in 44 patients. No statistically significant differences in measurements of testicular blood flow parameters or testicular volume were found. Postoperative LH levels were significantly higher [preoperative median 4.3IU/L (IQR 3.4-5.3) versus postoperative median 5.0IU/L (IQR 3.6-6.5), p=0.03]. Levels of inhibin B were significantly lower postoperatively [preoperative median 139.0ng/L (IQR 106.5-183.0) versus postoperative median 27.0ng/L (IQR 88.3-170.9), p=0.01]. No significant changes in FSH or testosterone levels were observed. There were no differences in semen quality. Our data suggest that bilateral endoscopic TEP hernia repair with polypropylene mesh does not impair fertility, as no differences in testicular blood flow, testicular volume, or semen quality were observed. Postoperative levels of LH and inhibin B differed significantly from preoperative measurements, yet no clinical relevance could be ascribed to these findings.

Male infertility after endoscopic Totally Extraperitoneal (Tep) hernia repair (Main): rationale and design of a prospective observational cohort study

BackgroundTo describe the rationale and design of an observational cohort study analyzing the effects of endoscopic Totally Extraperitoneal (TEP) hernia repair on male fertility (MAIN study).Methods and designThe MAIN study is an observational cohort study designed to assess fertility after endoscopic TEP hernia repair. The setting is a high-volume single center hospital, specialized in TEP hernia repair. Male patients of 18-60 years of age, with primary, reducible, bilateral inguinal hernias and no contraindications for endoscopic TEP repair are eligible for inclusion in this study. Patients with an ASA-classification ≥ III and patients with recurrent and/or scrotal hernias and/or a medical history of pelvic surgery and/or radiotherapy, known fertility problems, diabetes and/or other diseases associated with a risk of fertility problems, will be excluded. The primary outcome is the testicular perfusion before and 6 months after TEP hernia repair (assessed by means of a scrotal ultrasonography). Secondary endpoints are the testicular volume (Ultrasound), semen quality and quantity and the endocrinological status, based on serum levels of the sexual hormones follicle-stimulating hormone (FSH), luteinizing hormone (LSH), testosterone and inhibin B before and 6 months after TEP hernia repair.DiscussionThe use of polypropylene mesh is associated with a strong foreign body reaction which could play a role in chronic groin pain development. Since the mesh in (endoscopic) inguinal hernia repair is placed in close contact to the vas deferens and spermatic vessels, the mesh-induced inflammatory reaction could lead to a dysfunction of these structures. Relevant large and prospective clinical studies on the problem are limited. This study will provide a complete assessment of fertility in male patients who undergo simultaneous bilateral endoscopic TEP hernia repair, by analyzing testicular perfusion and volume, semen quantity and quality and endocrinological status before and 6 months after TEP repair.Trial registrationThe MAIN study is registered in the Dutch Trial Register (NTR2208)

Bilateral Endoscopic Total Extraperitoneal (TEP) Inguinal Hernia Repair Does Not Induce Obstructive Azoospermia: Data of a Retrospective and Prospective Trial

The endoscopic totally extraperitoneal (TEP) mesh repair is nowadays a well-established tension-free method for inguinal hernia repair. Mainly based on animal studies and case reports, a concern about the risk of postoperative infertility was expressed. This clinical study aimed to evaluate the risk of infertility due to obstructive azoospermia in men of fertile age who underwent a bilateral hernia repair. Over 3years (2005-2008) 59 male patients, 18-60years of age, underwent a bilateral TEP repair. Twenty-one of them were prospectively ("light mesh") and 38 retrospectively ("heavy mesh") evaluated for testicular volume and perfusion, serum levels of sexual hormones, ejaculate volume, and number of spermatic cells. Those parameters were determined preoperatively (prospective group) and not earlier than 3months postoperatively (both groups). No significant difference between pre- and postoperative values was detected in the prospectively studied group. All postoperative parameters were within the normal range in the retrospective group. There was no evidence of impaired fertility in any patient due to the operation. The standardized TEP technique for simultaneous bilateral inguinal hernia repair in male patients was not associated with a higher risk for postoperative infertility after mesh implantation. The use of heavy-weight meshes had no negative effect on fertility.

