Modified Implantation of Self-Adhesive Mesh in Laparoscopic Total Extraperitoneal Inguinal Hernia Repair

Introduction

Inguinal hernia repair is one of the most frequently performed surgical procedures worldwide in general surgery. Compared with open technique, laparoscopic inguinal hernia repair is associated with a lower rate of postoperative pain, much superior esthetic results and a much faster postoperative recovery.^1,2

Transabdominal preperitoneal prosthetic (TAPP) and total extraperitoneal (TEP) were the most frequently performed methods of laparoscopic hernia repair, but the superiority of one method over the other had not yet been demonstrated. ³ As compared with other endoscopic techniques, TEP avoids the penetration in the peritoneal cavity and thus it has less association with intra-abdominal complications. ⁴

Prosthetic materials that were used to implant to the groin were many and their safety had been verified clinically. The reliability of self-adhesive mesh in hernia reparation had also been confirmed by authors.^5,6

In a study to open hernia repair, self-gripping mesh did not show better outcomes in either short- or long-term complications compared with suture fixation, but self-gripping mesh had a significantly shorter operative time. ⁷

Traditionally, the implanting technique is to hold the mesh at the center of the nonadhesive side and insert it into the preperitoneal envelope through the 10 mm port.^5,6,8But practically we found this insertion of the mesh could meet insertion resistance in the port, and this technique was easy to cause unexpected adhesions within the groin when spreading the self-adhesive mesh. Thus, we designed a modified implantation of self-adhesive mesh to avoid these problems.

Materials and Methods

Surgical technique

Urinary catheterization was used in all cases to maintain the bladder in repletion, thus avoiding the narrowing of the operative field. Patient was in a Trendelenburg position after general anesthesia. A 10 mm incision was made on the hernia side 1 cm below the umbilicus. After identifying the anterior rectus sheath, we made a transversal incision at this level. Blunt dissection of the rectus abdominis muscle was subsequently made to reach the posterior sheath. A 10 mm trocar was then inserted into the incision and a 30° optics was used to dissect the extraperitoneal space, avascularly toward the pubic symphysis.

Extraperitoneal space was established by carbon dioxide (CO₂) infusion. Two 5 mm trocars were, respectively, placed at the upper and inferior one-third point between the pubis and the umbilicus. Further dissection in the retropubic and iliac fossa spaces was performed to extend the inguinal region until it reached the anatomic reference points of pubis, Cooper's ligament, and psoas muscle.

The covering area on the inside should surpass the middle line to cover the pubic symphysis, whereas the covering area on the outside was on the level of the psoas muscle and the anterior superior iliac spine. The upper side of the covering area included 2–3 cm of the tendo conjunctivis inguinalis, and the inferior side should cover the deep inguinal orifice and the medial portion of the external iliac vein.

A 15 cm × 9 cm size plastic membrane was put on the microgrip side of the same size self-adhesive mesh (Fig. 1A). With the membrane on the outer, the mesh complex was rolled up to a cigarette shape. To keep the mesh complex from loosening itself, a suture thread was used to bundle it (Fig. 1B). Nearly 10 mm length of microgrip side of the mesh's distal end would be exposed with no membrane covering after rolling up.

OPEN IN VIEWER

FIG. 1.

Mesh preparation. (A) Put the membrane on the mesh. (B) Roll up the mesh.

After the bundled mesh being inserted through the 10 mm port on the median line to the covering area, the exposed microgrips should be placed at the inferior side of the covering area, with one end across the middle line (Fig. 2A). The exposed microgrips was fixed by gently pressing with a grasper. Then the bundling thread was cut and removed, spreading out the mesh upward. Two graspers gradually pressed and spread the mesh complex, removing the membrane meanwhile. CO₂ exsufflation was carried out after confirming the correct placement of the mesh (Fig. 2B).

OPEN IN VIEWER

FIG. 2.

Mesh fixation. (A) Insert the mesh to the groin. (B) Spread the mesh.

Results

All the operations were successfully completed. We found that the mesh was easy to be inserted and put on the right position with no readjustment and unexpected adhesions. The spreading of the mesh and the removing of the membrane were also not a frustrating maneuver, which largely shortened the operation time in laparoscopic TEP.

