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334
D. Lomanto and E. L. S. Clara
avoiding any contact with the skin. The mesh is then placed horizontally and unrolled over the myopectineal orice making sure to cover all the hernia sites. One-third of the mesh should be below the symphysis pubis, the upper margin reaching the lower trocar medially and laterally lying over the psoas muscle. In bilateral hernias, there should be a 1–2cm overlap of the meshes at the midline. It is important to make sure that no part of the peritoneum is under the mesh to pre­vent any recurrence.
The mesh is then anchored using tackers or sealant to prevent mesh migration and possible recurrence. Two to three points of xation are necessary: Cooper’s ligament, medial to the infe­rior epigastric vessels at the rectus muscle and, if necessary, lateral to the inferior epigastric ves­sels. Avoid tacker or stapler xation below the iliopubic tract and too laterally considering 15–20% of abnormalities in the nerve paths. This will help to prevent any nerve injuries and conse­quent postoperative chronic pain.
An accurate hemostasis should be guaranteed if the correct surgical plane is identied. The car­bon dioxide is then released while checking visu­ally that the mesh is not rolled, and the peritoneum stays in front of the mesh so as to prevent any recurrence. The lateral inferior edge of the mesh can be held with a grasper, if necessary. The ports are then removed, and the anterior rectus sheath incision at the 10-mm trocar site is sutured. The skin incisions are then closed with absorbable sutures or glue.
33.7.5.6 Reduced- andSingle-Port
Technique
Since the advent of the laparoscopic technique, the trend toward scarless surgical techniques con­tinued. Since then, a few novel approaches have been utilized in hernia repair such as needle­scopic surgery and the single incision endolapa­roscopic surgery (SPES) [6, 7].
For needlescopic surgery, smaller size instru­mentation is utilized to perform the procedure; challenges are the exibility of the instruments especially in large defects or thickened peritoneal sac. Clinical studies showed comparable results with the standard technique, but nevertheless the
needlescopic technique has never been success­ful with worldwide acceptance [6, 8].
The latest approach, SPES, which uses a sin­gle device in which all the telescope and working ports are inserted, has seen much enthusiasm not only for inguinal hernia repair but also for chole­cystectomy, appendectomy, adrenalectomy, etc. [9–13]. The possible advantages of single or reduced port surgery in hernia repair can be attributed to less pain, better cosmesis, less risk for port-site hernia, and even shorter hospital stays. A technical challenge is the ergonomics, as the approach is more affected by constraints in exposure, adequate retraction, conict between the instruments, and lack of triangulation [14]. In standard TEP with a midline approach, this is less evident because of the almost parallel axis of the two working ports, resulting in a shorter learning curve.
Recent studies also show at least equivalent pain scores, operative duration, and complication rates when comparing conventional laparoscopic surgery to reduced-/ single-port surgery in hernia repair, making this novel approach acceptable and comparable to standard TEP inguinal hernia repair [15, 16].
33.8 Postoperative Care
• Diet as tolerated is resumed.
• Analgesics are given (etoricoxib 90mg daily
for 3days).
• Patient is discharged on the same day once
voiding freely.
• Follow-up is at l week, l and 3months.
33.9 Complications
Complications can be categorized into intraoper­ative and postoperative complications. Intraoperative complications specic to TEP occur in about 4–6% of the cases and can be due to injury to the vascular, visceral, nerve, and sper­matic cord structures [17–19]. Vascular injuries would include injury to the external iliac vessels, inferior epigastric vessels, spermatic vessels, or
33 Total Extraperitoneal (TEP) Approach inInguinal Hernia Repair: TheOld andtheNew
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335
the vessels over the pubic arch including the corona mortis veins. The most common are injury to the IEV, and this can be avoided by using the midline approach and by inserting all the ports under direct vision. Injury to the major vessels is catastrophic; a correct lateral traction of the sac and spermatic structure with medial approach may be helpful in avoiding it. A careful practice should be used when retracting or dissecting closer to the “triangle of doom.” Visceral injuries including but not limited to the bowels and uri­nary tract can be reduced by careful dissection and limiting the use of diathermy. Transmitted energy through the thin peritoneal layer may result in injury to the underlying bowel. Patients with previous pelvis surgery, sliding hernia, and large inguinoscrotal hernia are at risk for bladder injury, in which case urinary catheterization may be necessary. In the event of injuries, these can be managed by an endolaparoscopic suture repair. Nerve injuries can be prevented by accurate lat­eral dissection, limiting the number of staplers/ tackers if xation is needed and using of absorb­able tackers or sealant. Spermatic cord injuries can be lessened by properly identifying the anat­omy and avoiding too much traction of the cord. Tears in the peritoneum can also occur especially during the early stage of the learning curve. All peritoneal tears should be closed by using suture loops or hem-o-loks.
