Different Approaches to an Inguinal Hernia Repair During a Simultaneous Robot-Assisted Radical Prostatectomy

Introduction

I t has been well established that there is an increased risk of developing an inguinal hernia after a prostatectomy. The incidence ranges between 7% and 21%. ¹ Risk factors that contribute to postoperative inguinal hernia include age and previous inguinal hernia repair. ¹ Repairing an incidental or known inguinal hernia ahead of or at the time of surgery reduces the risk of developing this future potential complication. It has been well established that repairing an inguinal hernia at the time of a prostatectomy is safe and feasible. ² Other groups have shown that it is feasible to do a laparoscopic hernia repair during a laparoscopic prostatectomy. Most recently, Finley et al ³ have shown the ease and safety of doing a robotic inguinal hernia repair combined with a robot-assisted radical prostatectomy (RARP). At our institution, we perform all three different approaches of inguinal hernia repairs—open, laparoscopic, and robotic—during a robotic prostatectomy based on surgeon preference. We wanted to see if there was one modality that had greater benefit over the other and if we should change our practice patterns doing these combined surgeries.

Materials and Methods

We performed a retrospective review of an Institutional Review Board–approved prospectively generated database of all RARP performed at the Mayo Clinic Arizona between March 2004 and September 2009. Patients who had a simultaneous inguinal hernia repair were identified. We categorized these patients by what type of repair they underwent at the time of surgery: robotic, laparoscopic, or open inguinal hernia repair. We also identified an age-matched and body mass index (BMI)-matched cohort who underwent RARP alone. Baseline characteristics such as age, BMI, American Society of Anesthesiologists, Gleason sum, prostate size, and baseline prostate-specific antigen were compared between the groups. Data on operative time, complications, transfusion rates, length of stay, and estimated blood loss were also examined. Complications were reported within 30 days of surgery. All complications were either Clavien I or II. We compared outcomes between combined hernia repairs versus our control group using chi-square analysis. We also compared outcomes between robotic versus laparoscopic versus open inguinal hernia repair done concurrently with RARP using chi-square and analysis of variance multivariable analysis.

All RARPs were performed in the usual standard transperitoneal fashion by six different surgeons. A standard bilateral lymph node dissection was performed in one patient from each group (open, laparoscopic, and robotic inguinal hernia repair groups) that underwent a concurrent inguinal hernia repair. Three patients from the control group also underwent a standard bilateral lymph node dissection. All inguinal hernias, except for one patient, were identified preoperatively and repaired by a general surgeon. There were six different general surgeons who performed the inguinal hernia repairs, and the decision on what methodology to use was based on general surgeon preference. Open inguinal hernia repairs were performed using the Lichtenstein method with mesh.

Laparoscopic hernia repair was performed in a transperitoneal fashion using the same ports that were placed for the RARP. The peritoneum was taken down to expose the preperitonel space and a piece of Prolene mesh was used in all cases to cover the defect. These were held in place by spiral tacks. The peritoneum was then tacked back into place over the mesh.

Robotic inguinal hernias were repaired primarily suturing the transversus abdominis fascia to the shelving edge of the inguinal ligament using interrupted silk sutures in two cases. In one case Prolene mesh was used, held in place by spiral tackers in the preperitoneal space. Two other cases utilized Parietex PCO-coated polyester mesh and the peritoneum was not placed over the mesh. The coated mesh faced outward to the abdominal wall to prevent the formation of bowel adhesions.

Follow-up included standard visits every 3 months for the first year and then at least annually thereafter by the urologist, including a physical examination. A single 1-month postoperative visit with physical examination was performed by the general surgeon. Any recurrences were referred back to general surgery.

Results

A total of 1224 RARPs were performed between March 2004 and September 2009. There were 21 inguinal hernias repaired simultaneously during RARP in 18 patients. Three patients had bilateral hernia repairs (two laparoscopic and one open) performed. There were five pure laparoscopic inguinal hernia repairs, eight open inguinal hernia repairs, and five robotic inguinal hernia repairs. All inguinal hernias were recognized preoperatively except for one patient (who underwent robotic hernia repair).

