Repeat Laparoscopic Totally Extraperitoneal Hernia Repair After Primary Laparoscopic Totally Extraperitoneal Hernia Repair for Inguinal Hernia

Introduction

After the introduction of endoscopic hernia repair by Ger in 1982, the number of laparoscopic totally extraperitoneal hernia repairs (TEPs) has been constantly rising. ¹ The laparoscopic approach has been associated with less postoperative pain, shorter hospital stay, and low recurrence rate.^2–4 Some studies reported that recurrence rates ranged from 0.3% to 8.5%, ⁵ and the rate of contralateral occurrence was about 1%.^6,7 As the period of postoperative surveillance is extended, it is thought that the number of patients with recurrence or with a new hernia on the contralateral side will increase.

Laparoscopic technique as the treatment for recurrent hernia has been reported to be superior to open anterior repair.^8–11 Although laparoscopic transabdominal preperitoneal repair (TAPP) for recurrence after primary TEP or TAPP has also proven feasible,^8,12,13 only a few studies have reported on TEP for recurrence after primary TEP. Felix et al. reported that TEP after primary TEP is virtually impossible. ¹² Therefore, the purpose of this study was to review our experience with TEP of contralateral hernia recurrence after a primary TEP.

Patients and Methods

From April 2003 to May 2009, 215 TEPs had been performed for inguinal hernia in Beppu Medical Center. Of these, 30 TEPs were performed for bilateral inguinal hernia, 157 TEPs for primary inguinal hernia, and 28 TEPs for contralateral occurrence. We retrospectively reviewed the cases of the 28 patients who underwent TEP for contralateral hernia occurrence (Table 1). Twenty-three of those 28 patients had undergone primary TEP before April 2003 and 5 had developed contralateral inguinal hernia from April 2003 to May 2009. ¹⁴ The follow-up period was between 1 and 72 months (median 35.9 months). The surgeons, each experienced over 10 years, were considered to be experienced in laparoscopic gastrointestinal surgery.

Our approach to these contralateral occurrences was not markedly different from that of standard TEP. A small paraumbilical incision was made and the ipsilateral anterior rectus sheath was opened. The extraperitoneal space was created without exposing the primary repair using a PDB 1000 (Covidien). There was no additional dissection. Carbon dioxide gas was insufflated to an intraperitoneal pressure of 10 mmHg to create a surgical field. The ENDOPATH XCEL 5-mm port (Ethicon Endo-Surgery) was made on the ipsilateral rectus or lower midline. We used polypropylene three-dimensional mesh to cover the inguinal bed and ProTack^TM (Autosuture; Tyco Healthcare) to fix the mesh.

Results

A total of 28 TEPs were performed for inguinal hernia occurring on the contralateral side after primary TEP. The patients comprised 26 men and 2 women with a mean age of 63.7 years (range: 23–88 years) (Table 2). Of the contralateral hernias, 27 were indirect hernias and 1 was a direct hernia. The mean period to contralateral occurrence was 54.6 months (range: 2–131 months) after primary surgery. The mean operation time was 73.8 minutes (range: 25–217 minutes) and the conversion to anterior repair was made in 7 of 157 patients who had undergone primary TEP for unilateral inguinal hernia. There were no significant difference in operation time and rate of conversion by using Mann–Whitney U test and χ² test.

Repeat TEP was applied to repair the contralateral inguinal hernia after primary TEP in these patients. In 3 patients, conversion to an anterior open procedure was made because of injury to the peritoneum due to adhesions on the midline preperitoneal space in 1 patient and due to difficulties in dissecting the preperitoneal space with a blunt balloon-tip cannula at the beginning of surgery in 2 patients. However, these converted 3 cases had occurred in first 10 cases and there were no convert after these sequential cases. The inferior epigastric artery and vein were divided in 4 patients because of bleeding in 2 cases and strong adhesion to peritoneum in 2 cases during the dissection of PDB 1000. There were no postoperative complications (Table 3). There were no recurrences in these 28 patients after secondary TEP. The follow-up period was between 1 and 70 months.

