Transabdominal Preperitoneal Technique Research Articles

Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years

Two revolutions in inguinal hernia repair surgery have occurred during the last two decades. The first was the introduction of tension-free hernia repair by Liechtenstein in 1989 and the second was the application of laparoscopic surgery to the treatment of inguinal hernia in the early 1990s. The purposes of this study were to assess the safety and effectiveness of laparoscopic totally extraperitoneal (TEP) repair and to discuss the technical changes that we faced on the basis of our accumulative experience. Patients who underwent an elective inguinal hernia repair at the Department of Abdominal Surgery at the Institute of Laparoscopic Surgery (ILS), Bordeaux, between June 1990 and May 2005 were enrolled retrospectively in this study. Patient demographic data, operative and postoperative course, and outpatient follow-up were studied. A total of 3,100 hernia repairs were included in the study. The majority of the hernias were repaired by TEP technique; the repair was done by transabdominal preperitoneal (TAPP) repair in only 3%. Eleven percent of the hernias were recurrences after conventional repair. Mean operative time was 17 min in unilateral hernia and 24 min in bilateral hernia. There were 36 hernias (1.2%) that required conversion: 12 hernias were converted to open anterior Liechtenstein and 24 to laparoscopic TAPP technique. The incidence of intraoperative complications was low. Most of the patients were discharged at the second day of the surgery. The overall postoperative morbidity rate was 2.2%. The incidence of recurrence rate was 0.35%. The recurrence rate for the first 200 repairs was 2.5%, but it decreased to 0.47% for the subsequent 1,254 hernia repairs According to our experience, in the hands of experienced laparoscopic surgeons, laparoscopic hernia repair seems to be the favored approach for most types of inguinal hernias. TEP is preferred over TAPP as the peritoneum is not violated and there are fewer intra-abdominal complications.

Laparoscopic repair of recurrent groin hernia: results of a prospective study

Recurrences continue to be seen after repair of inguinal hernias. The repair of these recurrent hernias is a more complex and demanding procedure, with a high re-recurrence rate. Definite advantage has been demonstrated with endoscopic repair of these hernias. The results for this prospective study from January 2003 to December 2006 were evaluated after laparoscopic repair of 65 recurrent hernias in 61 patients. The patients were followed up for 1 year. Longer follow-up evaluation was performed for the patients who underwent surgery in the initial 3 years. In this study, 37 recurrent hernias were managed using the transabdominal preperitoneal technique (TAPP) technique and 28 using the totally extraperitoneal (TEP) technique. There was no conversion and no cases of postoperative wound infection. Of the 12 metachronous hernias repaired simultaneously, 3 were occult. Seroma developed in five patients. At a follow-up assessment after 1 year, one patient had groin pain, and there was one re-recurrence. A longer follow-up period with a mean of 35.11 months failed to show any new re-recurrence. Laparoscopic repair of recurrent inguinal hernia is safe and effective. The morbidity and recurrence rates for the procedure are as low as for laparoscopic repair of primary hernias. Laparoscopic repair should be the gold standard for these hernias.

Laparoscopic repair of inguinal hernias using an intraperitoneal onlay mesh technique and a Parietex composite mesh fixed with fibrin glue (Tissucol). Personal technique and preliminary results

Laparoscopic repair of inguinal hernias is usually achieved by totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) techniques. The intraperitoneal onlay mesh (IPOM) could be an interesting alternative as it is much easier to perform and faster to execute. This technique is subject to correct selection of indications and to demonstration of its safety. From January 2003 to January 2006 we performed 61 laparoscopic hernia procedures on 60 selected patients (60 males with a mean age of 60 and mean weight of 76 kg) with an IPOM technique combining the Parietex composite mesh (12 cm circular model) and a fibrin glue (Tissucol) for its fixation. The glue was diluted to increase fixation time and applied to the mesh prior to positioning on the hernia defect. Mean operative time was 10 minutes. Mean hernia diameter was 2.5 cm (+/- 0.8 cm). 10 hernias were direct, 51 were indirect and 10 out of 61 were recurrent. We did not convert any of the laparoscopic procedures. Mean hospital stay was one day; mean recovery time for working and general physical activities was five days. Patients were checked after one week, 1-3-6 months and 1-2 years. Average follow up time was 23.7 months. 1.6 % of patients showed short-term complications: one trocar site haematoma. No additional complications were reported; particularly, we had no recurrence, no seroma, no mesh migration, and no bowel obstruction or fistula. Results of this study show intraperitoneal (IP) tolerance to this kind of mesh and the safety of its fixation with Tissucol. The absence of recurrence and complications could be a good reason to extend the indication of IPOM hernia repair. However, these preliminary results should be confirmed by longer follow-up.

