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.     

Single-Incision Laparoscopic Intraperitoneal Onlay Mesh Repair for the Treatment of Multiple Recurrent Inguinal Hernias

Introduction:

Despite an exponential rise in laparoscopic surgery for inguinal herniorrhaphy, overall recurrence rates have remained unchanged. Therefore, an increasing number of patients present with recurrent hernias after having failed anterior and laparoscopic repairs. This study reports our experience with single-incision laparoscopic (SIL) intraperitoneal onlay mesh (IPOM) repair for these hernias.

Materials and methods:

All patients referred with multiply recurrent inguinal hernias underwent SIL-IPOM from November 1 2009 to October 30 2013. A 2.5-cm infraumbilical incision was made and a SIL surgical port was placed intraperitoneally. Modified dissection techniques, namely, “chopsticks” and “inline” dissection, 5.5 mm/52 cm/30° angled laparoscope and conventional straight dissecting instruments were used. The peritoneum was incised above the symphysis pubis and dissection continued laterally and proximally raising an inferior flap, below a previous extraperitoneal mesh, while reducing any direct/indirect/femoral/cord lipoma before placement of antiadhesive mesh that was fixed into the pubic ramus as well as superiorly with nonabsorbable tacks before fixing its inferior border with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.

Results:

There were 9 male patients who underwent SIL-IPOM. Mean age was 55 years old and mean body mass index was 26.8 kg/m². Mean mesh size was 275 cm². Mean operation time was 125 minutes with hospital stay of 1 day and umbilical scar length of 21 mm at 4 weeks'' follow-up. There were no intraoperative/postoperative complications, port-site hernias, chronic groin pain, or recurrence with mean follow-up of 20 months.

Conclusions:

Multiply recurrent inguinal hernias after failed conventional anterior and laparoscopic repairs can be treated safely and efficiently with SIL-IPOM.     

Laparoscopic repair of inguinal hernia using Surgisis mesh and fibrin sealant.

OBJECTIVE: We tested the hypothesis that laparoscopic inguinal herniorrhaphy using Surgisis mesh secured with fibrin sealant is an effective long-term treatment for repair of inguinal hernia. This case series involved 38 adult patients with 51 inguinal hernias treated in a primary care center. METHODS: Between December 2002 and May 2005, 38 patients with 45 primary and 6 recurrent inguinal hernias were treated with laparoscopic repair by the total extraperitoneal mesh placement (TEP) technique using Surgisis mesh secured into place with fibrin sealant. Postoperative complications, incidence of pain, and recurrence were recorded, as evaluated at 2 weeks, 6 weeks, 1 year, and with a follow-up questionnaire and telephone interview conducted in May and June 2005. RESULTS: The operations were successfully performed on all patients with no complications or revisions to an open procedure. Average follow-up was 13 months (range, 1 to 30). One hernia recurred (second recurrence of unilateral direct hernia), indicating a 2% recurrence rate. CONCLUSIONS: Laparoscopic repair of inguinal hernia using Surgisis mesh secured with fibrin sealant can be effectively used to treat primary, recurrent, direct, indirect, and bilateral inguinal hernias in adults without complications and minimal recurrence within 1-year of follow-up.     

Repair of inguinal hernias using the mesh technique during extraperitoneal pelvic lymph node dissection.

PURPOSE: This article describes our experience of using a totally extraperitoneal approach for endoscopic pelvic lymphadenectomy and inguinal hernia repair with the mesh technique in one procedure. MATERIALS AND METHODS: A total of 52 patients underwent modified pelvic lymph node dissection for the staging of prostate cancer. Eight of them had hernia defects; 1 was recurrent. Five patients with direct and 3 patients with indirect inguinal hernias were treated by totally extraperitoneal hernia repair with the placement of a mesh measuring at least 10 x 15 cm (prolene mesh with incision and flap). RESULTS: The mean duration of the lymphadenectomy itself was decreased from 150 min (first 20 patients) to 70 min (n = 21-52). The mean additional procedure time for hernioplasty was 15 min. The overall lymph node-positive rate was 9.6%. The complication rate was 7.7%. Four patients developed symptomatic lymphoceles, 1 of whom developed deep venous thrombosis. No complications occurred which were attributed to hernia repair. Morbidity did not rise, and hospitalization time did not increase for the patients who underwent hernioplasty. There were no recurrences or neuralgias on follow-up up to 2 years. CONCLUSIONS: By avoiding entry into the peritoneal cavity, the extraperitoneal approach obviates intra-abdominal complications (ileus, bowel injury, peritonitis) in both techniques. The extraperitoneal approach for pelvic lymph node dissection allows concomitant inguinal hernia to be repaired with low morbidity and within an acceptable operating time.     

