Laparoscopic Inguinal Hernia Repair: A New Approach

Abstract

Objective:

Over a 5-year period, patients, who underwent laparoscopic total peritoneum intraperitoneal onlay mesh (TPIPOM) hernioplasty were retrospectively examined. The investigation focused on technique feasibility and complication incidence, in particular complication related to this novel hernia therapy.

Patients and Methods:

Between January 2002 and March 2003, 54 patients were treated with TPIPOM hernioplasty.

Results:

Mean overall surgery time was 25.45 ± 5.2 minutes, and hospital stay was 3.8 ± 1.3 days. Mean follow-up time was 72.4 ± 3.1 (range, 69–84) months. The overall recurrence rate was 1.8% (1/54). Complications, in the form of persistent neuralgia, osteitis pubis, subcutaneous hematoma, numbness, or vascular injury, did not occur. All patients returned to usual activities of social life, hobbies, looking after the house, and work by 1 month after surgery.

Conclusions:

On the basis of our initial experience, laparoscopic TPIPOM hernioplasty is feasible, effective, and easy to perform by experienced surgeons, with good results.

Introduction

In 1990, Ger et al.¹ performed the first laparoscopic inguinal hernia repair in dogs by stapling the abdominal opening of the patent processus vaginalis. Subsequently, intraperitoneal onlay mesh repair (IOPM) techniques were later developed.² Because this surgery is relatively simple and does not require preperitoneal dissection, it has been widely accepted. However, the technique was abandoned due to the risk of small-bowel obstructions related to adhesions and mesh erosion into the bowel.³

Currently, most laparoscopic inguinal hernia repairs are performed by using two methods: the transabdominal preperitoneal (TAPP) approach and total extraperitoneal (TEP) approach.^4–6 The TAPP approach requires laparoscopic access into the peritoneal cavity and placement of mesh into the preperitoneal space after reducing the hernia sac. TEP inguinal hernia repair involves preperitoneal dissection and mesh placement without entering the abdominal cavity. However, both approaches are complicated. In the following study, mean surgery time for TAPP and TEP was 39 ± 2.8 and 45 ± 4.5 minutes, respectively. Hernia sac dissection was a time-consuming process in patients with large-sized hernias (>4 cm). The search for simple surgical methods remains a focus in this field. The aim of this study was to describe a novel laparoscopic technique for inguinal hernia repair, namely the total peritoneum intraperitoneal onlay mesh repair approach (TPIPOM), to provide indications and contraindications for this approach and to discuss the advantages and disadvantages of the technique.

Patients and Methods

Patients were recruited between January 2002 and March 2003. Patients with primary inguinal hernias were eligible, unless they were medically unfit for anesthesia, had a previous midline or paramedian incision, had an uncorrected coagulation disorder, or were pregnant. The study was approved by the ethics committees of our hospitals, and all patients provided informed consent after a physician informed them of the trial details. The preoperative work-up (i.e., chest X-rays, electrocardiogram, and routine blood tests) was identical to other laparoscopic procedures. There were a total of 52 males and 2 females, with a median age of 40 years (range, 18–53). Specifically, 6 patients presented with bilateral hernias (1 exhibited unilateral recurrent disease), and 48 patients had unilateral hernia (no patients presented with recurring disease). All participants were mailed a reply-paid comprehensive questionnaire during a minimum of 5 years after surgery. The questionnaire included questions regarding groin or testicle pain, impaired sensitivity (defined as loss of ability to register touch, unpleasant sensation produced by normal touch, or presence of numbness and tingling), complete recovery, impact of surgery on day-to-day life, and whether the patient was satisfied with results of surgery and recovery. All patients, who returned the questionnaire and provided their written informed consent, were subsequently contacted by telephone for complementary questions and information. They were also offered a follow-up consultation at the outpatient clinic by the same independent surgeon who performed the 1-year follow-up examination. At the follow-up examination, the inguinal area was examined, impaired sensitivity was recorded, and testicle atrophy was registered. The presence of recurrent hernia was recorded, based on clinical examination revealing a palpable, reducible lump in the treated groin, or with herniography in clinically uncertain cases. When applicable, the patient was asked to provide a more thorough pain history.

Surgical procedure

The patient was supine with both arms tucked in, and general anesthesia was used. A monitor was placed at the foot of the operation table, and the surgeon stood by the patient's shoulder opposite to the hernia. The patient underwent tracheal-intubation anesthesia to allow for relaxation of the median umbilicus ligament. Surgery was performed with two trocars: one 10-mm subumbilical port and one 5-mm port, 5–7 cm opposite to the lower quadrant in the same axial plane as the subumbilical port. Using a 10-mm, 30-degree-angled laparoscope, the groin anatomy was inspected. The inferior epigastric vessels, the internal inguinal ring with the spermatic vessels, and the vas deferens were identified. A purse-string suture was placed around the internal hernia opening and tied by using intraperitoneal knotting (Fig. 1). A polypropylene mesh (6 × 7 cm) was then placed into the abdomen through the 10-mm port, and the mesh was fixed with tacks or staples to cover the orifices, including the direct and indirect hernia spaces (Fig. 2). Finally, the mesh was covered by securing the median umbilicus ligament (Figs. 3 and 4). When the bilateral hernia was localized, the lateral umbilicus ligament was used to cover the mesh. When the ligament was determined to be too short and unable to provide adequate coverage, the ligament was dissected (Figs. 5 –8).

FIG. 1.

Suture of the hernia.

FIG. 2.

Onlay mesh.

FIG. 3.

Partial peritoneal.

FIG. 4.

Total peritoneal.

FIG. 5.

Median umbilicus ligament.

FIG. 6.