Unexpected Adhesions to a Previously Inserted Preperitoneal Mesh Plug

Adhesion formation is a long-term complication of laparoscopic inguinal hernia surgery-particularly by the transabdominal preperitoneal technique; but it is not thought to occur after open repair. We describe a gentleman presenting with a recurrent hernia who had previously undergone an open mesh plug repair 4 years earlier. At laparoscopy he was found to have considerable adhesions associated with the plug. These were successfully divided before repair. This case illustrates the possibility of intra-abdominal adhesions developing even after open hernia surgery.

Laparoscopic groin hernia repair: results of 200 consecutive herniorraphies.

Laparoscopic hernia surgery was introduced in this unit in May 1992. Up to September 1993, 175 patients with 200 inguinal and femoral hernias were treated using this approach. This prospective study deals with intraoperative and postoperative complications, patient recovery and early operative results. The median (range) age was 58 (21-87) years and the median (range) follow-up was 12 (5-24) months. A laparoscopic transabdominal preperitoneal technique was used. The median (range) operation time was 67 (23-160) min for unilateral hernias and the median (range) hospital stay was 1 (0-27) day. Major complications were two postoperative bowel obstructions and seven recurrences, six of these in the first 31 patients. Overall, 17 minor complications were recorded; 52 per cent of the patients were back at work within 1 week, and 94 per cent within 1 month. The value of laparoscopic hernia repair remains to be determined and randomized controlled trials will be necessary.

The totally extraperitoneal approach (TEP) to inguinal hernia repair

INTRODUCTION Laparoscopic hernia surgery has been the subject of over 40 randomized trials. Many metaanalyses have drawn together their results, the most recent and possibly the least biased from NICE 2004 con rms the proven bene ts of accelerated recovery, less early and persistent post-operative pain and reduced risk of wound bleeding, seroma and infection after laparoscopic hernia repair.1 Recurrence rates are the same as open mesh repair. Open repair has no proven bene t over laparoscopic repair except that it is technically easier to perform. Major blood vessel, bowel and bladder injury are extremely rare and mostly associated with the trans-abdominal pre-peritoneal (TAPP) technique. NICE recommends that patients should be made aware of the risks and bene ts of open and laparoscopic mesh repair. It is dif cult to know why a patient might opt for open surgery when made fully aware of the facts. We believe that laparoscopic totally extra-peritoneal (TEP) repair, carried out by appropriately trained surgeons, is superior to open hernia repair. NICE also states that laparoscopic TEP repair should only be performed by trained surgeons but does not de ne what constitutes a “trained” operator. This practical guide to the operation of laparoscopic TEP repair is based on the combined 10-year experience of over 1000 operations performed by two surgeons. Laparoscopic TEP repair can be performed without expensive technical aids such as balloon dissectors, specialised ports or staple guns for mesh xation. In our routine hospital practice, it is performed in slightly less time than open repair in equivalent patients. SURGICAL PROCEDURE

Laparoscopic Repair of Groin Pain in Athletes

Background There has been increasing interest regarding the cause and treatment of groin pain in athletes. The most common finding is a deficiency of the posterior wall of the inguinal canal, often repaired with bilateral inguinal myorrhaphy. Hypothesis Laparoscopic repair will offer a shorter convalescent period and better results as compared with open myorrhaphy. Study Design Retrospective review of prospectively collected data. Methods Between October 1993 and October 2002, 131 athletes with groin pain unrelieved after 2 to 8 months of conservative management underwent bilateral laparoscopic repair with the transabdominal preperitoneal technique for hernias. In 123 (94%) patients, physical examination revealed a dilated external ring, unilateral or bilateral, of the inguinal canal, and in 8 patients (6%) it was normal. Results During laparoscopy, a deficiency of the posterior inguinal wall was seen in all athletes. All patients left the hospital 24 hours after the procedure, discontinued oral analgesics within 72 hours of surgery, and were back to full sporting activities with- in 2 to 3 weeks. Four patients (3%) complained of thigh pain. After a mean follow-up of 5 years (range, 4 months to 10 years), there was 1 recurrence (0.76%). Conclusions Laparoscopic repair is an efficient method for the treatment of groin pain originating from a deficiency of the posterior inguinal wall, having fast recovery and excellent long-term results.