Endoscopic extraperitoneal inguinal hernia repair with double mesh: indications, technique, complications, and results

Although totally extraperitoneal laparoscopic hernia repair has the same benefits attributed to the traditional preperitoneal prosthetic surgical repair, this procedure is not used widely because of perceived difficulty in dissection. Since one of the most common causes of hernia recurrence in this procedure is inadequate lateral inferior and medial inferior mesh fixation, we have introduced a double-mesh technique in an effort to reduce the rate of recurrence. Our procedure is a variation of the totally extraperitoneal laparoscopic inguinal hernia repair and provides a more secure inguinal floor by adjusting the second mesh to the area of weakness. We describe the laparoscopic inguinal hernia repair by the extraperitoneal double-mesh technique performed in 53 selected patients with very large indirect hernias and extremely large bilateral or recurrent hernias. The mean operative time was 74 minutes for unilateral hernias and 110 minutes for bilateral hernias. The median follow-up time was 65 months (range, 9-97 months) with no recurrences, neuralgia, or bleeding complications. We believe that this technique offers perfect positioning of the meshes and provides the most secure inguinal floor. Therefore, the method is presented for consideration in the laparoscopic repair of large indirect, direct, or recurrent hernias.     

The feasibility of laparoscopic extraperitoneal hernia repair under local anesthesia

Background: Laparoscopic preperitoneal herniorrhaphy has the advantage of being a minimally invasive procedure with a recurrence rate comparable to open preperitoneal repair. However, surgeons have been reluctant to adopt this procedure because it requires general anesthesia. Methods: In this report, we describe the technique used in the laparoscopic repair of inguinal hernias under local anesthesia using the preperitoneal approach. We also report our results with 10 inguinal hernias repaired using the same technique. Results: Ten patients underwent their primary inguinal hernia repairs under local anesthesia. None were converted to general anesthesia. Four patients received a small amount of intravenous sedation. Three patients had bilateral hernias. There were five direct and eight indirect hernias. The average operative time was 47 min. The average lidocaine usage was 28 cc. All patients were discharged within a few hours of the surgery. There were no complications. Follow-up has ranged from 1 to 6 months. There has been no recurrences to date. Conclusions: The extraperitoneal laparoscopic repair of inguinal hernia is feasible under local anesthesia. This technique adds a new treatment option in the management of bilateral inguinal hernias, particularly in the population where general anesthesia is contraindicated or even for patients who are reluctant to receive general or epidural anesthesia. Received: 22 July 1998/Accepted: 18 September 1998     

Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy

Background: Although the recurrence rate for endoscopic herniorraphy is low (0–3%), it is still debatable whether these recurrences should be corrected laparoscopically or by the conventional method. The aim of this study was to investigate whether these recurrences can be repaired by means of the laparoscopic approach with acceptable complication and recurrence rates. Methods: From October 1992 to December 1997, 34 patients with recurrent inguinal hernias at physical examination underwent surgery at our institutions. All the recurrences occurred following endoscopic inguinal hernia repair with mesh prostheses. The recurrences were repaired endoscopically using a transabdominal approach. Depending on the size of the defect, a new polypropylene mesh was used. Results: Mean surgery time was 69 min. There were no conversions to the anterior approach. After a mean follow-up of 35 months, no recurrences had been diagnosed. Conclusion: The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy. Received: 7 September 1998/Accepted: 13 October 1998     

A Prospective Randomized Study of Lichtenstein Open Tension-free Versus Laparoscopic Totally Extraperitoneal Techniques for Inguinal Hernia Repair

Ideal technique for effective inguinal hernia repair is still controversial. Although open tension free mesh techniques of inguinal hernia repair offers good results but the superiority of laparoscopic technique was reported for postoperative pain, discomfort and earlier return back to work. A prospective, randomized study was conducted to compare Lichtenstein open tension free mesh technique with the laparoscopic totally extraperitoneal technique. 62 male patients with Lichtenstein open tension free mesh technique and 61 male patients with totally extraperitoneal technique were operated and compared postoperatively. The patients were followed-up for 24 months with a median of 18 months. In terms of recurrence, postoperative pain, analgesic requirement, complications, hospital stay lenght, duration of limitation of normal daily activities there were no significant differences between the two groups. Operating time for totally extraperitoneal hernia repair was 16 minutes longer than Lichtenstein open tension free technique. The totally extraperitoneal technique was considerably expensive than Lichtenstein technique, however the duration of returning back to work was shorter in patients repaired with totally extraperitoneal technique.

