Laparoscopic Inguinal Hernia Repair
All patients cleared for general anesthesia were candidates for this repair. Our youngest patient was fifteen years old and our oldest 88 years old. Previous intra-abdominal surgical procedures were not a contraindication. The surgeon decides on a per case basis if an extensive, lengthy enterolysis is in the best interest of the patient or if a TEP technique should be used. It has been reported that the major indications of this technique are recurrent inguinal hernias and bilateral inguinal hernias. We recommended that all inguino-femoral hernias including single, unilateral defects be repaired via laparoscopy.
The TEP and TAPP laparoscopic techniques are identical techniques with different, anatomical access routes. The TAPP is a Trans-Abdominal route, the TEP a Pro-Peritoneal route (see technique). Our recent analysis showed there was no increase in the rate of intra-operative injuries with the TEP or TAPP technique when performed by experienced laparoscopic surgeons. Surgeons should however take advantage of these different access routes in different clinical settings.
We use these techniques in the following settings:
Although various prosthetic Mesh-s were used to perform these repairs, we routinely use a tailored 6"x 6" USSC SurgiPro® Mesh. As we reported, we initially used a 3 x 5 Mesh. When analyzed most of our recurrence could have been prevented by using a larger 6x6 Mesh. For this reason, we now use large SurgiPro® Mesh for all repairs.
We have used two different variations for the placement of this Mesh. Approximately 500 cases were done with the graft wrapped around the spermatic cord and more than 700 cases were on lay placement. To date, there has been no difference in outcome or recurrence rates with either of these variations. As of October 1996, we now preferentially use the on lay Mesh placement with TAPP or TEP Repairs.
- Onlay Placement of SurgiPro® Mesh -
- SurgiPro® Mesh Around Spermatic Cord -
Anchoring the Mesh has been subject to most controversy. Early on in the history of this laparoscopic technique, some surgical teams claimed the anchoring or stapling of the Mesh has been responsible for a significant rate of post-operative neuropathy. Compression of branches of the genito-femoral and lateral cutaneous nerve by staples or tacks on the lateral aspect of the inguinal ring may have been the cause for this post-operative complication. For these reasons, authors have developed numerous techniques, i.e. "no anchor-staple technique" or no lateral fixation of the Mesh. Our experience is somewhat different. A recent analysis of 2300 laparoscopic inguinal hernia repair ( with lateral fixation of the Mesh) demonstrated that patients may develop a transient neuropathy without any reported permanent neuropathy. In addition we firmly believe that stapling or anchoring the Mesh is responsible for reported low recurrence rate.
The laparoscopic inguinal
hernia repair remains a difficult surgical repair. It is best demonstrated
by the analysis of our mean operating time versus the number of cases
performed. Our mean operative time was 1 hour and 39 minutes for our
first ten patients. For the last 50 patients, it was 27 minutes.
We strongly believe these repairs are best done by surgeons who have
performed at least 40 procedures assisting other laparoscopic surgeons
well-trained in this procedure. Neophyte operators performing this repair
without the proper training or guidance may generate an inordinate and
inappropriate morbidity rate.
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