Laparoscopic Inguinal Hernia Repair: Background, Indications, Contraindications. Schultz L, Graber J, Pietrafitta J, Hickok D. Laser laparoscopic herniorraphy: a clinical trial preliminary results. J Laparoendosc Surg. Schultz LS, Graber JN, Pietrafitta J, Hickok DF. Early results with laparoscopic inguinal herniorrhaphy are promising. Morbid obesity is a chronic condition that arises when the BMI is 40 or more. Laparoscopic gastric banding surgery is offered at Keyhole Obesity Surgery Centre in.![]() Nath, MD, FACS Dennis G. Begos, MD, FACS, FASCRS Andras Sandor, MD, FACS, FASMBS Matthew W. Brown, MD Michael N. Tameo, MD Erin O’Sullivan, NP, CWS Molly. Activity restrictions after hernia surgery First week. First Month. No exertion. After one month. No restrictions. The purpose of restricting activity during. Surgery Overview. Laparoscopic hernia repair is similar to other laparoscopic procedures. General anesthesia is given, and a small cut (incision) is made in or just. Laparoscopic Inguinal Hernia Surgery Care Instructions What to Expect Surgery & Follow-up. Expect to go home after surgery, so plan for a friend/family member to. Clin Laser Mon. Blamey SL, Wale RJ. Laparoscopic repair of inguinal hernia. Nov 1. 8. 1. 55(1. Lichtenstein IL, Shulman AG, Amid PK. Laparoscopic hernioplasty. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc Surg. Jenkins JT, O'Dwyer PJ. Inguinal hernias. Demographic and socioeconomic aspects of hernia repair in the United States in 2. Surg Clin North Am. Kuhry E, van Veen RN, Langeveld HR, Steyerberg EW, Jeekel J, Bonjer HJ. Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review. Surg Endosc. 2. 1(2): 1. Neumayer L, Giobbie- Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2. 00. Apr 2. 9. 3. 50(1. Eklund A, Montgomery A, Bergkvist L, Rudberg C. Chronic pain 5 years after randomized comparison of laparoscopic and Lichtenstein inguinal hernia repair. Kark AE, Kurzer MN, Belsham PA. Three thousand one hundred seventy- five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg. 1. Novitsky YW, Czerniach DR, Kercher KW, Kaban GK, Gallagher KA, Kelly JJ, et al. Advantages of laparoscopic transabdominal preperitoneal herniorrhaphy in the evaluation and management of inguinal hernias. Takata MC, Duh QY. Laparoscopic inguinal hernia repair. Surg Clin North Am. Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR. Meta- analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Mc. Cormack K, Scott NW, Go PM, Ross S, Grant AM. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. Brough W, Deans G, Wilson M, Royston C. Early results of laparoscopic intraperitoneal onlay mesh repair for inguinal hernia. Chan AC, Lee TW, Ng KW, Chung SC, Li AK. Early results of laparoscopic intraperitoneal onlay mesh repair for inguinal hernia. Fitzgibbons RJ Jr, Salerno GM, Filipi CJ, Hunter WJ, Watson P. A laparoscopic intraperitoneal onlay mesh technique for the repair of an indirect inguinal hernia. Laparoscopic inguinal hernia repair by an intraperitoneal onlay mesh technique using expanded PTFE: a prospective study. Surg Laparosc Endosc. Chung L, O'Dwyer PJ. Treatment of asymptomatic inguinal hernias. O'Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Fitzgibbons RJ Jr, Giobbie- Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. Jan 1. 8. 2. 95(3): 2. Chung L, Norrie J, O'Dwyer PJ. Long- term follow- up of patients with a painless inguinal hernia from a randomized clinical trial. Nov 3. 0. Eklund A, Rudberg C, Leijonmarck CE, Rasmussen I, Spangen L, Wickbom G, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc. 2. 1(4): 6. Keidar A, Kanitkar S, Szold A. Laparoscopic repair of recurrent inguinal hernia. Surg Endosc. 1. 6(1. Mahon D, Decadt B, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc. 1. 7(9): 1. Wauschkuhn CA, Schwarz J, Boekeler U, Bittner R. Laparoscopic inguinal hernia repair: gold standard in bilateral hernia repair? Results of more than 2. Surg Endosc. 2. 