In conclusion in primary inguinal hernia repair Lichtenstein technique should be preferred and the totally extraperito neal technique should be considered for recurrent and bilateral hernias.     

Single-Port Onlay Mesh Repair of Recurrent Inguinal Hernias after Failed Anterior and Laparoscopic Repairs

Methods:Patients referred with two or more recurrences of inguinal hernia underwent SIL-IPOM from November 1, 2009, to June 24, 2014. A 2.5-cm infraumbilical incision was made, and an SIL port was placed intraperitoneally. Modified dissection techniques were used: chopstick and inline dissection, 5.5-mm/52-cm/30° angled laparoscope, and conventional straight dissecting instruments. The peritoneum was incised above the pubic symphysis, and dissection was continued laterally and proximally, raising the inferior flap below the previous extraperitoneal mesh while reducing any direct, indirect, femoral, or cord lipoma before placement of antiadhesive mesh, which was fixed to the pubic ramus, as well as superiorly, with nonabsorbable tacks before the inferior border was fixed with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.Results:Nine male patients underwent SIL-IPOM. Their mean age was 53 years and mean body mass index was 26.8 kg/m². Mean mesh size was 275 cm². Mean operation time was 125 minutes, with a hospital stay of 1 day. The umbilical scar length was 23 mm at the 6-week follow-up. There were no intra-/postoperative complications, port-site hernias, chronic groin pain, or recurrence of the hernia during a mean follow-up of 24 months.Conclusion:Inguinal hernias recurring after two or more failed conventional anterior and laparoscopic repairs can be safely and efficiently treated with SIL-IPOM.     

Needlescopic extraperitoneal repair of inguinal hernias

Laparoscopic inguinal herniorrhaphy has traditionally been performed using one 5-mm and two 11-mm trocars. In this report, we evaluate the feasibility of the preperitoneal repair of inguinal hernias using the needlescopic method (2-mm ports) and describe the technique used in this repair. A total of 11 inguinal hernias were treated with needlescopic extraperitoneal repair. There were five direct and six indirect hernias. One patient had a bilateral hernia. The average operative time was 54 min. One patient was converted to the standard laparoscopic extraperitoneal method. All patients were discharged a few hours after the procedure. They were able to resume activity within a few days and required only minimal analgesic intake. Follow-up ranged from 1 to 6 months. All patients were followed up by one of the surgeons at 1, 3, and 6 weeks, and then at 6 months. No complications were encountered. There have been no recurrences to date. Overall, needlescopic extraperitoneal repair of inguinal hernias is a feasible procedure in male patients seeking better cosmetic results than can be achieved with standard laparoscopic extraperitoneal repair. This procedure is technically more demanding. The operative time is longer. The cosmetic aspect is the only advantage of this technique. Received: 22 July 1998/Accepted: 13 October 1998     

Sutureless laparoscopic extraperitoneal inguinal herniorrhaphy using reusable instruments: two hundred three repairs without recurrence

Laparoscopic extraperitoneal hernia repair has several distinct advantages over the anterior repair and the laparoscopic transabdominal preperitoneal method. Laparoscopic extraperitoneal hernia repair allows detection and repair of occult contralateral defects with minimal risk of intraabdominal injury or adhesion formation and is associated with less pain and a quicker recovery. However, there are disadvantages. Circumferential mobilization of the spermatic cord and the use of staples to secure the mesh have been associated with injury to the spermatic cord and nerves. The cost of the laparoscopic approach is higher than that of open herniorrhaphy. Additionally, it is more difficult to do because there is a poor understanding of the preperitoneal fascial anatomy. A method of totally extraperitoneal inguinal herniorrhaphy emphasizing anatomic dissection and landmarks is described. The authors use only reusable instruments, no balloon dissector, and no fixation of the mesh. The wide dissection of the myopectineal orifice allows placement of a large mesh and utilizes intraabdominal pressure alone to secure the mesh on the posterior aspect of the abdominal wall, as described by Stoppa et al. (1). Operative costs are minimized. From experience with 203 sutureless extraperitoneal repairs, a low incidence of complications and no recurrences are demonstrated. It is extrapolated that the cost of this laparoscopic repair will approximate more closely that of open anterior herniorrhaphy.     

