Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies

Laparoscopic hernia repair remains controversial, and its position in current hernia surgery remains in flux. In this article we attempt to put the laparoscopic approach in perspective by describing the rationale for its development. We summarize studies comparing it with open repairs, including recent publications, meta-analyses, and systematic reviews; and we then contrast the data with recent findings of the United States Veterans Affairs Cooperative study 456. We discuss the current and future status of the laparoscopic approach to inguinal hernia repair and present an update of our own laparoscopic totally extraperitoneal technique without mesh fixation. From 1994 to 2004 we performed 314 hernia repairs on 224 patients with no intraoperative complications, no conversions to an open procedure, and no mortality. Thirty (14%) minor postoperative complications occurred. There were three herniated lipomas (preperitoneal fat) but no true peritoneal reherniations. We evaluate critical points of laparoscopic hernia repair including extensive preperitoneal dissection, mesh configuration, size and fixation, cost reduction, and the learning curve.     

Single surgeon experience with bilayer polypropylene mesh repair of inguinal hernia

Background: Open mesh repair of inguinal hernia has been shown to be an effective and safe method of hernia repair. In search of the ‘ideal’ method of open mesh hernia repair, many different methods of mesh placement have been developed. Laparoscopic hernia repair is reported to be superior to open repair in terms of postoperative pain and rehabilitation. These improved functional outcomes could be the result of placement of mesh in the preperitoneal space (underlay), rather than the laparoscopic method per se. A bilayer polypropylene mesh implant has been developed that provides onlay and underlay (preperitoneal) mesh layers. The present study reports the singular experience of a general surgeon with this bilayer polypropylene mesh implant. Methods: A retrospective audit of the first 169 consecutive inguinal hernia repairs was conducted by mailed questionnaire and telephone interview. Data was collected on patient demographics, postoperative pain scores and complications. Patients with potential recurrences at the time of follow up were invited for clinical review. Results: One hundred and three patients (71%) participated in the audit. Thirteen per cent of cases were for recurrent hernia. Median age was 60 years (range 21?99). Median length of follow up was 19 months (range 8?27). No recurrences were detected in the patients who underwent primary repair of inguinal hernia. Conclusion: Inguinal hernia repair with bilayer polypropylene mesh is safe and has low complication and recurrence rates.     

Laparoscopic Mesh Versus Open Preperitoneal Mesh Versus Conventional Technique for Inguinal Hernia Repair: A Randomized Multicenter Trial (SCUR Hernia Repair Study)

OBJECTIVE: To evaluate the influence of the laparoscopic technique in hernia repair regarding time to full recovery and return to work, complications, recurrence rate, and economic aspects. SUMMARY BACKGROUND DATA: Several studies have shown advantages in terms of less pain and faster recovery after laparoscopic hernia repair, whereas others have not, and the cost-effectiveness has been questioned. The laparoscopic technique must be thoroughly compared with the open procedures before its true place in hernia surgery can be defined. METHODS: Six hundred thirteen male patients aged 40 to 75 years were randomized to the conventional procedure, preperitoneal mesh placed by the open technique, or laparoscopic preperitoneal mesh (TAPP). Follow-up was after 7 days, 8 weeks, and 1 year. RESULTS: Of 613 patients undergoing surgery, 604 (98.5%) were followed for 1 year. Patients who underwent TAPP gained full recovery after 18.4 days, compared with 24.2 days for open mesh (p < 0.001) and 26.4 days for the conventional procedure (p < 0.001). Patients who underwent TAPP returned to work after 14.7 days, compared with 17.7 days for open mesh (p = 0.05) and 17.9 days for the conventional procedure (p = 0.04). They also had significantly less restriction in physical activities after 7 days. The TAPP procedure was more expensive, mainly as a result of longer surgical time and equipment costs, even after compensation for earlier return to work. Complications were more common in the TAPP group, with a varying pattern between the groups. Four recurrences in the conventional, 11 in the open mesh, and 4 in the TAPP group were recorded after 1 year (p = n.s.). CONCLUSION: The laparoscopic technique results in both shorter time to full recovery and shorter time to return to work, at the price of substantially increased costs.     

