Laparoscopic Inguinal Hernia Repair
Laparoscopic Repair of Inguinal & Femoral Hernias
Management of Acceptable Complications
|TEP Repair: Closing the Peritoneal Defects|
Peritoneal defects generated by during a TEP repair
must be repaired. This defects can generate delayed small bowel
obstructions and other significant complications. For these reasons they
need to be clearly identified and immediately repaired.
These defects can be repaired using SURGICON™ 5mm Clips, an ENDOLOOP
5 mm USSC ENDOCLIP™ . The edges of the defects are approximated with
one graspers and clipped closed with clip applier. This repair is safe and
has been proven to hold well.
If the operator is not certain all defects have been
appropriately closed, a completion laparoscopy can be easily performed at
the end of the TEP repair.
|Injuries to the Epigastric Vessels|
The Epigastric vessels
are dangerous vascular structures. The laparoscopic surgeon should at all
time know their location. All bleeding complications
with or without re-exploration have
been secondary to an intra-operative injury to the Epigastric vessels.
For these reasons, we
have set forth rigid operative guidelines with which one should always
comply. They are as follows:
Whenever feasible, always insert the
lateral trocars using trans-illumination.
Always locate the Epigastric vessels
before making the peritoneal incision.
Always know the position of the
Epigastric vessels during the entire hernia repair.
When anchoring the Mesh, always staple or
place tacks on each side of the Epigastric vessels.
When closing the peritoneum [TAPP
Repairs], always staple or place tacks on each side of the epigatric
When an injury to the Epigastric vein or
artery is suspected, ligation of the epigastric vessels should be performed.
During a TEP repair, if the dilating
balloon has migrated the Epigastric vessels inferiorly [on the inferior
aspect of the repair or the peritoneum], they should ligated and cut them
If a patient, become hypo-tensive or
tachycardic during his immediate recovery, always suspect an Epigastric
|Immediate Post-operative Bleeding|
Immediate, minimal post-operative bleeding
[without hypotension or tachycardia] should prompt the surgeon to admit the
patient to the surgical service. A stable hematoma restricted to
the inguinal region and scrotum does not require re-exploration. Serial CBC
and observation should be obtained.
post-operative bleeding [with hypotension and/or tachycardia] requires an
aggressive management. The patient will be immediately transferred to a
monitored unit. Serial [every 3 hours] CBC will be ordered as well as a Type
and Hold for 4 Packed Red Blood Units. If the hypotension does not respond
to intra-venous fluid , re-exploration should be contemplated. An
injury to the Epigastric vessels is almost always the etiology. If the
hemodynamic indices of the patient respond to intravenous fluid hydration,
observation is warranted with transfusion if the Hemoglabin level drops below
8mg/ml. Continuously dropping hemoglobin level, will require re-exploration.
|Hernias without a Peritoneal Sac|
The classical concept that all inguinal
hernias must be accompanied with a hernia sac has been questioned since the
introduction of the laparoscopic inguinal hernia repair. In our latest
series of 2300 laparoscopic inguinal hernia repairs, eleven patients
undergoing a TAPP repairs where found to have a direct inguinal hernia
without a peritoneal sac. In addition, we believe we are probably
underestimating this number. Nonetheless, all patients undergoing a TAPP
repair should have their inguinal region fully investigated [without
peritoneal coverage] even in the absence of a peritoneal sac.
Injuries to the neural structure in the inguino-femoral area
are reported to happen during a laparoscopic repair. Some authors claim that
using a Mesh without any means of fixation [tacks] eliminates this
complication. There are however no long term studies available with this
However in our latest analysis of 2500 repairs, the
occurrence of permanent, post-operative neuralgia was negligible even when
placing tacks lateral to the spermatic cord or inguinal rings. Temporary,
short term neuropathy do commonly occur but do not impair the recovery
of the patient but subside within a few days.
Injuries to the
lateral cutaneous nerve and to the genital branch of the genito-femoral
nerve can be minimized by using simple maneuvers.
Do not use abdominal
wall counter pressure when placing a tack,
Dissect the abdominal
wall meticulously and try to identify obvious neural branches,
Do not place and tack
the Mesh under tension,
Make all patients
exercise starting the day after the procedure [minimal exercise: a 1 to 3
miles, daily walk].