The femoral hernia: an ideal approach for the transabdominal preperitoneal technique (TAPP).

We designed a study to determine the rate of intra- and postoperative complications as well as the rate of recurrences in elective operated femoral hernias treated via the laparoscopic technique. Between 1993 and 1998, we performed 1,097 operations in our department using the laparoscopic transabdominal preperitoneal (TAPP) technique. Femoral hernias amounted to only 4.6% (51 cases) of these patients. The male/female ratio was 1:2. The data concerning the operations and pre- and postoperative treatment were recorded prospectively. The patients were followed up at 2 weeks and 1 year after the operation. We encountered one intraoperative bladder lesion, one subcutaneous port site infection, two postoperative hematomas that required reoperation, and two nerve irritation syndromes, which disappeared spontaneously after 6 months. Two patients developed an ileus; one required laparoscopic reintervention, and the other was treated with conventional open reoperation and intestinal resection. There were no recurrences. The application of the laparoscopic approach to the treatment of femoral hernias using the TAPP technique in nonemergency situations is highly effective. To date, we have seen no recurrences. Although the rate of major complications is low, current surgical techniques need to be perfected to avoid the type of complication recognized in this study.

The cutaneous nerves encountered during laparoscopic repair of inguinal hernia: new anatomical findings for the surgeon.

With an incidence rate of 2%, injury to the nerves of the lumbar plexus is the most common complication of laparoscopic hernioplasty, particularly when the transabdominal preperitoneal (TAPP) technique is used. The course of the genitofemoral nerve, lateral femoral cutaneous nerve, and ilioinguinal nerve within the operation site was investigated in 53 adult dissecting-room bodies. Their relationship to the deep inguinal ring, iliopubic tract, and anterior superior iliac spine was also examined. Both the femoral and genital branches of the genitofemoral nerve may penetrate the abdominal wall lateral to the deep ring and cranial to the iliopubic tract. The lateral femoral cutaneous nerve and the ilioinguinal nerve may run immediately lateral to the anterior superior iliac spine. Contrary to the previously accepted opinion, dissection and the placement of staples either cranial to the iliopubic tract or lateral to the anterior superior iliac spine can result in injury to the nerves.

Laparoscopic hernia repair: the learning curve.

The performance of a laparoscopic inguinal hernia repair requires unique technical and cognitive skills which, until recently, were not routinely taught to general surgeons. The initial experience of three surgeons with laparoscopic hernia repair was audited prospectively to assess the learning curve for the technique. From March 1992 to June 1994, transabdominal preperitoneal (TAP) mesh repair was attempted on 172 consecutive inguinal hernias. Three procedures were converted to traditional repairs. The three independent surgeons that performed the repairs had minimal or no prior clinical experience with the technique in the role as primary surgeon. The hernia repairs were divided into two groups. Group 1 consisted of the first 90 hernia repairs in the series, 30 repairs per surgeon. This group was compared to the subsequent 82 repairs (group 2), approximately 27 repairs per surgeon. Patients were followed up for a median of 31 months. Group 1 had more patients who were hospitalized overnight (37% versus 31%), a greater rate of conversion (2.2% versus 1.2%), a higher complication rate (11.7% versus 0%), a higher recurrence rate (12.2% versus 0%), and a longer delay in the return to full activity (11 weeks versus 8 weeks). Also, overall patient satisfaction with their hernia repair was slightly greater in group 2 (score, 9.0/10 versus 8.2/10). The lack of prior experience with the TAP technique (one surgeon) was associated with a marked increase in the number of conversions (two of three total conversions), complications (four of eight total), and hernia recurrences (8 of 11 total). This study demonstrates that a surgeon's initial experience with laparoscopic herniorrhaphy is associated with an identifiable learning curve. Significant improvements in complication and recurrence rates and overall patient satisfaction can be expected after the initial learning phase. Also, a complete lack of prior experience with laparoscopic herniorrhaphy is associated with a higher rate of conversion and significant increases in complications and hernia recurrences.