4(1. Demetrashvili Z, Qerqadze V, Kamkamidze G, Topchishvili G, Lagvilava L, Chartholani T, et al. Comparison of Lichtenstein and laparoscopic transabdominal preperitoneal repair of recurrent inguinal hernias. Jul- Sep. 9. 6(3): 2. Scott NW, Mc. Cormack K, Graham P, Go PM, Ross SJ, Grant AM. Open mesh versus non- mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev. Mok KT, Wang BW, Chang HT, Liu SI, Jou NW, Tsai CC, et al. Laparoscopic versus open preperitoneal prosthetic herniorrhaphy for recurrent inguinal hernia. Apr- Jun. 8. 3(2): 1. Tantia O, Jain M, Khanna S, Sen B. Laparoscopic repair of recurrent groin hernia: results of a prospective study. Surg Endosc. 2. 3(4): 7. Frankum CE, Ramshaw BJ, White J, Duncan TD, Wilson RA, Mason EM, et al. Laparoscopic repair of bilateral and recurrent hernias. Richards SK, Vipond MN, Earnshaw JJ. Review of the management of recurrent inguinal hernia. Janu PG, Sellers KD, Mangiante EC. Recurrent inguinal hernia: preferred operative approach. Bochkarev V, Ringley C, Vitamvas M, Oleynikov D. Bilateral laparoscopic inguinal hernia repair in patients with occult contralateral inguinal defects. Surg Endosc. 2. 1(5): 7. Simultaneous repair of bilateral groin hernias: open or laparoscopic approach? Surg Laparosc Endosc. Schmedt CG, D. Simultaneous bilateral laparoscopic inguinal hernia repair: an analysis of 1. Surg Endosc. 1. 6(2): 2. Neumayer LA, Gawande AA, Wang J, Giobbie- Hurder A, Itani KM, Fitzgibbons RJ Jr, et al. Proficiency of surgeons in inguinal hernia repair: effect of experience and age. Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group. Dulucq JL, Wintringer P, Mahajna A. Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,1. Surg Endosc. 2. 3(3): 4. Napier T, Olson JT, Windmiller J, Treat J. A long- term follow- up of a single rural surgeon's experience with laparoscopic inguinal hernia repair. Heikkinen T, Bringman S, Ohtonen P, Kunelius P, Haukipuro K, Hulkko A. Five- year outcome of laparoscopic and Lichtenstein hernioplasties. Surg Endosc. 1. 8(3): 5. Papachristou EA, Mitselou MF, Finokaliotis ND. Surgical outcome and hospital cost analyses of laparoscopic and open tension- free hernia repair. Edwards CC 2nd, Bailey RW. Laparoscopic hernia repair: the learning curve. Surg Laparosc Endosc Percutan Tech. Quinn TH, Annibali R, Dalley AF 2nd, Fitzgibbons RJ Jr. Dissection of the anterior abdominal wall and the deep inguinal region from a laparoscopic perspective. Koch A, Edwards A, Haapaniemi S, Nordin P, Kald A. Prospective evaluation of 6. Woods B, Neumayer L. Open repair of inguinal hernia: an evidence- based review. Surg Clin North Am. Lal P, Philips P, Saxena KN, Kajla RK, Chander J, Ramteke VK. Laparoscopic total extraperitoneal (TEP) inguinal hernia repair under epidural anesthesia: a detailed evaluation. Surg Endosc. 2. 1(4): 5. Sinha R, Gurwara AK, Gupta SC. Laparoscopic total extraperitoneal inguinal hernia repair under spinal anesthesia: a study of 4. J Laparoendosc Adv Surg Tech A. Zacharoulis D, Fafoulakis F, Baloyiannis I, Sioka E, Georgopoulou S, Pratsas C, et al. Laparoscopic transabdominal preperitoneal repair of inguinal hernia under spinal anesthesia: a pilot study. Tzovaras G, Symeonidis D, Koukoulis G, Baloyiannis I, Georgopoulou S, Pratsas C, et al. Long- term results after laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair under spinal anesthesia. Wauschkuhn CA, Schwarz J, Bittner R. Laparoscopic transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: is it safe? Results of prospectively collected data of more than 2. Surg Endosc. 2. 3(5): 9. Brick WG, Colborn GL, Gadacz TR, Skandalakis JE. Crucial anatomic lessons for laparoscopic herniorrhaphy. Lange JF, Rooijens PP, Koppert S, Kleinrensink GJ. The preperitoneal tissue dilemma in totally extraperitoneal (TEP) laparoscopic hernia repair: an anatomo- surgical study. Surg Endosc. 1. 