Dissection of the median umbilicus ligament.

FIG. 7.

Onlay mesh.

FIG. 8.

Overlap mesh.

Results

Clinical characteristics of the patients are listed in Table 1. The overall surgery time was 25.45 ± 5.2 minutes, and hospital stay was 3.8 ± 1.3 days. All major or minor morbidities (early or late), relapses, or signs of mesh-related complications (prosthesis rejection and/or infection) were registered. The mean follow-up time was 72.4 ± 3.1 months (range, 69–84). All patients were examined at the scheduled follow-up. Analgesics were required for a mean of 1.5 days. No patients required analgesia for 7 days or longer. There were no reports of sensations of stiffness or foreign bodies at follow-up. All patients reported complete satisfaction. The overall recurrence rate was 1.8% (1/54). Complications, in the form of persistent neuralgia, osteitis pubis, subcutaneous hematoma, numbness, or vascular injury, did not occur. All patients returned to usual activities of social life, hobbies, looking after the house, and work 1 month after surgery.

Table 1.

Patient Characteristics

Variable
Mean (SD) age in years	40 (range, 18–53)
Sex
Male	52
Female	2
Hernia site
Right	29
Left	19
Bilateral	6
Type of inguinal hernia
Direct	15
Indirect	30
Both direct and indirect	9
Recurrent hernia (yes/no)	0/54
Body-mass index^a
Median	24.0 (range, 18.0–40.5)
Prostatism (yes/no)	6/48
Smoking (yes/no)	23/31
Cough (yes/no)	8/46
Constipation (yes/no)	9/45
Intraoperative size of the hernia (cm)
Median	2.5 (range, 1–4)

The body-mass index was calculated as the weight in kilograms divided by the square of the height in meters.

SD, standard deviation.

Discussion

The optimal approaches and techniques for performing inguinal hernia repair are still under debate. Laparoscopic TAPP and TEP approaches have been documented as excellent choices in a number of studies.^7–11 For the surgeon, a surgical approach should be simple, not require preperitoneal dissection, and easy to handle. Further, the treatment should reduce recurrence and allow for fast recovery. Accordingly, the IOPM technique might be the ideal approach. However, it has been abandoned due to the risk of small-bowel obstructions related to adhesions and mesh erosions into the bowel. Currently, surgeons use new types of meshes, which are compatible with intra-abdominal placement. Therefore, peritoneal coverage should not be necessary. Nevertheless, few patients can afford the cost of the meshes, particularly in developing countries. A more suitable approach than the current TAPP and TEP ones has been under investigation for the treatment of groin hernias. During the Laparoscopic TAPP surgeries described in the present study, all patients with a median umbilicus ligament were investigated, and a novel method for inguinal hernia repair was developed. This method was termed the TPIPOM repair approach. This technique was shown to be feasible for inguinal hernia repair. The mean surgery time was significantly reduced, compared with the TAPP and TEP methods (P < 0.05). The need for analgesics was reduced, and the rate of recurrence was also extremely low. Based on these results, laparoscopic TPIPOM hernioplasty was feasible, effective, easy to perform by experienced surgeons, and provided good results.

The present study utilized a small mesh size (6 × 7 cm), and the mesh overlapped the defective margin by 1.5 cm. Various mechanisms for hernia recurrence have been suggested. Knook et al.¹² suggested that the mesh size should cover the defect by at least 3 cm, because the mesh could shrink following surgery. On the contrary, the present study presumed that if the mesh shrinks after surgery, it could be squeezed between the peritoneum and median umbilicus ligament, thereby preventing recurrence. The mesh was held in place by neighboring connective tissue lamellae, as well as growth of tissue into the mesh. Foreign-body reactions have been shown to lead to invasion of collagen fibers and fibroblasts, which further hold the mesh in place.^13–15 One patient from the present study accepted a second laparoscopic cholecystectomy because of a gallbladder stone 6 years after the TPIPOM hernioplasty (Fig. 9). Images demonstrated that the mesh size did not shrink, and connective tissue lamellae grew into the mesh. Therefore, a mesh size of 6 × 7 cm was sufficient to overlap the direct and indirect inguinal hernia and was overlapped by the median umbilicus ligament. Recurrence is due to the types of techniques used, as well as specific patient characteristics.^16,17 One (1.8%) 49-year-old patient experienced recurrence due to prostatism. The median umbilicus ligament also contributed to reduced recurrence rates. When the median umbilicus ligament was sutured to cover the mesh, the fat pad was moved up to the groin region, which altered the tension in this region. Indications for this technique are based on the following criteria: 1) indirect hernia, in particular large hernias (>4 cm), and 2) direct hernia. Contraindications were sliding, femoral, and recurrent hernias. However, there are no absolute indications, and this technique should not be used on recurrent hernias, because the median umbilicus ligament is often atrophied. In fact, 3 cases of atrophied median umbilicus ligaments were diagnosed by laparoscope in patients with recurrent hernias, after the open tension was repaired. Experience and intraoperative judgment of the surgeon play a major role in the success of this treatment. Longer follow-up periods, as well as prospective randomized, controlled trials, are needed to confirm these results. It is important to note that when the mesh has been fixed, forceps should be used to drag the ligament over the mesh, and the suture point should be determined according to the media umbilicus ligament and the abdomen wall. If a bilateral groin hernia were diagnosed, a lateral umbilicus ligament would be the best election.

FIG. 9.

Six years after the operation.

Conclusions

The present study suggested that adequate median umbilicus ligament mesh overlap presents with good results. Although the TPIPOM approach for inguinal hernia has decreased complication rates, TEP and TAPP might still be required in certain cases.

Footnotes

Disclosure Statement

No competing financial interests exist.

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