Laparoendoscopic Single-Site Extraperitoneal Inguinal Hernia Repair: Initial Experience in 10 Patients

Introduction

L aparoscopic endoscopic single-site (LESS) technique presents a newly introduced approach for laparoscopic surgery. LESS procedures are performed by inserting all laparoscopic instruments through a single multilumen port, and the use of several laparoscopic trocars is avoided. The LESS approach has been associated with shorter hospitalization, faster convalescence, less postoperative pain, and improved cosmetic outcome in comparison with conventional laparoscopy. ^{1 –4} A variety of urologic procedures have been successfully performed by the LESS approach. Although the accumulated experience with the LESS technique remains limited, continuous clinical evaluation has rendered the approach to a rapidly advancing field. ^5,6

Inguinal hernia is a common surgical problem that is associated with morbidity if left untreated. The principles of inguinal hernia repair are well established, including hernia reduction and repair or patching of the defect in an attempt to avoid hernia recurrence in the long term. There are two well-described techniques for laparoscopic repair of inguinal hernia: The totally extraperitoneal (TEP) and the transabdominal preperitoneal patch (TAPP). Laparoscopic repair of inguinal hernias has been well established because of its safety, efficacy, and patient satisfaction. When mesh implantation was introduced, the recurrence rates were minimized to less than 5%. ^7,8 TEP is associated with improved results (recurrence rates, postoperative pain, seroma formation) in comparison with TAPP, while the former technique provides access to the contralateral side without the need of further incisions. ^{7 –9} The recent evolution of single-incision surgery made the performance inguinal hernia repair possible. LESS hernia repair can be performed through either an extra- or intraperitoneal approach. ^{10 –13} We describe our technique and initial experience of extraperitoneal LESS hernia repair.

Patients and Methods

Ten consecutive men with unilateral inguinal hernias underwent TEP LESS hernia repair. Age range was 50.3 (28–64) years. Mean body mass index was 28.1 (range 23.9–29.7). Six were left inguinal hernias. There were six indirect and four direct hernias. Three patients had undergone previous open appendectomy. Incarcerated or bilateral hernias were excluded from our initial series. All cases were performed by three surgeons who were experienced in conventional TEP laparoscopic hernia repair as well as experienced in LESS.

The patient is placed in a supine, slight Trendeleburg position with the monitor at the caudal side of the patient. The bladder is drained by a urethral catheter to maximize the working space. An ipsilateral to the hernia incision, approximately 3-cm inferolateral to the umbilicus, provides access. After balloon dilation of the extraperitoneal space, a disposable multi-instrument access port (TriPort^TM–Olympus) is inserted. The TriPort consists of a retractor and a valve. The retractor includes one internal ring and two external rings and a doubled-over cylindrical plastic sleeve. The inner ring is inserted with a trocar-introducer system and tightened against the rectus muscle using the sleeve. The port allows for the introduction of two 5-mm instruments and one 12-mm instrument, while an additional port for gas insufflations is available on the port. Curved HiQ LS 5-mm hand instruments (Olympus) are inserted via the lubricated TriPort (Fig. 1). A combination of scissors and graspers is used. The curved shaft of the laparoscopic instruments is responsible for the decreased instrument crowding during the procedure. The distal end of the instruments can be rotated via the knob on the hand piece. Thus, the handle does not need to be rotated for the rotation of the instrument. To allow the surgeon unhindered freedom of movement outside the patient, we prefer a 5-mm EndoEYE (Olympus) laparoscope with flexible handle (30-degree) (Fig. 2).

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FIG. 1.

Instruments used for LESS extraperitoneal hernia repair. (A) HiQ LS curved 5-mm hand instruments (Olypmus, Germany); (B) a TriPort^TM disposable multi-instrument access port (Olypmus, Germany) with the appropriate trocar for placement; (C) a TriPort placed at 3-cm inferolateral to the umbilicus site. LESS=laparoendoscopic single-site.

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FIG. 2.