Postoperative complications like seroma com­monly occur in patients with large direct and indirect hernias. The seroma usually appears after 7–10 days and does not require any treat­ment. It may be mistaken for an early recurrence. In principle, it should be treated conservatively and will be reabsorbed spontaneously within 4–6 weeks. However, if it is symptomatic and persisting after 2months, it is advisable to drain it by aspiration and in sterile condition. In the case of complex sero-hematoma, an excision after 4–5months can be necessary.
Early recurrence is usually due to inadequate surgical technique and can be due to wrong case selection for beginners, inadequate xation of the mesh, inadequate mesh size, inadequate dissec­tion of the myopectineal orice, and failure to cover unidentied hernia defects [20].
Conclusion
Several clinical trials and meta-analyses have shown endoscopic preperitoneal hernia repair (TEP) performed by experienced surgeons to be associated with reduced postoperative pain, less need for postoperative analgesia, earlier return to work, fewer complications, and a low recurrence rate when compared to open mesh repair [1, 2, 21, 22]. These benets will be more signicant if the laparoscopic treat­ment is for bilateral or recurrent hernias. As for any successful surgical technique—but especially in hernia repair—a careful patient selection, a good understanding of the anat­omy, an adequate surgical technique, and the surgeon’s experience are very important key factors to achieve a good clinical outcome with a low rate of short-term and long-term complications.
References
1. Memon MA, Cooper NJ, Memon B, et al. Meta­analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg. 2003;90:1479–92.
2. Feliu X, Claveria R, Besora P, etal. Bilateral inguinal hernia repair: laparoscopic or open approach? Hernia. 2011;15:15–8.
3. Lomanto D, Katara AN. Managing intraoperative complications during totally extraperitoneal repair of inguinal hernia. Minim Access Surg. 2006;2:165–70.
4. Simons MP, Aufenacaker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treat­ment of inguinal hernia in adult patients. Hernia. 2009;13:343–403.
5. Bittner R, Arregui ME, Bisgaard T, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treat­ment of inguinal hernia [International EndoHernia Society (IEHS)]. Surg Endosc. 2011;25:2773–843.
6. Goo TT, Lawenko M, Cheah WK, Lomanto D. Endoscopic total extraperitoneal repair of recur­rent inguinal hernia: a 5–year review. Hernia. 2010; 14:477–80.
7. Lau H, Lee F. A prospective comparative study of needlescopic and conventional endoscopic TEP her­nioplasty. Surg Endosc. 2002;16:1737–40.
8. Goo TT, Goel R, Lawenko M, Lomanto D. Laparoscopic transabdominal preperitoneal (TAPP) hernia repair via a single port. Surg Laparosc Endosc Percutan Tech. 2010;20:389–90.
9. Wada H, Kimura T, Kawabe A, et al. Laparoscopic TAPP inguinal hernia repair using needlescopic
336
D. Lomanto and E. L. S. Clara
instruments: a l5–year single centre experience in Sl7 patients. Surg Endosc. 2012;26:1898–902.
10. Trastulli S, Cirocchi R, Desiderio J, etal. Systematic review and meta-analysis of randomized clinical trials comparing single-incision versus conven­tional laparoscopic cholecystectomy. Br J Surg. 2013;100:191–208.
11. Fung AK, Aly EH. Systematic review of single incision laparoscopic colonic surgery. Br J Surg. 2012;99:1353–64.
12. Rehman H, Mathews T, Ahmed I.A review of mini­mally invasive single port/incision laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A. 2012;22:641–6.
13. Goo TT, Agarwal A, Goel R, etal. Single-port access adrenalectomy: our initial experience. J Laparoendosc Adv Surg Tech A. 2011;21:815–9.