腹腔镜完全腹膜外免钉合腹股沟疝修补术45例

目的探讨腹腔镜完全腹膜外免钉合腹股沟疝修补术的可行性和安全性。方法 2007年1月~2010年3月我院对45例(52侧)腹股沟疝行腹腔镜完全腹膜外疝修补术,用镜头替代气囊分离器分离腹膜前间隙,用预成形巴德3D Max补片无钉合固定。结果 45例手术全部成功,手术时间(65.8±21.8)min,术中出血量(15.3±4.6)ml,术后住院时间(2.7±1.2)d。术后阴囊血清肿1例,局部穿刺抽液3次及理疗1个月后治愈。45例随访1~38个月,平均15.6月,其中随访1年36例,未见复发及腹股沟区慢性疼痛等并发症。结论免钉合TEP是一种可行、安全、有效的无张力疝修补技术。     

腹腔镜下腹腔内补片修补术治疗腹壁切口疝的临床研究

目的探讨腹腔镜下腹腔内补片修补术（IPOM）治疗腹壁切口疝的安全性及可行性。 方法回顾性分析2014-2019年中国人民解放军南部战区总医院对103例腹壁切口疝患者实施腹腔镜下IPOM的临床资料,观察其手术时间、术后排气时间、术后住院时间、并发症及复发情况。 结果103例患者均顺利完成手术,平均手术时间、术后排气时间及术后住院时间分别为（100±10）min、（40±8）h及（7.5±1.5）d。术中发现1例合并脐疝同时行脐疝修补,1例合并右侧腹股沟直疝同时行TAPP术,1例嵌顿性肠梗阻并肠坏死同时行肠切除吻合术。术后轻微并发症经短期治疗后痊愈,随访3~24个月,均无切口疝复发。 结论腹腔镜下IPOM治疗腹壁切口疝具有安全、有效、创伤小、可发现隐匿疝、术后康复快、能降低并发症、缩短住院时间、复发率低等优点。     

腹腔镜完全腹膜外腹直肌后间隙成人脐疝修补术

目的探讨全腹腔镜下将补片置于腹膜前腹直肌后间隙进行脐疝修补效果。 方法沈阳军区总医院2015年6月至2017年11月,共完成腹腔镜完全腹膜外肌后间隙脐疝补片修补术9例,其中男性5例,女性4例,平均年龄48.2（28～70）岁,术中采用全腹腔镜在腹直肌后方分离腹膜前间隙及脐疝缺损区,关闭缺损后将补片置于腹直肌后间隙内进行修补,对患者的临床资料进行回顾性分析。 结果9例患者均顺利完成手术,平均手术时间100 min（73～130 min）,术后平均住院时间1.8（1～3）d,发生脐部皮肤小面积坏死感染1例,脐部积液1例。无出血、肠梗阻、肠瘘等严重并发症,无复发及慢性疼痛。 结论采用腹腔镜完全腹膜外肌后间隙放置补片的方法进行脐疝修补是可行的,避免了腹腔内补片修补手术的不足,限于病例数原因,尚需进一步观察后续结果。该术式为脐疝的腔镜治疗提供了一个新的方法。     

Triple-Step Laparoscopic Incisional Hernia Repair: Midline Suture Closure Supported by Dorsal Component Separation and Intraperitoneal Onlay Mesh Reinforcement

Incisional hernias remain a surgical challenge when balancing surgical morbidity, functional restoration, and risk of recurrence. Laparoscopic intraperitoneal onlay mesh (IPOM) placement reduces postoperative wound infections and allows fast patient recovery. Yet, current IPOM techniques do not achieve closure of the midline hernia gap, thereby increasing the risk of persistent mesh bulging with poor abdominal wall function. We propose a novel triple-step hernia repair technique that includes tension-free midline reconstruction. It is achieved through laparoscopic dorsal component separation and laparoscopic suture closure of the midline with a 1.0 polydioxanone suture sling. Combining dorsal abdominal wall component separation, a midline closure with adequate suture strength, and IPOM reinforcement merges the benefits of open and laparoscopic hernia repair. This triple-step technique allows static and functional laparoscopic abdominal wall reconstruction.     

Robot-Assisted Transabdominal Preperitoneal Ventral Hernia Repair

Background and Objectives:

We believe that complications due to the mesh used in ventral hernia repairs can be reduced by using the natural barrier afforded by the peritoneum. This can be challenging to do laparoscopically, however we felt that the robot-assisted laparoscopic approach reduces the difficulty in placing the mesh in the preperitoneal space, and we want to share our early experiences with this approach. We describe the surgical technique used in robot-assisted laparoscopic transabdominal preperitoneal (TAPP) ventral hernia repair with mesh. In addition, we evaluate its feasibility and present preliminary perioperative results.

Methods:

We performed robot-assisted laparoscopic TAPP ventral hernia repairs in 3 patients in the spring of 2015. Demographic information and defect size were measured. Conversion from a laparoscopic to an open procedure was the primary outcome variable.