Instrument configuration and mesh for LESS hernia repair. (A) Laparoscopic camera with flexible handle and 5-mm diameter (EndoEYE 300, Olympus, Germany). Prebent laparoscopic instruments are also used. (B) Premilene^® (B. Braun, Germany) mesh used for the hernia repair with the flap sutured on it. (C) Premilene (B. Braun, Germany) mesh rolled and ready for insertion through a 10-mm channel of the Triport.^TM

A combination of sharp and blunt dissection defines and reduces the hernial sac. A straight 5-mm bipolar Johann grasping forceps is used for dissection and hemostasis. In cases of indirect hernias, the spermatic cord is carefully isolated and freed from the hernial sac. It is important to ensure adequate lateral dissection to the level of the anterior superior iliac spine to allow placement of the mesh. A 10 cm by 15 cm Premilene ® mesh (B. Braun, Germany) is prepared by making a 6-cm cut vertically 7.5-cm from the lateral end. A small cut is fashioned to accommodate the cord structures. The incised mesh is covered by a flap of mesh approximately 6 cm by 4 cm and sutured medially into place using a continuous 2.0 polypropylene suture (Fig. 2). The flap is temporarily sutured back with a single polypropylene suture, allowing the mesh to be placed around the cord and structures. The mesh is rolled up and tied with two stay sutures to allow easy insertion through the 12-mm trocar. Once inside, the stay sutures are cut and the mesh unfurled. It is positioned in place around the spermatic cord from the pubic symphysis in the midline to the anterior iliac spine laterally (Fig. 3). The gas is then released from the extraperitoneal space, and intraperitoneal pressure holds the mesh in place. No sutures or clips are used to fix the mesh in place. We have previously described this method in patients who were undergoing endoscopic extraperitoneal radical prostatectomy with concomitant inguinal hernia repair. ¹⁴

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FIG. 3.

The technique of laparoendoscopic single-site (LESS) extraperitoneal hernia repair: (A) The hernia sac is carefully prepared and reduced inside the abdomen; (B) The mesh is placed under the spermatic cord; (C) The mesh is unfurled and positioned in place; (D) The appearance of an incision performed for LESS hernia repair. Notice the limited length of incision. a=epigastric vessel; sc=spermatic cord; pr=prostate; aw=abdominal wall; bl=bladder.

Results

The mean operative time was 53 minutes (range 45–65 min). The average length of skin incision was 2.8 cm (range 2.3–3.2 cm). No drain was necessary in any of the patients, while no recordable bleeding was observed. There were no intraoperative or immediate postoperative complications. Hospitalization period was 2 days for all patients. After a limited follow-up of 1 month, there have been no recurrences and no complaints of testicular pain. Perioperative data of the current series are summarized in Table 1.

Discussion

Single-incision laparoscopic hernia repair has been reported in the literature, although experience is limited to small series and case reports (Table 2). Our technique includes minor refinements in comparison with published series. More advanced instruments have been used, such as the prebent instruments and a laparoscope with flexible handle. The above combination of instruments reduced the instrument crowding and crossing frequently observed in LESS. Furthermore, clips or sutures were not used for securing the mesh in place. Thus, there may be benefit in terms of complications related to the introduction of foreign material at the site of the procedure.

The majority of surgeons seem to use some form of multiaccess port for the performance of LESS hernia repair. Variations include the use of multiple ports placed at a single incision or only one single-access port. ^{10 –13,15 –20} We favored the use of the TriPort for the performance of the presented series. The extraperitoneal approach was responsible for prevention of any interference with the intestine. The latter advantage has been reported with conventional laparoscopic hernia repair and is associated with reduced incidence of bowel related complications. ²¹ In addition, the extraperitoneal approach (TEP) seems to be marginally more popular in the literature (Table 2). The disadvantage of TEP compared with the TAPP approach is the reduced working space. Nevertheless, bladder drainage significantly reduces the impact of the latter issue to the performance of the procedure.

The current series compares favorably with published series in terms of operative time, postoperative hospitalization, length of incision, and complications. Totally, 81 cases have been reported in the literature that have been performed by general surgeons and not by urologists (Table 2). The operative time ranged from 30 to 100 minutes for unilateral LESS hernia repair and 26 to 120 minutes for bilateral LESS hernia repair. Perioperative complications reported in the literature include five wound-related complications, one conversion to multisite laparoscopic repair, one case of significant intraoperative bleeding, and one case of postoperative (short-term) testicular pain. Thus, the currently presented series further establishes the LESS approach to TEP hernia repair as a safe and efficient alternative to the conventional laparoscopy and open surgery series. In the absence of randomized trials or long-term data, results should be interpreted with caution. Nevertheless, single-incision surgery has an obvious cosmetic advantage and, as instrumentation evolves, LESS hernia repair is likely to become more popular.

Conclusion

LESS extraperitoneal inguinal hernia repair is both feasible and safe, although more technically demanding than its conventional laparoscopic counterpart. Although the cosmetic result with the former approach may prove superior, there are standing questions regarding the complications and long-term outcome. Randomized and, if possible, blinded trials that compare conventional and single-incision laparoscopic hernia repair may help to distinguish the most advantageous technique.