14. Goel R, Lomanto D. Controversies in single port surgery. Surg Laparosc Endosc Percutan Tech. 2012;22:380–2.
15. Fuentes MB, Goel R, Lee-Ong AC, etal. Single-port endo-laparoscopic surgery (SPES) for totally extra­peritoneal inguinal hernia: a critical appraisal of the chopstick repair. Hernia. 2013;17:217–21.
16. Wijerathne S, Agarwal N, Ramzy A, et al. Single­port versus conventional laparoscopic total extra­peritoneal inguinal hernia repair: a prospective, randomized, controlled clinical trial. Surg Endosc. 2016;30:1356–63.
17. Tetik C, Arregui ME, Dulucq JL, etal. Complications and recurrences with laparoscopic repair of groin her­nias. A multi-institutional retrospective analysis. Surg Endosc. 1994;8:1316–23.
18. Kraus MA.Nerve injury during laparoscopic inguinal hernia repair. Surg Laparosc Endosc. 1993;3:342–5.
19. Felix E, Habertson N, Varteian S. Laparoscopic hernioplasty: surgical complications. Surg Endosc. 1999;13:328–31.
20. Miguel PR, Reusch M, daRosa AL, Carlos JR. Laparoscopic hernia repair—complications. JSLS. 1998;2:35–40.
21. Cavazzola LT, Rosen MJ. Laparoscopic versus open inguinal hernia repair. Surg Clin North Am. 2013;93:1269–79.
22. Bittner R, Montgomery MA, Arregui E, etal. Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc. 2015;29:289–321.
Primary Inguinal Hernia: TAPP
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DiegoCuccurullo andMartaCavalli
34
34.1 Introduction
The success of laparoscopic cholecystectomy in the late 1980s and the proposal of the giant pre­peritoneal reinforcement on the visceral sac (GPVRS) concept to cover the entire myopectin­eal orice by an open approach by Stoppa [1] and, later, by Wantz [2] attracted the interest of the placement of the mesh in the posterior space and then the interest of laparo-endoscopic sur­geons [3].
Three endoscopic techniques using a posterior approach were developed in the early 1990s: the transabdominal preperitoneal patch (TAPP) reported for the rst time by Schultz [4] and Arregui [5]; the total extraperitoneal patch plasty (TEP) promoted by Dulucq [6], Ferzli [7], and McKernan [8]; and the intraperitoneal onlay mesh (IPOM) reported by Fitzgibbons [9].
In the latter a nonabsorbable prosthetic mesh is placed upon the defect, exposing the viscera to
D. Cuccurullo (*) U.O.C. di Chirurgia Generale—Centro di Chirurgia Laparoscopica e Robotica Ospedale Monaldi, Naples, Italy e-mail: diego.cuccurullo@ospedalideicolli.it
M. Cavalli University of Insubria, Varese, Italy
Centro di Ricerca di Alta Specializzazione sulla Patologia della Parete Addominale e sulla Chirurgia Riparativa delle Ernie Addominali, Istituto Clinico Sant’Ambrogio, Hernia Center di Milano, Milan, Italy
potential adhesion and morbidity. For this reason, it has been soon rejected by the surgeon commu­nity, and now it is considered an inappropriate and ineffective therapy [10].
The objective of the minimal laparo­endoscopic approach to groin hernia repair is the deployment of a large nonabsorbable mesh in a widely dissected preperitoneal space covering and overlapping all potential inguino-femoral defects. Both TAPP and TEP do reach the same nal objective in different ways.
Recently, the key points of the techniques have been described and validated according to the criteria of evidence-based medicine (Oxford Classication) by Kukleta and Bittner (for TAPP) and by Chowbey, Köckerling, and Lomanto (for TEP) [11].
34.2 Indication forTAPP
Technique
In the author’s opinion, TAPP is indicated in the bilateral primary hernia and recurrent inguinal hernia after the previous anterior approach. In the latter case, it would always be advisable to know the real type of repair and mesh used in the previ­ous surgery: the presence of a plug placed in the internal inguinal ring (Fig. 34.1) could make intraperitoneal dissection more difcult, espe­cially during learning curve.