6(6): 9. Vidovic D, Kirac I, Glavan E, et al. Laparoscopic totally extraperitoneal hernia repair versus open Lichtenstein hernia repair: results and complications. J Laparoendosc Adv Surg Tech A. Skandalakis JE, Skandalakis PN, Skandalakis LJ (Editors). Surgical anatomy and technique: a pocket manual. New York: Springer; 2. Malangoni M, Rosen R. Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery: the Biological Basis of Modern Surgical Practice. Philadelphia, PA: Elsevier; 2. O'Malley KJ, Monkhouse WS, Qureshi MA, Bouchier- Hayes DJ. Anatomy of the peritoneal aspect of the deep inguinal ring: implications for laparoscopic inguinal herniorrhaphy. Eugene JR, Gashti M, Curras EB, Schwartz K, Edwards J. Small bowel obstruction as a complication of laparoscopic extraperitoneal inguinal hernia repair. J Am Osteopath Assoc. Lange B, Langer C, Markus PM, Becker H. Mesh penetration of the sigmoid colon following a transabdominal preperitoneal hernia repair. Surg Endosc. Ramshaw B, Shuler FW, Jones HB, Duncan TD, White J, Wilson R, et al. Laparoscopic inguinal hernia repair: lessons learned after 1. Surg Endosc. Taylor C, Layani L, Liew V, Ghusn M, Crampton N, White S. Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomised clinical trial. Surg Endosc. 2. 2(3): 7. Vilos GA, Ternamian A, Dempster J, Laberge PY, The Society of Obstetricians and Gynaecologists of Canada. Laparoscopic entry: a review of techniques, technologies, and complications. J Obstet Gynaecol Can. Ahmad G, O'Flynn H, Duffy JM, Phillips K, Watson A. Laparoscopic entry techniques. Cochrane Database Syst Rev. Feb 1. 5. Moore JB, Hasenboehler EA. Orchiectomy as a result of ischemic orchitis after laparoscopic inguinal hernia repair: case report of a rare complication. Patient Saf Surg. Peeters E, Spiessens C, Oyen R, De Wever L, Vanderschueren D, Penninckx F, et al. Laparoscopic inguinal hernia repair in men with lightweight meshes may significantly impair sperm motility: a randomized controlled trial. Sajid MS, Kalra L, Parampalli U, Sains PS, Baig MK. Complications of Laparoscopic Inguinal Hernia Repair. Edward L. Felix, MD, FACSINTRODUCTIONHigh morbidity and recurrence rates as well as prolonged recovery have led to a gradual evolution in inguinal hernia repair. Bassini. 1 began the era of modern hernia repair more than 1. Mc. Vay. 2 and later Shouldice. Bassini’s technique. Next, mesh- reinforced repairs were introduced to further decrease the incidence of failure. Lichtenstein et al. Nyhus et al. 5 and Stoppa et al. In 1. 99. 0, laparoscopic surgeons took the posterior mesh repair one step further, utilizing modern laparoscopic instrumentation to reduce morbidity and recurrence rates seen with conventional open hernia repairs. At first, surgeons tried simple approaches like Ger’s. Shultz’s. 8 plug and patch, but these failed to improve on the results of open repairs. When surgeons realized that laparoscopic repairs had to mimic the open posterior repairs of Nyhus and Stoppa, results dramatically improved. Although new laparoscopic approaches were developed to reduce complications seen with open repairs, a whole new set of problems, as well as some of the old ones, were experienced by patients. It was only when the laparoscopic surgeon completely understood the possible complications inherent to the laparoscopic repair and the causes of these complications that postoperative morbidity could be decreased and the surgeon could handle the complications that cannot be avoided. In multi- institutional reviews and single- center studies,9- 1. The incidence of major complications (approximately 1% for experienced surgeons), however, is consistent across these large studies and is similar to that reported for open hernia repairs. The purpose of the present review is not to give a detailed summary of the literature, but rather to explain why the most common and important complications occur and how they might be prevented or handled if they do develop. COMPLICATIONS RELATED TO ANATOMYPerforming a successful laparoscopic hernioplasty requires a thorough knowledge of the anatomy of the pelvis and groin as viewed