Operation time was varied from 42 to 80 minutes, and the mean operation time was 55.76 ± 11.11 minutes. This surge variation might be due to the different hernia sizes and hernia histories of patients. The details of postoperative complications are listed in Table 2.

Discussion

With excellent medium- and long-term results, the TEP technique remains one of the most frequently used surgical techniques in the repair of hernia defects. ⁹ Although the intraoperative and general postoperative complication rates as well as the reoperation rate for complications show no significant difference between TEP and TAPP, the TEP is a total extra peritoneal technique that theoretically avoids the potential injury to viscera in operation. ¹⁰

The creation of extraperitoneal space is crucial during TEP repair, which usually requires an expensive commercially available balloon. However, study showed that balloon dissection did not offer significant advantage over direct telescopic dissection in the overall long-term outcome of TEP repair. ¹¹ Regarding the economical priority, all our patients were performed direct telescopic dissection in the extraperitoneal space and the results were satisfactory.

Generally, meshes should be stabilized at the site of implantation with additional invasive fixation in a form of spirals, clips, screws, and so on. Self-adhesive meshes in laparoscopic inguinal hernia repair had been described by authors.^8,12 The self-adhesive mesh was a light weight mesh, consisted of a monofilament polyethylene terephthalate covered by a resorbable layer of microgrips. The microgrips could adhere with the contacted tissues in the groin, fixing itself on the repairing field without staple, which could reduce the incidences of postoperative chronic inguinal pain. Migration and folding of the mesh were rare after fixation, which preserved its reliability for hernia repair.

We began to perform laparoscopic inguinal hernia repair using self-adhesive mesh nearly 2 years ago. The mesh implantation described in the literature was performed by directly holding the center of the nonadhesive side, being inserted through the 10 mm trocar to the groin. ⁸ We found this was technically challenging because the microgrips would enhance insertion resistance in the trocar and produce unexpected adhesions in the groin. Repeatedly removing the mesh might cause injury or bleeding and prolong operation time.

To smoothly introduce the mesh through the trocar, we rolled the mesh up like a cigarette, which greatly facilitated the implantation process, but the opening of the mesh in the groin was still a challenge if no plastic membrane was used. The microgrips side of the mesh would adhere to the nonmicrogrips side, which resulted in a consequence that the opening of the mesh in a much-limited operative field was difficult.

The smooth plastic membrane should be covered on the adhesive side, which would prevent unexpected adhesions. When rolled up, nearly 1 cm distal end of the mesh's microgrips would be exposed without membrane covering. It happens naturally that the outer layer is about 1 cm shorter than the inner one when the two layers of the mesh are rolled up. We found this uncovered end was proper to first fix the rolled-up mesh at the inside of the repairing region. During unwrapping of the mesh, the plastic membrane could be removed fluently. To avoid the mesh loosening itself after insertion, the bundling thread was needed. The opening of this bundled mesh complex was relatively a simple process.

Seroma was not a seldom encountered complication in laparoscopic TEP hernia repair.^2,13 Two patients in our study developed seromas, which were spontaneously resolved in 6 months after surgery. It should be noted that sometimes we found early postoperative bulges in the groin area, which were neither seroma nor recurrence. It was a pseudo-bulge caused by the outstretched abdominal wall in the groin, and the thinning hernia covering tissue also played a role in this bulge. Patients might regard this as a surgical failure. To avoid this problem, we pulled the roof of hernia covering tissue back to the level of hernia neck after sac dissection and fixed it on the nearby abdominal wall with a tacker to avoid immediate bulge in the early days after surgery.

Laparoscopic and open preperitoneal mesh repair were equivalent in terms of recurrence. ² We did not encounter recurrence in all our 21 patients, which might be attributed to the small size of cases.

The overall operation time could be influenced by factors such as patient's weight, size of hernia sac, anatomic difficulty, or bleeding. But the mesh implanting time was mainly related to implanting technique and the surgeon's professionalism. We found that this modified technique largely shortened the mesh implanting time and the total surgical duration, which led us to state that this technique might simplify the surgical process and was reproducible in laparoscopic TEP hernia repair.