© Springer International Publishing AG, part of Springer Nature 2018 G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_34
337
338
Fig. 34.1 Plug placed in previous surgery pushes out to
the preperitoneal space
D. Cuccurullo and M. Cavalli
34.3 The Standardized TAPP Technique
This technique requires evidently general anes­thesia. The patient is required to empty his/her bladder before the operation because a urinary catheter is not inserted routinely, but it is strictly recommended during learning curve and if a pro­longed operating time is expected or in the pres­ence of a recurrence in which the urinary bladder could be involved.
34.3.1 Pneumoperitoneum
The establishing of the pneumoperitoneum enlarges the preexistent virtual abdominal cavity and offers from the very start a spacious working environment.
There is no denitive evidence that the open­entry technique for establishing the pneumoperi­toneum is superior or inferior to the other techniques currently available (level 1A).
The open access should be utilized as an alter­native to the Veress needle technique, especially in patients after the previous open abdominal sur­gery (grade A) [11].
The pneumoperitoneum is established at a CO
gas pressure of 12 mmHg. A 10 mm 30°
2
optic is normally used.
The exploration of the abdominal cavity allows the inspection of the anatomy of both sides of the groin, the real type of hernia, and the content of the sac, if it is an incarcerated hernia.
Fig. 34.2 Trocar placement: optical trocar at umbilical
site, a 10 mm trocar at the right side along the lateral medio-clavicular line, 5mm trocar at the left side along the lateral medio-clavicular line
34.3.2 Trocar Placement
The lateral working port is always inserted under direct vision. The radially dilating trocars cause less acute injuries, like bleeding, and less chronic tissue damage that could result in trocar hernias (level 1B) [11]. The cutting trocars should be avoided (grade A) [11]. If a bilateral hernia repair is expected, a 10mm trocar is placed at the right side along the lateral medio-clavicular level of the umbilicus level and 5mm trocar at the left side along the lateral medio-clavicular level at the umbilicus level (Fig.34.2). Otherwise, in case of unilateral repair, the trocar at the opposite side of the hernia can be placed slightly caudally, allow­ing a more ergonomic position for the surgeon. The 12mm trocar is necessary for mesh introduc­tion and hemostatic clip dispenser.
When the trocar placement is completed, both the rst surgeon and camera assistant stay at the opposite side of the hernia, and the patient is placed in a head-down position and slightly turned toward the surgeon.
34.3.3 Dissection
With a blunt grasper in the left hand and an elec­tried scissors in the right hand, the preperitoneal
34 Primary Inguinal Hernia: TAPP
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339
space is entered through a planned incision of the visceral peritoneum 3–4 cm above the visible hernia defect; the incision is not tailored to hernia type and size (Fig.34.3): a wide incision in the peritoneum is recommended to achieve broad and clear access to the preperitoneal space from the anterior superior iliac spine (ASIS, consid­ered the rst landmark of the procedure) to the medial umbilical ligament (MUL), which does not have to be transected. If more space is needed, a cranial extension of the peritoneal incision par­allel to the MUL may be helpful.
The preparation of the peritoneal ap starts laterally in a fairly avascular plain, and it is sup­ported by the “pneumodissection” of CO2 gas under pressure (Fig. 34.4). Here it is important that the grasper in the left hand pulls in the right way. We are entering the space of Bogros. Crossing the epigastric vessels in a medial direc­tion (second landmark), the endoabdominal fas­cia may continue being a solid barrier which
must be entered to reach another spiderweb-like compartment—the space of Retzius.
These two anatomical spaces are not a con­tinuation of each other, because they are not on the same level [12].
Further dissection deeper and medially nds the Cooper’s ligament (third landmark, Fig.34.5) and the superior pubic arch until the landmark of the symphysis pubis (Fig. 34.6). In case of a bilateral inguinal hernia repair, meshes should meet on the symphysis pubis.
Caudal and lateral of the onset of epigastric ves­sels and the inner inguinal ring, the gure of “A” is encountered (Fig.34.7). The medial arm is the vas deferens complex and the lateral one the spermatic vessels. This region is often called “doom triangle” (because of underlying extern iliac vessels). Medial to the spermatic cord, a vascular anomaly of arte­rial or venous corona mortis (or both) anastomosis between the iliac and the obturator vessels can be found in about 20% of the population.
