A new approach in laparoscopic repair of ingulnal and femoral hernias

Since 1992, as defined by Dulucq, laparoscopic inguinal hernia has become more popular than open repair due to its advantages (1). The main transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) approaches have been described in the repair. In these techniques, mesh detection is usually done with tact in the preperitoneal area. This increases both cost and certain complications, especially chronic pain.In this new study, which is based on my previous work ‘A new method for the repair of femoroinguinal hernias by videolaparoscopic method’ (Sakman Method) (2); we proposed a method that eliminates classical mesh fixation areas and associated complications but does not increase the recurrence rate and analyzed the results in the light of the literature.35 male patients who underwent inguinal or femoral hernia repair by laparoscopic TEP were included in the study. A 15×15 cm polypropylene mesh was prepared to plug in the posterior way. We have fixed the mesh we have prepared under the skin using vicryl. Patients are followed up prospectively peroperatively and postoperatively.

Results:

When we compare the results obtained with patients who underwent the method we have developed, ‘plug mesh and fixation with vicryl under the skin’ technique,  with other laparoscopic techniques described in the literature, we obtained less postoperative stay, less postoperative analgesic requirement, decreased urinary retention and seroma rates. There was also no significant difference in returning to normal activity and recurrence of hernia in prospective follow-ups of 24 months.

Laparoscopic TEP ‘plug mesh and subcutaneous vickryl fixation method’ developed in inguinal hernia repair does not cause any increase in narcotic analgesic requirement, hospital stay, urinary retention and seroma formation, and additionally no increase in recurrence rate. It is also cost-effective and is a an option for suitable cases.

Introduction:
Today, approximately 20% of all inguinal hernia repairs are performed with a laparoscopic approach. The most preferred method is TEP. Although TAPP repair has its own advantages, complications such as intra-abdominal organ injury are more serious. In our previous study, we preferred the TAPP approach (2), but in our new study, we preferred TEP approach. In classic TEP inguinal hernia repair, the potential hernia development area is covered with a prosthetic mesh, and mesh is usually fixed to the abdominal wall with spiral tact. Mesh detection is controversial, but it is aimed at reducing the recurrence rate (3). However, fixation with tact may cause some complications such as nerve damage and chronic pain. The femoral branch of the genitofemoral nerve and the lateral femoral cuteneous nerve are injured 2-4% in laparoscopic inguianal hernia repair (4).

We aimed to reduce the complication rate by eliminating the mesh fixation with the tact to the preperitoneal area in the light of our previous study (2) and to reduce the recurrence rate by fixing it under the skin by a new method that we defined.

Method:
This study was planned as prospective between the dates of 2013-2015 in S. B. Istanbul Education and Research Hospital with approval of local ethics committee.

Patients:

35 male patients with ASA Score1-2 who were diagnosed as inguinal and femoral hernia between 18-80 years of age were included in the study. Patients who were not suitable for general anesthesia, who had drug or alcohol habits and coagulopathy and those who had previous surgery were excluded from the study. They were followed up to the 24th month peroperatively and postoperatively. The data were analyzed in the context of the literature.

Surgical technique:

Mild trendelenburg position was given to the patients to whom foley catheter were inserted before the procedure. The prophylactic antibiotic was given during the incision phase. The patients underwent general anesthesia with a classical 3-port laparoscopic TEP method

The operations were performed under general anesthesia. Following a 1-cm infraumbilical skin incision, the anteriorfascia of the rectus sheath was incised, the rectus muscleretracted laterally, and the area between the rectus muscleand the posterior fascia of the rectus sheath was developed.A 10-mm trocar was inserted and the preperitoneal space insufflated with carbon dioxide to a pressure at 12 mmHg.The preperitoneal space was dissected up to the space ofRetzius using a 0 degree video telescope. Two 5-mm trocars were inserted on the midline, one just above the pubic symphysis and the other between the two trocars. Following the dissection and reduction of the peritoneal sac

Mesh prepeariton and appliaction:

The 15×15 cm polypropylene mesh was cut as T-shape from the edge by 2.5 cm. The short legs were rolled into cigarettes and transformed into plug. One third of the mesh plug was placed on top of itself and fixed with a vicryl suture. Thus, a 10×15 cm mesh with folded on itself was obtained with a plug in the middle of the 1/3 posterior. The tip of the plug was fixed by gently approximating the vial with vicryl suture and this suture was left long enough to be pulled under the skin (Fig.1). We left the mesh in the preperitoneal area medio-laterally adjusting with the location of the defect. Using a conventional laparoscopic instrument, the vicryl suture which on the top of the long plug wrap was carefully extended from the hernia defect in the preperitoneal area to the subcutaneous area and removed from the skin with a cut of about 1-2 mm made on the skin. Thus, the diffusion of the mesh into the preperitoneal area, including the mycopectineal orifice, was ensured, while the plug was staying in the defect. The externalized vicryl suture was fixed subcutaneously.