Results:

There were 3 cases of robot-assisted TAPP ventral hernia repair with mesh. The mean age of the patients was 49 years, the mean body mass index was 32.6 kg/m², and the mean operative time was 163.7 minutes. The mean defect size was 1219.0 mm². There were no conversions to open during this early learning phase. All patients were discharged home within the 24-hour postoperative period. No complications were noted during a mean follow-up of 3 months.

Conclusions:

We present our early experience with robot-assisted TAPP ventral hernia repair. We note that because of improved ergonomics and wristed instrumentation, the robotic platform enabled creation of peritoneal flaps and complete coverage of mesh with peritoneum after primary closure of the defect. The robotic approach is feasible and may provide a better environment for mesh integration and protection. Further investigations with long-term follow-up are needed to verify that this technique is effective in reducing mesh-related intra-abdominal complications.     

Intraperitoneal Polypropylene Mesh Hernia Repair Complicates Subsequent Abdominal Surgery

Background Prosthetic incisional hernia repair (PIHR) is superior to primary closure in preventing hernia recurrence. Serious complications have been associated with the use of prosthetic material. Complications of subsequent surgical interventions after prior PIHR in relation to its anatomical position were the objectives of this study. Patients and Methods Patients who underwent subsequent laparotomy/laparoscopy after PIHR between January 1992 and February 2005 at our institution were evaluated. Intraperitoneal and preperitoneal mesh was related to complication rates after subsequent surgical interventions. Results Sixty-six of 335 patients underwent re-laparotomy after PIHR. The perioperative course was complicated in 76% (30/39) of procedures with intraperitoneal placed grafts compared to 29% (8/27) of interventions with preperitoneally positioned meshes (P < 0.001). Small bowel resections were necessary in 21% of the intraperitoneal group (8/39) versus 0% in the preperitoneal group. Surgical site infection rates were higher in the intraperitoneal group (10/39, 26%, versus 1/27, 4%). Enterocutaneous fistula formation was rare and occurred in two patients after subsequent laparotomy (5%). Conclusions Re-laparotomy after PIHR with polypropylene meshes are associated with more preoperative and postoperative complications when the mesh is placed intraperitoneally. Therefore 0intraperitoneal positioning of polypropylene mesh at incisional hernia repair should be avoided if possible. J. A. Halm and L. L. de Wall contributed equally to the writing of this article.     

Laparoscopic Repair of Left Lumbar Hernia After Laparoscopic Left Nephrectomy

Lumbar hernias, rarely seen in clinical practice, can be acquired after open or laparoscopic flank surgery. We describe a successful laparoscopic preperitoneal mesh repair of multiple trocar-site hernias after extraperitoneal nephrectomy. All the key steps including creating a peritoneal flap, reducing the hernia contents, and fixation of the mesh are described. A review of the literature on this infrequent operation is presented. Laparoscopic repair of lumbar hernias has all the advantages of laparoscopic ventral hernia repair.     

腹腔镜腹腔内补片置入术在半月线疝修补中的应用

目的探讨腹腔镜腹腔内补片置入术行半月线疝修补的临床效果。 方法2010年10月至2016年12月,复旦大学附属中山医院闵行分院在腹腔镜下对11例半月线疝患者进行修补治疗。手术采用超声刀进行疝环周围组织分离后,应用螺旋钉联合补片四角悬吊将防粘补片固定覆盖疝环完成半月线疝修补术。分析总结腹腔镜腹腔内补片置入术行半月线疝修补的临床效果。 结果11例患者均成功地在腹腔镜下行腹腔内补片置入无张力半月线疝修补术。手术时间30～60 min,平均40 min。术中出血10～20 ml,平均15 ml。患者术后排气、排便时间18～30 h,平均25 h。术后住院3～7 d,平均5.5 d。住院期间均未发生感染,无手术副损伤和死亡病例,2例患者发生血清肿。所有患者均获随访,时间6～50个月,未发现复发病例。 结论腹腔镜腹腔内补片置入术修补半月线疝具有创伤小、恢复快、并发症少等优点,符合疝无张力修补原则。     

Emergency Intraperitoneal Onlay Mesh Repair of Incarcerated Spigelian Hernia

Background and Objectives:

Spigelian hernia is a rare cause of incarcerated ventral abdominal hernia that may pose a diagnostic dilemma. However, with the increasing utilization of double contrast computed tomography (CT) for undiagnosed small bowel obstruction in a virgin abdomen, more such cases are being diagnosed with increasing confidence. Furthermore, with the rapid expansion of the indications for minimal access surgery in emergency situations, these rare emergencies are increasingly tackled using a laparoscopic approach leading to swift patient recovery and discharge.