Serious life-threatening complication 5 years after laparoscopic totally extraperitoneal hernia repair: case report and discussion of the literature

The purpose of this paper is to report the case of a serious life-threatening infection of the mesh occurring 5 years after totally extraperitoneal (TEP) hernia repair and to highlight the persistent risk of infection that may exist even after a long period following the primary repair. We also aim to raise the awareness of surgeons to the subtle presentation. We have reviewed the clinical presentation, past medical history and relevant pre-operative and post-operative investigations in a case of mesh infection 5 years after primary surgery. We have also reviewed the literature regarding long-term complications that may occur after TEP repair. A 62-year-old man presented with severe mesh infection 5 years and 4 months after primary bilateral TEP hernia repair. He rapidly progressed into septic shock and had to be managed in the intensive care unit. He is a current smoker of 30 pack years. Post-operative contrast computed tomography (CT) revealed previously undiagnosed diverticuli scattered throughout the colon with points of minor narrowing at the sigmoid and transverse colons. Although the risk of mesh infection following TEP hernia repair is small, it persists for more than 5 years and probably as long as the mesh remains in the body. Our report also raises the question as to whether there is a specific long-term risk of mesh infection following TEP hernia repair in patients with underlying inflammatory bowel disease and/or chronic heavy smoking. This needs to be studied prospectively.

Prospective, randomized, controlled trial comparing lightweight versus heavyweight mesh in chronic pain incidence after TEP repair of bilateral inguinal hernia

This prospective, clinical, randomized, controlled study was performed to define the incidence of chronic pain after total extraperitoneal (TEP) repair with a light-weighted mesh compared with heavyweight mesh in patients with bilateral inguinal hernias. Consecutive patients with bilateral inguinal hernias were recruited for TEP inguinal hernia repair under general anesthesia. Heavyweight mesh was randomly assigned to one side of the groin and lightweight mesh to the other. Patients were followed up regularly for up to 1 year by an independent surgeon who was unaware of the mesh assignment. The postoperative pain score by means of a visual analogue scale (VAS) and other data were recorded. Fifty bilateral TEP hernia repairs were performed between September 2007 and February 2009. Six patients (12%) complained of chronic pain 3 months after the operation. A higher average pain score was observed for the side of hernia repaired by heavyweight mesh compared with lightweight mesh, but the difference was not statistically significant. More patients complained about foreign body sensation on the side repaired with heavyweight mesh (24%) compared with the side with lightweight mesh (8%; P < 0.05). There was no recurrence or need for reintervention for either type of mesh. Lightweight polypropylene mesh may be preferable to heavyweight mesh for TEP inguinal hernia repair because it provides less postoperative foreign body sensation; however, there was no significant difference in the incidence of chronic pain.

Is unilateral laparoscopic TEP inguinal hernia repair a job half done? The case for bilateral repair

Bilateral laparoscopic totally extraperitoneal (TEP) repair of unilateral hernia is conspicuous in published literature by its absence. There are no studies or data on the feasibility, advantages or disadvantages of bilateral repair in all cases or in any subset of patients with unilateral primary inguinal hernia. The objective of this study is to investigate the feasibility of bilateral laparoscopic exploration for all unilateral cases followed by laparoscopic TEP in all cases and to compare complications, recurrence rates, postoperative pain, patient satisfaction, and return to work retrospectively with a similar number of age-matched retrospective controls. One hundred fifty TEP operations were performed in 75 patients (group A) prospectively and were compared with 75 unilateral TEP operations (group B) in age-matched controls done previously by the same surgeon. All cases were performed under general anesthesia, and TEP repair was performed using three midline ports. All uncomplicated patients were discharged at 24 h, in keeping with departmental policy. Of 75 patients (group A), 25 (33.3%) were clinically diagnosed with bilateral hernia and the rest (50, 66.66%) with unilateral hernia. The distribution of the 25 bilateral cases was 11 bilateral direct and 14 bilateral indirect inguinal hernias. The distribution of the 75 age-matched controls (group B) was all unilateral hernia, of which 47 were right-sided and 28 were left-sided. There were 23 direct hernias and 52 indirect hernias among the control group. The mean operative time for all 150 cases was 76.66 +/- 15.92 min. The operative time in the control group (unilateral hernias) was 66.16 +/- 12.44 min, whereas the operative time in the test group (bilateral repair) was 87.2 +/- 11.32 min. The operative time in the bilateral group was significantly higher, by 21.04 min or 31.88% (p = 0.000). The operative time in the true unilateral group was 82.45 +/- 9.38 min, whereas the operative time in the former group [occult contralateral hernias (OCHs) + bilateral hernias] was 91.35 +/- 11.95 min, which is a statistically significant difference (p = 0.0015). Occult hernia was seen in a total of 15 cases, of which 13 were OCHs (26%) and 2 were occult ipsilateral hernias (OIH). The mean operative time in the OCH cases was 81.46 +/- 7.9 min, whereas in those without OCH it was 82.45 +/- 9.38 min, which is not a statistically significant difference (p = 0.46). Regarding complications, there were no cases of seroma, hematoma, wound infection, visceral injury or postoperative neuralgia in either group A or B. On statistical analysis, visual analog score (VAS)-measured pain score, at 12 h only, was significantly higher in the unilateral repair group as compared with the bilateral TEP group; VAS scores at all other times were not statistically significantly different between the two groups. The average time of return to light routine or activities of daily living was 1 day in group A, whereas in group B it was 1.91 days (range 1-3 days), which is a statistically significant difference (p = 0.000). There was one case of recurrence in this study, in a left-sided hernia in group A, over a follow-up period of 60-72 (mean 66) months; all patients reported for follow-up by office visit or correspondence until 2 years, and two patients were lost to follow-up after 2 years. In group B, there was no recurrence over a follow-up period of 72-84 months, with three patients lost to follow-up after 3 years. In the present study bilateral TEP was performed in three types of patients: those with clinically bilateral hernias, those with clinically unilateral hernia but with an OCH, and in truly unilateral hernias. All of these were compared with unilateral TEPs in clinically unilateral hernias, and we found no significant increase in morbidity, pain, recurrence or complications in bilateral repairs. Convalescence from surgery, as determined by return to activities of daily living and return to work parameters, was also comparable. Surgeons experienced in laparoscopic TEP, in high-volume centers, can provide bilateral repairs in patients with inguinal hernia, bearing in mind its advantages and comparable morbidity. We also feel that, in elective repair of inguinal hernia, the patient should be given the option of bilateral repair. Bilateral repair does not add to the risk of surgery in experienced hands and we strongly feel that unilateral TEP is actually a job half done.