Laparoscopic Hernia Repair: The Learning Curve

The performance of a laparoscopic inguinal hernia repair requires unique technical and cognitive skills which, until recently, were not routinely taught to general surgeons. The initial experience of three surgeons with laparoscopic hernia repair was audited prospectively to assess the learning curve for the technique. From March 1992 to June 1994, transabdominal preperitoneal (TAP) mesh repair was attempted on 172 consecutive inguinal hernias. Three procedures were converted to traditional repairs. The three independent surgeons that performed the repairs had minimal or no prior clinical experience with the technique in the role as primary surgeon. The hernia repairs were divided into two groups. Group 1 consisted of the first 90 hernia repairs in the series, 30 repairs per surgeon. This group was compared to the subsequent 82 repairs (group 2), approximately 27 repairs per surgeon. Patients were followed up for a median of 31 months. Group 1 had more patients who were hospitalized overnight (37% versus 31%), a greater rate of conversion (2.2% versus 1.2%), a higher complication rate (11.7% versus 0%), a higher recurrence rate (12.2% versus 0%), and a longer delay in the return to full activity (11 weeks versus 8 weeks). Also, overall patient satisfaction with their hernia repair was slightly greater in group 2 (score, 9.0/10 versus 8.2/10). The lack of prior experience with the TAP technique (one surgeon) was associated with a marked increase in the number of conversions (two of three total conversions), complications (four of eight total), and hernia recurrences (8 of 11 total). This study demonstrates that a surgeon's initial experience with laparoscopic herniorrhaphy is associated with an identifiable learning curve. Significant improvements in complication and recurrence rates and overall patient satisfaction can be expected after the initial learning phase. Also, a complete lack of prior experience with laparoscopic herniorrhaphy is associated with a higher rate of conversion and significant increases in complications and hernia recurrences.

Incisional Hernia and Fascial Defect Following Laparoscopic Surgery

Complications involving the abdominal wall, particularly incisional hernias, were not expected when laparoscopic procedures were first introduced. With the increasing number of laparoscopies in abdominal surgery, more incisional hernias are observed. The authors report 13 cases of umbilical incisional hernia, which occurred late after laparoscopic cholecystectomy, and one case of omental procidentia through a lateral port, which occurred early after laparoscopic hernia repair with the transabdominal preperitoneal technique. There are 4 men and 10 women (mean age, 59.8 years; range, 40-74 years). Between March 1991 and December 1997, a total of 1,287 patients underwent laparoscopic operations at the Surgical Department of the Gradenigo Hospital in Turin, Italy. Incisional hernia incidence is 1%. Risk factors, such as chronic bronchitis or weight increase, which give rise to endoabdominal pressure, are present in some cases. Malnutrition may have a major role in many cases. Calculi larger than 15 mm are also seen frequently. Postlaparoscopy incisional hernia is generally a minor complication--only once did its occurrence cause a strangulated hernia. All precautions, including fascial suturing, must be taken to reduce the 1% incidence of postoperative incisional hernias.

Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC).

This article reports the results of a multicenter prospective audit of totally extraperitoneal (TEP) inguinal hernia repair conducted by the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC) from May 1995 to August 1996. At 29 Swiss centers 1,605 inguinal hernia repairs were performed in 1,186 patients. Half of the repairs were performed by operators whose experience consisted of fewer than 51 procedures. Patients were followed up for 1 year. Bilateral repairs were performed in 35% of the patients, and 15% of all repairs were for recurrent hernia. Conversion rates to the transabdominal preperitoneal (TAPP) technique and open surgery were 1.8% and 1.6%, respectively. Main postoperative complications were hematoma and urinary retention. At 3 months, seroma was more frequent with slit prosthesis. The recurrence rate was 0.6% at 3 months and 1.6% at 1 year, not depending on the type of implant. The rate for recurrent hernias did not differ from that for primary repairs. Total extraperitoneal (TEP) repair can be performed with low morbidity and a high level of patient satisfaction. The effects of the learning curve are not to be neglected. The 1-year recurrence rate is 1.6%. Published data on TEP suggest that late recurrences may be less frequent than after open repair.