Methods:

We present the case of an emergency intraperitoneal onlay mesh (IPOM) repair of Spigelian hernia, causing acute small bowel obstruction in a 55-year-old man with liver disease and ascites that was diagnosed using a CT scan. We conducted a search of Medline, Embase, Science Citation Index, Current Contents, PubMed, and the Cochrane Database to review the history of laparoscopic repair of Spigelian hernia and its various advancements, which are briefly presented here.

Results:

The hernia was successfully reduced using laparoscopy, revealing a moderate-size defect in the linea semilunaris. The hernial defect was repaired with a composite mesh that was tacked into position. The patient was discharged from the hospital on the second postoperative day.

Conclusions:

Spigelian hernia in an emergency setting can be easily and swiftly repaired using the IPOM method utilizing a composite mesh.     

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??Discussion of laparoscopic transabdominal preperitoneal prosthetics in the treatment of recurrent inguinal hernia WANG Ming-gang. Department of Hernia and Abdominal Wall Surgery, Chaoyang Hospital of Capital Medical University??Beijing 100043, China
Abstract The treatment of recurrent hernia after inguinal operation especially tension-free repair has been a difficult problem that hernia surgeons must face. Laparoscopic technique has been accepted and used gradually by surgeons with the advantages of retroperitoneal approach and direct vision. At present??there has been not yet a normalized operation manual and guideline of laparoscopic technique in the treatment of recurrent hernia because of the complex situation. The preperitoneal space could be gotten with TAPP completely in most cases; some could cut the peritoneum with shuttle or T-type incisions. There is no need to move the previous mesh and could relax restrictions appropriately in fixing mesh. In some particular cases, surgeons could repair defects with local repairing??intraperitoneal onlay mesh (IPOM) or transabdominal partial extraperitoneal ??TAPE??.     

腹股沟疝网塞修补术与前入路腹膜前修补术前瞻性对照研究(附67例报告)

目的比较两种开放式无张力疝修补术的疗效。方法采用前瞻性随机对照方法,将67例69侧腹股沟疝分为两组:网塞修补组(34例)采用网塞行Rutkow术式,前入路腹膜前修补组(33例)采用15 cm×15 cm预裁剪聚丙烯平片行前入路腹膜前无张力疝修补术。结果均获随访,网塞修补组平均随访7.9个月,前入路腹膜前修补组随访8.1个月。两组平均手术时间、平均住院时间、恢复日常生活时间、切口并发症及阴囊积液发生率比较无显著性差异(P>0.05)。前入路腹膜前修补组平均费用明显少于网塞修补组,术后复发率、腹股沟区疼痛不适、异物感发生率也明显降低(P<0.05)。结论采用预裁剪补片行前入路腹膜前无张力腹股沟疝修补,可明显减少手术费用,降低术后疼痛不适、异物感的发生率,改善疗效,操作简便,安全经济,具有推广价值。     

Chronic Pain after Laparoscopic Transabdominal Preperitoneal Hernia Repair: A Randomized Comparison of Light and Extralight Titanized Polypropylene Mesh

Background  

The aim of this prospective, randomized, single-blinded clinical trial was to compare the incidence of chronic pain after laparoscopic transabdominal preperitoneal hernia repair (TAPP) using a 35-g/m² titanized polypropylene mesh and a 16-g/m² titanized polypropylene mesh. The reported incidence of chronic pain in patients who underwent laparoscopic hernia repair is a serious problem. The techniques of dissection, mesh fixation, and the mesh material used have all been identified as being part of the problem. Excellent biocompatibility through a unique combination of a lightweight open porous polypropylene mesh covered with a covalent-bonded titanium layer has been claimed. The aim of this study was to find out whether the titanium surface alone or the difference in material load between the two available meshes influences clinical outcomes.     

Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic.

OBJECTIVE: The authors provide an assessment of mechanisms leading to hernia recurrence after laparoscopic and traditional preperitoneal herniorrhaphy to allow surgeons using either technique to achieve better results. SUMMARY BACKGROUND DATA: The laparoscopic and traditional preperitoneal approaches to hernia repair are analogous in principle and outcome and have experienced a similar evolution over different time frames. The recurrence rate after preperitoneal herniorrhaphy should be low (< 2%) to be considered a viable alternative to the most successful methods of conventional herniorrhaphy. METHODS: Experienced surgeons supply specifics regarding the mechanisms of recurrence and technical measures to avoid hernia recurrence when using the preperitoneal prosthetic repair. Videotapes of laparoscopic herniorrhaphy in 13 patients who subsequently experienced a recurrence also are used to determine technical causes of recurrence. RESULTS: Factors leading to recurrence include surgeon inexperience, inadequate dissection, insufficient prosthesis size, insufficient prosthesis overlap of hernia defects, improper fixation, prosthesis folding or twisting, missed hernias, or mesh lifting secondary to hematoma formation. CONCLUSIONS: The predominant factor in successful preperitoneal hernia repair is adequate dissection with complete exposure and coverage of all potential groin hernia sites. Hematoma mesh lifting and inadequate lateral inferior and medial inferior mesh fixation represent the most common causes of recurrence for surgeons experienced in traditional or laparoscopic preperitoneal hernia repair.     