Prospective double-blind randomized controlled study comparing heavy- and lightweight polypropylene mesh in totally extraperitoneal repair of inguinal hernia: early results

Success of totally extraperitoneal (TEP) inguinal herniorrhaphy depends upon strengthening of the weakened native tissue by inflammation resulting in mesh-aponeurosis scar tissue (MAST) complex formation. The inflammatory response attributable to polypropylene (PP) content of the mesh is linked to weight of PP and pore size of the mesh. Continuation of the inflammatory process beyond MAST complex formation can entrap contiguous structures, leading to adverse outcome such as groin pain. Reduction of PP content has been shown to be beneficial in animal studies. Paucity of randomized controlled trials (RCTs) on human beings has left choice of mesh to surgeon preference or cost. We carried out a double-blind RCT comparing heavy- and lightweight PP-based meshes in TEP. Consecutive, married, sexually active male candidates for bilateral TEP herniorrhaphy were enrolled without any exclusion, with ethical and informed consent protocol. Standard TEP technique was followed for day-care surgery. Heavy- and lightweight meshes were implanted in each patient, one in either groin after randomization. Surgeon and patient were blinded to side of groin and type of mesh. An independent doctor (AID) evaluated the patients for groin pain, discomfort, sexual dysfunction, and clinical recurrence. A nonmedical secretary/AID transferred prospective data for both sides of groin collected by AID to Microsoft Excel. Twenty-five bilateral TEPs implanting 25 heavy- and 25 lightweight PP meshes, one of each type in each patient, were performed from December 2005 to July 2007 without difficulty or complication. Lightweight PP mesh was associated with significantly better pain scores, patient comfort, and sexual function. There was no infection or recurrence with either type of mesh. Lightweight PP mesh is associated with significantly better outcomes in TEP inguinal herniorrhaphy as compared with heavyweight PP mesh.

Bilateral laparoscopic inguinal hernia repair in patients with occult contralateral inguinal defects

A high incidence of bilateral inguinal defects found on laparoscopic evaluation during hernia repair has been reported. However, expectation of bilateral inguinal defects in patients who are diagnosed with pure unilateral hernia might be underestimated. A prospective clinical study was performed to reveal a rate of contralateral occult defects in patients who were diagnosed with unilateral inguinal hernia prior to primary laparoscopic totally extraperitoneal (TEP) repair. One hundred consecutive male patients with primary unilateral inguinal hernias were included in the study. Patients with known bilateral inguinal hernias as well as femoral, giant and combined hernias were excluded. All patients underwent TEP with exploration and evaluation of the contralateral groin. Median follow-up was 24 (4-46) months. Median age was 48 (18-73). Mean operative time was 42.2 (18-167) min. There were 78 (78%) patients with pure unilateral hernias and 22 (22%) patients with bilateral hernias whose contralateral inguinal defect or hernia was revealed only intraoperatively. Of those, 19 (86%) had right and 3 (14%) left occult defects. Minor complications occurred in 17 (17%) patients. There were no major complications. Two patients required a 23-hour stay in the hospital for urinary retention and hypoxia. Median period of returning to normal activity was 7 (5-14) days. There were two (2%) recurrences. Median period of returning to normal activity was 6.2 days after unilateral repair and 8.4 days after bilateral TEP. This study revealed 22% occurrence of bilateral inguinal defects in the patients who are diagnosed with pure inguinal hernia before surgery, with higher incidence for those with left inguinal hernia. It appears that routine contralateral groin exploration and evaluation during TEP is valuable. Patients with occult bilateral hernias are benefit from bilateral TEP.