There were two bilateral, one right, and two left laparoscopic inguinal hernia repairs. There were five right, one bilateral, and two left open inguinal hernia repairs. There were four left and one right robotic inguinal hernia repairs (Table 1). There were three indirect inguinal hernias and the remaining hernias were direct hernias.

When compared with an age- and BMI-matched cohort of 40 patients who underwent RARP only, there were no statistically significant difference in estimated blood loss, length of stay, or complications (Table 2). The control group had a statistically significant shorter operative time than the simultaneous inguinal hernia and RARP group (179.5 vs. 215.5 minutes, p = 0.007; Table 3). When taking just the RARP operative time alone, there was no statistically significant difference between the two groups (Table 3). When comparing the different approaches of an inguinal hernia repair, the only statistically significant differences noted were operative time (Table 4). Operative time was statistically higher in open inguinal hernia repair than in robotic inguinal hernia repair (74 vs. 31.6 minutes, p = 0.006). There were only two recurrences that occurred, both after the open inguinal hernia repair. These were recognized during physical examination by the urologist 6 months and 1 year after the initial operation.

Discussion

Postprostatectomy inguinal hernias occur in about 7%–21% of patients. ¹ In laparoscopic procedures, the incidence has been reported to be as high as 14%. ⁴

Subclinical inguinal hernia repair is reported to occur in 20%–33% of patients and can be detected preoperatively on computed tomography. ^5,6 Some of the risk factors for progression or developing symptoms of a postprostatectomy inguinal hernia include previous hernia repair, wound-related infections, and age. ^1,7

Simultaneous open prostatectomy and inguinal hernia repair has been well established as a safe and feasible operation. The first reported surgery was in 1949 by McDonald and Huggins. ⁸ Since that time there have been a number of different approaches to the repair. This included two separate incisions, one single Pfannestiel incision, the Stoppa procedure, the Nyhus technique, and the Lichtenstein technique. ^2,9 All had excellent results. There are some potential complications of a concurrent hernia repair with a prostatectomy including infected mesh from urinary contamination, but this was not reported by many groups. ^2,9

Laparoscopic inguinal hernia repair has been shown to be safe and feasible during both an extraperitoneal and intraperitoneal laparoscopic radical prostatectomy. ^10,11 If an intraperitoneal approach was used, the surgeons would cover the mesh with peritoneum. On the other hand, performing a transabdominal preperitoneal repair after a radical prostatectomy is a difficult operation with higher morbidity and operative time compared with a primary transabdominal preperitoneal repair. ¹² Therefore, if a hernia is recognized at the time of prostatectomy, it is easier to perform the hernia repair simultaneously rather than deal with the postoperative scar tissue in a future repair.

Finley et al ³ performed a prospective study looking at 40 patients who underwent concurrent robotic hernia repair with RARP and found this to be a safe and feasible procedure. Their average operative time was only a mere 8 minutes, which confirms our findings of the fact that a robotic inguinal hernia repair is quicker than other approaches. In their series, the shorter operative time may also be accountable to the fact that the entire operation (including the hernia repair) was performed by one surgeon rather than two.

At our institution, the hernias are repaired by a general surgeon rather than the urologist themselves, which likely accounts for our extended operative time. In addition the general surgeon usually determines the approach that the inguinal hernia will be repaired. This is why we have a series of multiple approaches to simultaneous hernia repair during RARP.

Only one subclinical inguinal hernia was identified and repaired, and this was done robotically. The robotic approach did have an overall shorter operative time than the open approach. All patients did well in the postoperative period regardless of the approach. Even though the two re-occurrences occurred in the open approach, we cannot make definitive statements on outcomes given the small numbers overall and the retrospective nature of our study.

The limitations of our study include the small numbers of our overall cases and its retrospective nature. This is the first study to look at different approaches of inguinal hernia repair (open vs. laparoscopic vs. robotic) during an RARP to our knowledge. To make definitive conclusions on the best approach, a randomized trial should be completed.

Conclusions

Simultaneous inguinal hernia repair is a safe and feasible operation to perform during RARP. Although it does extend overall operative time, approaching the repair robotically is quicker than an open approach. A randomized study is needed to truly determine if one approach has better outcomes than the rest.