Simultaneous extraperitoneal laparoscopic radical prostatectomy and intraperitoneal inguinal hernia repair with mesh.

OBJECTIVE: This report depicts the feasibility of the concomitant repair of a large direct inguinal hernia with mesh by using the intraperitoneal onlay approach after extraperitoneal laparoscopic radical prostatectomy. METHODS: A 66-year-old man with localized adenocarcinoma of the prostate was referred for laparoscopic radical prostatectomy. The patient also had a 4-cm right, direct inguinal hernia, found on physical examination. To minimize the risk of infection of the mesh, an extraperitoneal laparoscopic prostatectomy was performed in the standard fashion after which transperitoneal access was obtained for the hernia repair. The hernia repair was completed by reduction of the hernia sac, followed by prosthetic mesh onlay. In this fashion, the peritoneum separated the prostatectomy space from the mesh. A single preoperative and postoperative dose of cefazolin was administered. RESULTS: The procedure was completed with no difficulty. Total operative time was 4.5 hours with an estimated blood loss of 450 mL. The final pathology revealed pT2cN0M0 prostate cancer with negative margins. No infectious or bowel complications occurred. At 10-month follow-up, no evidence existed of recurrence of prostate cancer or the hernia. CONCLUSION: Concomitant intraperitoneal laparoscopic mesh hernia repair and extraperitoneal laparoscopic prostatectomy are feasible. This can decrease the risk of potential infectious complications by separating the mesh from the space of Retzius where the prostatectomy is performed and the lower urinary tract is opened.     

Planned totally extraperitoneal laparoscopic Spigelian hernia repair

A Spigelian hernia is a congenital defect in the tranversus aponeurosis fascia. Traditionally, an open anterior hernioplasty was used to repair these defects. Recently, laparoscopic approaches have been described. This report describes the first application of the totally extraperitoneal laparoscopic approach to a planned repair of a Spigelian hernia. The patient was a 62-year-old white female with a reducible left lower quadrant anterior abdominal wall bulge consistent with a Spigelian hernia. At the time of surgery, we exposed the posterior rectus fascia and modified our extraperitoneal inguinal hernia technique by passing the balloon dissector in a more lateral orientation. This created a unilateral preperitoneal space with adequate room for dissection and mesh fixation. The Spigelian defect was easily identified. Its preperitoneal fat contents were reduced, and a 5-mm laparoscopic tacking device was used to secure a piece of prolene mesh. The patient was discharged home with no complications. Placement of the mesh in the preperitoneal space avoids direct interaction of the mesh prosthesis and the intraperitoneal viscera. In conclusion, we find that a laparoscopic totally extraperitoneal approach is technically feasible and advantageous when a Spigelian hernia is diagnosed preoperatively.     

单侧复发性腹股沟疝腔镜下修补的临床分析

目的探讨单侧复发性腹股沟疝腔镜下修补术的临床体会。 方法回顾性分析2009年1月至2019年1月，福建医科大学附属第一医院收治的123例腔镜下修补单侧复发性腹股沟疝患者的临床资料。通过手术时间、有无中转手术、发生副损伤、术后第1天疼痛评分、术后住院时间、术后并发症发生情况，分析腔镜修补单侧复发性腹股沟疝的临床效果。 结果123例单侧复发性腹股沟疝患者，采用腹腔镜完全腹膜外疝修补术（TEP）患者54例，采用腹腔镜经腹腹膜前疝修补术（TAPP）患者59例，采用腹腔内修补术（IPOM）患者10例。平均手术时间（50.68±9.46）min，术后第1天视觉模拟疼痛评分（2.19±1.76）分，术后住院时间（2.25±1.40）d。术后累计并发症患者12例（9.76%），均治愈出院，随访时间内无复发。 结论腔镜修补手术（TEP、TAPP及IPOM）是治疗复发性腹股沟疝安全有效的方法，可以在有条件的单位开展。