through the laparoscope. For many surgeons, this exposure is totally foreign. If the surgeon is ill prepared to approach the groin laparoscopically, he or she may become lost and totally overlook an obvious hernia. The result is an immediate failure of the repair. Worse, however, is the situation in which the surgeon begins the dissection of the posterior floor, but is unable to properly identify the anatomical structures, which results in an injury to the iliac vein, bladder, cord structures, or intestine. These complications can be avoided in almost all cases by understanding the normal anatomy. This can be accomplished by reviewing recordings of dissections performed by other experienced laparoscopic surgeons. Before undertaking one’s first laparoscopic hernia repair, it is essential that the surgeon assist others as part of the educational process. In some cases, a complex recurrent or incarcerated hernia can mask the normal anatomy. In these instances, the surgeon should begin dissecting from an area of normal anatomy and slowly dissect away the tissue so the landmarks can be identified. In the totally extraperitoneal approach, the pubis and Cooper’s ligament will lead the surgeon to the iliac vein and inferior epigastric vessels, important guideposts to the repair. If an incarcerated femoral hernia is present, however, the iliac vein will be hidden behind the incarcerated sac, which must be reduced before the vein can be visualized. Knowing where the vein is located should prevent inadvertent injury and sudden blood loss. If a direct hernia is incarcerated, the inferior epigastric vessels may not be visible until the sac is reduced. The direct sac, however, should not be ligated because the tip of the bladder may make up part of the hernia sac and will be injured in the process. The indirect sac, if present, is lateral to the inferior epigastric vessels, and identification of these vessels is essential. The surgeon must dissect this lateral tissue away from the abdominal wall to identify the peritoneum and sac, as well as the cord structures. Unlike the transabdominal preperitoneal approach (TAPP) in which the indirect sac is obvious, in the totally extraperitoneal approach the indirect space and the lateral aspect of the spermatic cord must be dissected and identified by the surgeon so as not to overlook an indirect hernia. In the transabdominal prepertitoneal approach, the anatomy of the groin is usually more easily understood, but even in this approach, a complicated incarcerated or sliding hernia can cause confusion (Figure 1). By starting the dissection of the peritoneum above and lateral to the internal ring, the peritoneum can usually be peeled off the cord. If the sac is too long or adherent to the testicular vessels and vas deferens, it can be opened from lateral to medial, watching for the cord structures on the inferior medial aspect of the sac. The most common complication due to a lack of understanding of the anatomy or respect for the location of the normal structures is injury to the sensory nerves: the femoral branch of the genito- femoral nerve, the lateral cutaneous nerve, or the femoral nerve itself. Cauterization, transection, or entrapment of the nerves can usually be avoided if the surgeon is respectful of the tissue below the iliopubic tract. The tract can be identified visually as a fibrous band at the lower edge of the internal ring or manually by placing one’s hand on the abdominal wall and palpating an instrument placed laparoscopically at the level of the iliopubic tract. If the surgeon cannot feel the instrument, the point of contact of the probe is below the iliopubic tract. Because the nerves usually enter the thigh below this line, placing fixation above the iliopubic tract reduces the chance of injuring the nerves. A German. 