Incisional hernia and fascial defect following laparoscopic surgery.

Complications involving the abdominal wall, particularly incisional hernias, were not expected when laparoscopic procedures were first introduced. With the increasing number of laparoscopies in abdominal surgery, more incisional hernias are observed. The authors report 13 cases of umbilical incisional hernia, which occurred late after laparoscopic cholecystectomy, and one case of omental procidentia through a lateral port, which occurred early after laparoscopic hernia repair with the transabdominal preperitoneal technique. There are 4 men and 10 women (mean age, 59.8 years; range, 40-74 years). Between March 1991 and December 1997, a total of 1,287 patients underwent laparoscopic operations at the Surgical Department of the Gradenigo Hospital in Turin, Italy. Incisional hernia incidence is 1%. Risk factors, such as chronic bronchitis or weight increase, which give rise to endoabdominal pressure, are present in some cases. Malnutrition may have a major role in many cases. Calculi larger than 15 mm are also seen frequently. Postlaparoscopy incisional hernia is generally a minor complication--only once did its occurrence cause a strangulated hernia. All precautions, including fascial suturing, must be taken to reduce the 1% incidence of postoperative incisional hernias.

Inguinal hernia repair by laparoscopic surgeons: early experience and attitudes.

The introduction of laparoscopic inguinal hernia repair (LIHR) has been controversial. A questionnaire was sent to all general surgeons in New Zealand to document the early experience with LIHR and attitudes towards it. Of the 118 replies (response rate 55%), 74 were from laparoscopic surgeons, 26 of whom had performed 564 (201 public, 363 private) LIHR (23 bilateral) until January 1994. Only nine (35%) of these surgeons had assisted an experienced surgeon before performing an LIHR, and only four (15%) were supervised by an experienced surgeon during their first case. The transabdominal preperitoneal technique of LIHR was used by 14 (54%) surgeons, the extraperitoneal technique by eight (31%), and the transabdominal onlay technique by four (15%). There were 29 (5%) recurrences, 17 (3%) neuropathies, seven (1.2%) conversions, four (0.7%) major perforations, and one (0.17%) death. Of the 26 surgeons who performed LIHR, 20 (77%) were concerned about the absence of long-term results, 14 (54%) considered that the optimal technique had not been established, 13 (50%) were concerned about the unique complications associated with LIHR, 11 (42%) were less enthusiastic about performing LIHR than previously, 10 (38%) were doubtful about its advantages, and six (23%) were uncertain about its future and considered that it should only be performed within the context of a controlled trial. This study highlights a number of issues that need to be addressed before the role of LIHR can be determined.

Incidence of complications following laparoscopic hernioplasty

Smaller individual series on the outcome of laparoscopic hernioplasty techniques have been reported. This study reports on the complications of 3,229 laparoscopic hernia repairs performed by the authors in 2,559 patients. The TAPP (transabdominal preperitoneal) technique was the most frequently performed: 1,944 (60%). The totally preperitoneal technique was performed 578 (18%) times. The IPOM (intraperitoneal onlay mesh) repair was performed 345 (11%) times. The plug-and-patch technique was used 286 (9%) times and simple closure of the hernia defect without mesh was used in 76 (2%) repairs. Overall, there were 336 (10%) complications: 17 (0.5%) major and 265 (8%) minor. There were 54 (1.6%) recurrences, with a mean follow-up of 22 months. The TAPP technique had 19 (1%) recurrences and 141 (7%) complications. There were four bowel obstructions in this subgroup from herniation of small bowel through the peritoneal closure and trocar sites. The totally preperitoneal technique had no recurrence and 60 (10%) complications. The IPOM group had 7 (2%) recurrences and 47 (14%) complications. The plug-and-patch technique had 26 (9%) recurrences and 24 (8%) complications. The simple closure of the internal ring had 2 (3%) recurrences and 10 (13%) complications. Laparoscopic hernioplasty is not without complications. Laparoscopic hernioplasty is not without complications. Training, experience, and attention to technique will prevent some of these complications.