Mesh-free laparoscopic spigelian hernia repair

Varied Spigelian hernia mesh repair techniques have been described, although evidence suggests laparoscopy results in less morbidity and shorter hospitalization compared with open procedures. Laparoscopic suture repair of Spigelian hernias is rarely reported. Two patients with small Spigelian hernias (< or =2 cm) were diagnosed and repaired laparoscopically using a transabdominal suture technique. Under laparoscopic guidance, a suture-passer was used to place two or three transfacial, interrupted 0 polypropylene sutures along the horizontal plane of the defect. Sutures were tied extracorporeally and closure was confirmed laparoscopically. These cases spurred a review of world literature (2001-2007) including clinical characteristics, operative techniques, and urgency of operations in Spigelian hernia patients. Data were compared using Fisher's exact test. One year postoperatively, the patients are without sequelae or recurrence. Literature review demonstrated most patients were females (P < 0.001), ranged in age from 60 to 80 years (P = 0.042), and presented with left-sided hernias (P = 0.026). Open mesh repair (182/392 cases; 47%) was the most common technique; however, increasingly articles describe laparoscopic mesh repair. Mesh-free laparoscopic suture repair is feasible and safe. This novel uncomplicated approach to small Spigelian hernias combines the benefits of laparoscopic localization, reduction, and closure without the morbidity and cost associated with foreign material.     

Laparoscopic repair of recurrent hernias

The purpose of this study was to evaluate the results of a laparoscopic approach to recurrent inguinal hernia repair which dissected the entire inguinal floor and repaired all potential areas of recurrence without producing tension. Both a transabdominal preperitoneal and a totally extraperitoneal laparoscopic approach were utilized. Ninety recurrent hernias were repaired in 81 patients. The patients had 26 indirect, 36 direct, and 26 pantaloon recurrent hernias of which eight had a femoral component. In all but one patient the primary operations were open anterior repairs. The median follow-up was 14 months, ranging from 1 to 28 months. Patients returned to normal activities in an average of 1 week. The only recurrence observed was in the one patient whose primary repair was laparoscopic. When the entire inguinal floor of the recurrent hernia was redissected and buttressed with mesh, early recurrence was eliminated and recovery was shortened.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Laparoscopic repair of bilateral spigelian and inguinal hernias

Spigelian hernias are rare and difficult to diagnose. Treatment has previously been limited to open surgical repair. We report the successful laparoscopic repair of bilateral spigelian and inguinal hernias using mesh. Received: 14 January 1997/Accepted: 11 April 1997     

Transperitoneal robotic-assisted laparoscopic radical prostatectomy and inguinal herniorrhaphy

Patients undergoing radical prostatectomy are at increased risk of development of post-operative inguinal hernias (IH). We present the largest series of transperitoneal combined robotic-assisted laparoscopic prostatectomy (RALP) and IH. After IRB approval, data from patients undergoing RALP at two centers were prospectively entered into a database and analyzed. IH were repaired robotically via a transperitoneal route with mesh. Between June 2002 and May 2007, 837 RALPs were performed, 80 of which included combined IH repair (9.6%), by two surgeons, T.A. and D.S. Forty-two patients (52.5%) had IH on pre-operative exam. Twenty-four hernias were left, 32 right, and 24 bilateral. Twenty-two patients had prior ipsilateral or contralateral herniorrhaphy. After dissection of the hernia sac, a swatch of flat Marlex mesh (n = 22), a polypropylene mesh plug (n = 19), an Ultrapro hernia system (n = 7), a Proceed coated mesh (n = 19), a 3D-Max (n = 37), a combination of both umbrella and flat mesh (n = 3), or suture alone (n = 2) was used. Inguinal herniorrhaphy added approximately 15 min of operative time in all cases. There was one hernia recurrence over an average follow-up period of 12.5 months (0.2–52 months). There was one complication attributable to IH repair—a urine leak which was attributed to anastomotic stretch due to reperitonealization. Urological surgeons should perform a thorough inguinal exam during preoperative evaluation and intraoperatively to detect subclinical inguinal hernias. Inguinal herniorrhaphy at the time of RALP is safe and should be routinely performed.     

A prospective randomized study of Lichtenstein open tension-free versus laparoscopic totally extraperitoneal techniques for inguinal hernia repair

Ideal technique for effective inguinal hernia repair is still controversial. Although open tension free mesh techniques of inguinal hernia repair offers good results but the superiority of laparoscopic technique was reported for postoperative pain, discomfort and earlier return back to work. A prospective, randomized study was conducted to compare Lichtenstein open tension free mesh technique with the laparoscopic totally extraperitoneal technique. 62 male patients with Lichtenstein open tension free mesh technique and 61 male patients with totally extraperitoneal technique were operated and compared postoperatively. The patients were followed-up for 24 months with a median of 18 months. In terms of recurrence, postoperative pain, analgesic requirement, complications, hospital stay length, duration of limitation of normal daily activities there were no significant differences between the two groups. Operating time for totally extraperitoneal hernia repair was 16 minutes longer than Lichtenstein open tension free technique. The totally extraperitoneal technique was considerably expensive than Lichtenstein technique, however the duration of returning back to work was shorter in patients repaired with totally extraperitoneal technique. In conclusion in primary inguinal hernia repair Lichtenstein technique should be preferred and the totally extraperitoneal technique should be considered for recurrent and bilateral hernias.     