16 cadaver study of the anatomy of the posterior groin, however, showed that in 1. This makes the nerves at risk for injury even if staples or tacks are properly placed. For this reason, more and more surgeons have moved toward mesh repairs that do not require fixation or have chosen adhesive fixation. If severe pain presents immediately after surgery in the distribution of a major named nerve (Figure 2), the surgeon should explore the posterior wall laparoscopically, looking for the offending staple to remove it. Pain presenting days or weeks after surgery is usually transient and due to irritation of the nerves rather than entrapment. Only on a rare occasion will surgical re- exploration be necessary for this situation and reoperation should only be suggested if time and other measures, such as anti- inflammatory medication, have not helped. If pain persists despite conservative measures and the pain is isolated to a specific point on the abdominal wall or the distribution of a specific nerve, exploration is warranted. We have seen symptoms relieved as long as 6 months after the initial repair after removal of a tack or irritating mesh. COMPLICATIONS RELATED TO TECHNIQUESmall- Bowel Obstruction. Small- bowel obstruction after a laparoscopic hernia repair can occur. It is the result of adhesions to inadequately covered mesh or due to intestines being entrapped in a defect left in the peritoneum. Exposed mesh with either the TAPP or the totally extraperitoneal hernia repair (TEP) is rare, if the surgeon mobilizes the peritoneum to fully cover the mesh. Adhesions to spiral tacks used to close the peritoneum during TAPP repairs do occur, but can be avoided by suturing the peritoneal defect instead of tacking it. If the peritoneum is inadequately closed after a TAPP repair, an internal hernia can occur in the defect in the peritoneum. Whether staples or sutures are used to close the peritoneum, gaps cannot be left in the peritoneal closure. If a defect in the peritoneum is left after a TEP repair, rarely the bowel can become incarcerated (Figure 3). A potential space is created between the peritoneum and the abdominal wall by the dissection of the posterior floor and by the CO2 gas. Bowel may become obstructed at the entrance to this space. Trocar Hernia. A new complication after inguinal hernia repair, the late development of a trocar hernia (Figure 4),has been seen after the TAPP approach. They may be Richter hernias or typical incarcerated hernias. They usually occur in ports that are . Now several techniques have been developed to assist in closing these puncture sites. In addition, the use of 5- mm lateral trocars and noncutting 1. Trocar hernias almost never occur after TEP repairs, which have gained in popularity over the last 1. Hemorrhage. Bleeding can occur during any operation, but it is especially troublesome during laparoscopic hernioplasty. Because of limited access to the bleeding site and high flow rates of those vessels most likely to be injured, bleeding must be controlled quickly or avoided completely. The location of the inferior epigastric vessels may vary, and injury to these vessels is the most common cause of bleeding. Therefore, the surgeon must stay lateral to the rectus muscles to avoid injuring them when placing the lateral trocars in the TAPP approach. If hemorrhage results following trocar insertion, it can be controlled with a U- stitch made with a suture passer. A surprisingly large amount of blood can be lost if these vessels are not controlled immediately. Remember that the arterial supply comes from the caudal aspect of the inferior epigastrium. In the TEP approach, the expansion of the balloon dissector may pull the inferior epigastric vessels away from the abdominal wall, tearing small branches and filling the potential space with blood. If the surgeon is confronted with a darkened, bloody field when the camera is reinserted, the light intensity should be immediately increased and the 2 midline trocars placed so that the extraperitoneal space can be irrigated to allow the surgeon to find the source of bleeding.
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