Discussion

Laparoscopic repair of recurrent hernia has been shown to be effective.^8–11 Many studies concerning the repair of recurrent hernia were reported after 1999, and most of the procedures reported were TAPP for recurrent hernia. In these reports, several authors reported the feasibility of TAPP repair for recurrence after primary laparoscopic hernia repair by TAPP or TEP.^8,12,13 Leibl et al. reported TAPP repair of the recurrence in 46 of 5005 patients, and the total complication rate was 10.9%. ⁸ Felix et al. reviewed 35 recurrences in 10,053 hernias in 7661 patients, of which 29 were repaired by TAPP. Four patients were converted to an open approach. They asserted that it was virtually impossible to reexplore an extraperitoneal repair extraperitoneally. ¹² However, Tamme et al. reported on 5203 TEPs in 3868 patients, in whom 29 recurrent hernias had been detected in 28 patients. ¹⁵ Among these patients, 26 had primary hernia and 3 had recurrent hernias. Reoperation had been performed for 23 recurrent hernias in their institution, 18 by Lichtenstein technique, 3 by TAPP, and 2 by TEP. Ferzli et al. reported the repair of 1059 inguinal hernias in 804 patients by means of TEP. ⁷ Twenty patients had recurrent hernia and underwent TEP. In these patients, 12 hernias were on the ipsilateral side, and 8 were on the contralateral side. Only 1 patient converted to an anterior approach, and there were no postoperative complications. They concluded that TEP for recurrent inguinal hernia after primary TEP was entirely feasible as well as safe. In our cases, the operation time for TEP after primary TEP was not prolonged compared with that of the primary TEP, and there were no postoperative complications in any patient. These results suggest that, in general, reexploration of the extraperitoneal space after primary TEP appears to be feasible.

We do not routinely perform bilateral examination to rule out contralateral occult inguinal hernia because of low rate of contralateral occurrence. In our institution, only 5 (3.2%) patients developed contralateral hernia in our 157 patients undergoing primary TEP for unilateral inguinal hernia between 2003 and 2009. ¹⁴ Koehler reported observing occult contralateral hernia in 13% of patients when examined by transabdominal diagnostic laparoscopy, ¹⁶ and Thumbe and Evans reported finding incidental defects in 22% of patients during TAPP. ¹⁷ However, Saggar and Sarangi reported that a hernia developed on the contralateral side after only 6 of 446 unilateral repairs, ⁶ and Ferzli et al. noted that 4 contralateral hernias occurred after a primary unilateral endoscopic repair in 549 patients. ⁷ The contralateral occurrence rate after TEP is low, and few reports mention laparoscopic repair for new contralateral hernias. We start all contralateral occurrences as TEPs; however, if we have some trouble, it is thought to choose open method, not TAPP, because of possibility of intraoperative injury of intestinal tract and postoperative ileus. In our patients, 3 (11%) of 28 patients converted to an anterior approach because of difficulties in reexploring the preperitoneal space. The remaining 25 patients underwent TEP without injury to the peritoneum, including division of the inferior epigastric artery and vein in 4 patients. However, none of our patients suffered ipsilateral recurrence after primary TEP. Reexploration of the ipsilateral peritoneal space after primary TEP when the contralateral peritoneal space had been created with a blunt balloon-tip cannula could be performed in only a few patients. Reexploration of the ipsilateral peritoneal space after primary TEP is controversial, and further accumulation of data on ipsilateral recurrence after primary TEP is necessary.

Conclusions

Repeat TEP had no longer operation time and no higher conversion rate compared with primary TEP. It is thought to be feasible for contralateral occurrence. Although it has some difficulty during the dissection of the preperitoneal space, repeat TEP might be an alternative method for contralateral occurrence after primary TEP.