Totally extraperitoneal laparoscopic hernia repair in patients with previous lower abdominal surgery

Patients with lower abdominal scars are generally excluded from laparoscopic hernia repair due to the perceived technical difficulty and risk of visceral injury. This study examines the outcome of a series of patients who underwent totally extraperitoneal (TEP) inguinal hernia repair despite previous lower abdominal surgery. Retrospective review of 47 consecutive patients who underwent TEP inguinal hernia repair in the presence of lower abdominal scars between 1993 and 2002. Thirty-five unilateral and 12 bilateral TEP hernia repairs were performed in the presence of 20 appendicectomy, 10 lower midline, 18 suprapubic and 5 paramedian incisions. Two cases were converted to open repair. There were no major complications and no early or late recurrences. Median operating time was 67.5 min and 83% of patients were managed as day cases. Totally extraperitoneal laparoscopic hernia repair can be carried out safely in the presence of scars from previous lower abdominal surgery.

Acute pain after endoscopic totally extraperitoneal (TEP) inguinal hernioplasty: multivariate analysis of predictive factors.

Pain is the most common complaint after inguinal hernia surgery. The present study was undertaken to evaluate the significance of various perioperative clinical factors on the severity of postoperative pain following endoscopic totally extraperitoneal (TEP) inguinal hernioplasty. Between November 1999 and December 2002, 509 patients who underwent unilateral ( n = 389) and bilateral ( n = 120) TEP were recruited for this study. There were 491 men and 18 women. Severity of postoperative pain at rest and on coughing was assessed by a linear analogue pain score (scale, 0-10) on a daily basis after operation. Univariate and multivariate analyses were performed to identify the significant independent factors affecting pain. By univariate analysis, pain scores at rest were significantly higher in young (< or =65 years) female patients, as well as patients who underwent unilateral and day case TEP. Clinical factors associated with a significantly higher pain score on coughing included mesh fixation by stapling, female sex, and age (< or =65 years). Other factors, including unilateral vs bilateral TEP, seroma formation, direct vs indirect hernia, primary vs recurrent hernia, and operative time, had no impact on postoperative pain. On multiple regression analysis, age and sex were found to be independent predictive factors for mean daily pain score at rest. Independent factors influencing mean pain score on coughing included age, sex, and prosthetic stapling. Patient age and sex are the most significant factors determining the degree of pain after TEP. Analgesic therapy should therefore be adjusted in accordance with the age of the patient. With regard to operative factors, avoidance of prosthetic stapling might help to reduce the severity of pain on coughing.

A prospective endoscopic study of retropubic vascular anatomy in 121 patients undergoing endoscopic extraperitoneal inguinal hernioplasty.

A sound knowledge of retropubic pelvic vascular anatomy is pivotal to the successful performance of endoscopic total extraperitoneal (TEP) inguinal hernioplasty. The objective of the current study was to evaluate the incidence and anatomy of iliopubic and aberrant obturator vessels. Between July 2001 and March 2002, a prospective endoscopic evaluation of retropubic vascular anatomy was performed on patients who underwent TEP. Endoscopic photographs of the vasculature overlying the superior pubic ramus in the recruited patients were captured on a computer. The retropubic vascular anatomy of 121 patients, who underwent either unilateral (n = 100) or bilateral (n = 21) TEP was examined. The iliopubic artery and vein were invariably present in every patient, and traversed along the iliopubic tract toward the pubic symphysis. The aberrant obturator artery was present in 31 pelvic halves, giving an overall incidence of 22%. The aberrant obturator vein existed between the external iliac and obturator venous system in 27% (n = 38) of the 141 pelvic halves examined. The overall incidence of corona mortis, in the form of either an aberrant obturator vein or artery, was 40% (n = 56). Iliopubic vein and artery are universal findings in every patient. Both aberrant obturator artery and vein cross the superior pubic rami, and are therefore susceptible to injuries during dissection of the Bogros space and stapling of the mesh onto Cooper's ligament. Awareness of these aberrant vessels will help to reduce bleeding and subsequent morbidity. Tracing along the aberrant vessel can easily identify the obturator foramen, which is an anatomic landmark that indicates an adequate inferior dissection of the preperitoneal space.

An Unexpected Complication During Laparoscopic Herniorrhaphy

An Unexpected Complication During Laparoscopic Herniorrhaphy