The totally extraperitoneal laparoscopic hernia repair

Background: The totally extraperitoneal laparoscopic hernia repair has become our procedure of choice to manage inguinal hernia in adult patients since March 1993. This technique was developed in an attempt to diminish post-operative pain, shorten the convalescence period and equal the recurrence figures of the classical tension-free repair. Methods: A complete extraperitoneal dissection is performed. A large Marlex prosthesis (15×15 cm) is placed and covers all potential defects. Results: A consecutive series of 195 hernias in 158 patients is proposed. The minimum follow-up in our series is at least 6 months. Morbidity is low and so far, no recurrences have been seen. Conclusions: The totally extraperitoneal laparoscopic approach for repairing inguinal hernia should have a promising future, because the same principles as the classical tension-free repair are followed. Preliminary results are promising. Further studies, even randomized prospective trials and fair reports of complications, will determine the future of laparoscopic hernia surgery.     

完全腹膜外腹腔镜腹股沟疝修补术的临床应用

目的：总结完全腹膜外腹腔镜腹股沟疝修补术（totally extraperitoneal prosthetic,TEP）的临床应用经验。方法：回顾分析2007年4月至2008年8月我院收治的58例腹股沟疝患者行TEP手术的临床资料。其中直疝16例、斜疝42例;单侧疝46例、双侧疝12例;复发疝16例。结果：手术均获成功,无中转手术。手术时间50～140min（平均单侧90min、双侧120min）。术后无须使用镇痛剂,住院时间3～10d,平均5d。术后出现阴囊血肿4例,血清肿21例。随访1～15个月,术后无复发。结论：TEP手术安全可靠,具有并发症少,术后疼痛轻、康复快、复发率低等优点,可同时对双侧疝进行处理,无需全身麻醉,具有明显的优越性,有广泛的应用前景,是值得临床推广的微创技术。     

Mesh fixation in laparoscopic totally extraperitoneal inguinal hernioplasty by percutaneous subcutaneous suture technique

Aim: The method of mesh fixation remains an issue of argument in laparoscopic totally extraperitoneal inguinal hernia repair. Laparoscopic staplers, bioactive tissue glues and tacks had been used by various institutions for the same purpose. In the present article, we describe the percutaneous subcutaneous suture technique, which is an inexpensive method of mesh fixation in laparoscopic inguinal hernia repair. Methods: We carried out a retrospective case series review of cases with laparoscopic totally extraperitoneal inguinal hernia repair carried out in Pok Oi Hospital, Hong Kong from 19 November 2008 to 4 June 2009. Mesh fixation by percutaneous subcutaneous suture technique was carried out for patients with large hernial defects (≥ 4 cm), bilateral or recurrent hernias. Results: One out of 31 hernioplasties (3.2%) carried out with mesh fixation was complicated by recurrence up to 3 months of median follow up. Conclusion: We describe our alternative method of mesh fixation by percutaneous subcutaneous suture technique in laparoscopic totally extraperitoneal inguinal hernia repair. However, further clinical studies are required to elaborate the benefits and long-term results of this method.     

The open mesh repair of Spigelian hernia

BACKGROUND: Spigelian hernias are rare defects of the abdominal wall usually appearing between the abdominal muscles, lateral to the rectus abdominis and through a debilitated Spigelian aponeurosis. Recently, mesh repair has been introduced for the treatment of these types of hernias and different approaches have been proposed. METHODS: Nine patients with Spigelian hernia were prospectively treated by placing a mesh prosthesis between the external oblique and the internal oblique muscles, based on principles of mesh repair established by the Lichtenstein group. RESULTS: Five women and 4 men, mean age 75.7 years, were operated on. In 1 patient the Spigelian hernia was an incidental finding during an inguinal hernia repair. Two patients were operated on an emergency basis. Elective operations were undertaken in ambulatory facilities in 3. Two patients had postoperative ecchymosis with no associated morbidity. No recurrences have been observed during follow-up. CONCLUSIONS: Open mesh repair of Spigelian hernias placing the mesh between the external and internal oblique muscles is a simple and safe approach that can prevent morbidity related to other techniques.