Figure-1

(Figure-1:  AC= 2.5 cm CB=10cm AD=15cm)

Preoperative evaluation:

Pain levels were determined preoperatively on the Numeric Rating scale (no pain: 0, severe pain: 10). The degree of difficulty of the operation during surgery was rated (0: difficult, not difficult: 1, very difficult: 2). Patients’ pain levels, analgesic requirements, complication development, time to discharge from hospital, return to work were recorded. The patients were checked for hematomas, seroma, orchitis, mesh infection findings, pain, and recurrences at 7th day and 1st, 6th and 24th months of discharge.

Results:

The demographic findings of the patients are summarized in Table-1.

Table-1: Demographic findings

Total number of patients: 35
Age 43.6 ± 1.5
BMI 28.3 ± 2.8
Hernia type
  Indirect 15
  Direct 19
  Femoral 1
ASA
1 31
2 4

BMI: Body Mass Index

No intraoperative complications were observed. All patients were discharged on the first day postoperatively.

Postoperative findings of the patients are summarized (Table-2). The analgesic requirement in the first postoperative hours and the average stay at the hospital were significantly lower than in the classical tact mesh described in the literature. Urinary retention was observed in only 1 patient (0.35%). The degree of surgical difficulty was similar when compared with other methods. There was no difference in terms of return to activity. There was no recurrence of nerve damage or recurrence in long term follow ups. Seroma was not observed in the patients. 1 patient developed orchitis which was responsive to medical treatment. Table-2: Postoperative findings

Total number of patients: 35
Operation duration (min) 58,4 ± 16,5
Stay in hospital 9,1 ± 5,2
Pain (0-10)
Preop 0,5 ± 1,9
Postop analgesic need 2, 37 ± 1,0
Urinary retention 1
Surgical difficulty level
Difficult 5
Mid level 7
Not difficult 23
Postoperative early (Day 7)
Hemaoma 0
Seroma 0
Orchitis 1
Infection 0

Discussion:

In laparoscopic TEP inguinal hernia repair, the neccessity to fix the mesh, which is used to prevenet recurrence,  with the tact in the the preperitoneal area to prevent recurrence should be discussed. Many experts worry that unrecognized mesh can displace and cause recurrence. In many randomized prospective controlled studies, mesh fixation was compared to unfixed repair. At the same time, the search for the best method for mesh fixaiton is ongoing. In many cases, mesh fixation is unnecessary. However, in both TAP and TAPP approaches, mesh fixation is recommended to reduce recurrence in large hernias (24).Mesh fixation with tact traditionally can prevent mesh displacement and recurrence (5,6). However, it can increase both cost and acute and especially chronic pain. Khajanchee et al. reported increased neuropathic complications in the group of tactile mesh fixation in 172 laparoscopic inguinal hernia repair (7, 8, 13, 14, 15). On the other hand, some specific studies emphasize the necessity of mesh fixation (10,11,12), as the absence of mesh enhancement does not increase recurrence.

Lau and Patil pointed out that the rate of recurrence was increased especially when there were more than 4 cm of defects in cases without fixation of the mesh (16). A large series of 686 cases, Dehal et al. (17) reported higher recurrence rates compared to literature regarding their series in which mesh was not fixed. In the technique we propose, the mesh plug is placed in the defect, which is advantageous in terms of recurrence especially in cases with wide defects.

Urinary retention, which may be due to mesh fixation with tact, was not seen in our method. This was due to reduced postoperative pain and fewer narcotic agents. Lau and Petit (16) found that the postoperative pain level in the group to which they applied mesh fixation was significantly higher than the group without the fixation. Taylor and colleagues found that pain scores were significantly higher in patients who underwent mesh fixation. Interestingly, the pain score was significantly higher in those with more than 6 tact application (22).

In our study, the level of postoperative pain was lower than the literature because we did not apply tact to the preperitoneal area

Koch et al. Reported the use of postoperative narcotic agents as a risk factor for developing urinary retention. (18)The rate of seroma development in a 1220 case series is given as 0,52% -37,8%, and the rate of urinary retention (0,38% -8,3%) (23). Mulroy (19) reported that increased postoperative pain, causing increased sympathetic stimulation which leads to increased urinary retention. In our method, fewer narcotic agents were needed in our patients. In our study, only one patient developed urinary retention.

The development of seroma due to laparoscopic hernia repair is a frequent problem in some series and can be perceived as hernia recurrence by patients (20). Our study did not develop seroma. We have seen the benefit of our proposed technique also in this sense. There is no sing/symptom regarding spinal cord compression or sexual dysfunction due to plug application (25).  We have not encountered any problem due to plug during our study.

No cost analysis was done in this study. However, when compared with the materials described above and mesh fixation with tact, elimination of fixation in the preperitoneal area in our technique is considered to be cost effective. In some studies it has been reported that mesh fixation increases the cost from $ 120 to $ 375 (21, 22).

Conclusion:
In laparoscopic TEP hernia repair, complications related to mesh fixation with preperitoneal tact can develop. We have seen that the rate of complications is reduced without increasing the recurrence rate, by fixing the plug mesh under the skin using vicryl. In addition, our technique can be suggested as an alternative to avoid the risk of complications in patients with a wide defect and need of mesh fixation. However, larger series and subgroup analyzes are needed.

References:

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Sexual function and testicular perfusion after inguinal hernia repair with mesh.

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