Fig. 34.3 Right inguinal region with landmarks. Incision
line is dotted. Direct inguinal hernia is present
Fig. 34.4 Preparation of the ap in the right inguinal
region
Fig. 34.5 Identication of Cooper’s ligament
Fig. 34.6 Right inguinal side: the dissection of Cooper’s
ligament is complete, and now the mesh placed on the contralateral side is reached
340
D. Cuccurullo and M. Cavalli
The femoral canal is encountered between the iliopubic tract, Cooper’s ligament, and external iliac vein.
Lateral of the onset of epigastric vessels, the top of gure “A” enters the inguinal canal. Lateral of the spermatic vessels, a fat pad covers some nerves of the lumbar plexus (the genitofemoral nerve, the lateral femoral cutaneous nerve, and the femoral nerve). This area is called “pain tri­angle” (Figs.34.8 and 34.9).
Fig. 34.7 The dissection is complete, and the gure of
“A” is encountered
In case of insecurity during the dissection, the TAPP technique allows the immediate view of intraperitoneal structures behind the ap, thereby avoiding possible sectional or thermal damage.
Whereas dissection of a direct hernia sac is a simple procedure, dissection of an indirect sac may be very difcult. The following steps are recommended: rst, complete dissection of the spaces of Retzius (medial) and Bogros (lateral). Second, remove all adhesions between the hernia sac and other structures, including the spermatic cord and vessels (Figs.34.10, 34.11, 34.12), the epigastric vessels and the external iliac vessels.
Cord lipomas or lipomas in the femoral canal may mimic a hernia recurrence, and for this rea­son, they should be dissected (level 2C) [11].
If dense adhesions to the cord structures are present in a long hernia sac, the sac may be tran­sected at the level of the inner inguinal ring in order to prevent injury to the cord structures (grade D) [11].
The incidence of seromas in direct hernias can be signicantly reduced when the lax transversa-
Fig. 34.8 Dissection proceeds laterally in the left ingui-
nal region: psoas muscle is identied with nerves running on it
Fig. 34.9 Psoas dissection is complete: iliohypogastric,
ilioinguinal, and genitofemoral nerves are visible
Fig. 34.10 During the dissection of an indirect inguinal
sac, spermatic vessels are recognized
Fig. 34.11 Smooth dissection between indirect inguinal
sac and spermatic vessels
34 Primary Inguinal Hernia: TAPP
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Fig. 34.12 The same procedure in Fig. 34.10 and
Fig.34.11. Dissection proceeds and vas appears medially to spermatic vessels
lis fascia is inverted and xed to Cooper’s liga­ment (level 2B) [11].
The dissection of the upper ap can be easily performed bringing it with a grasper in both hands and overturning toward cranial direction.
A complete anatomical dissection of the pel­vic oor is completed if a at and wrinkle-free placement of the mesh is possible.
34.3.4 Mesh Placement
341
2–3cm of mesh overlapping the hernia openings may lead to a protrusion of the mesh into the defect. The larger is the hernia opening, the more overlap there should be. In large direct defects, the danger that the mesh will protrude into the opening is increased (level 4) [
11]. We usually
smooth out all the corners.
According to the register-based (Herniamed) analysis of more than 10,000 cases [18], the only highly signicant factor impacting onset of recur­rence following TAPP for primary unilateral inguinal hernia repair in men is a medial or com­bined hernia. That nding is also conrmed in the systematic review by Burcharth et al. [
19].
Therefore, the requirements for adequate overlap in patients with this type of hernia are more stringent.
We usually roll up the mesh along the long side, and we insert it by the lateral 10mm trocar with a grasper. It is advisable to maintain the mesh with the grasper until it is placed beyond the peri­toneal ap previously prepared (Fig.34.13), so in the preperitoneal space, only in that moment, one grasper keeps the superior edge of the mesh in the correct position, and the second grasper unrolls down the mesh (Fig.34.14).
Once the correct extent of the landing zone is achieved and hemostasis is secured, an adequate mesh is inserted. Based on the hypothesis that heavyweight mesh could be involved in postop­erative pain, surgeons assisted in the last 15years to a slight trend to reduce the material amount, using large-pore and so-called lightweight meshes. However, a clear recommendation can­not be made based on currently published RCTs [13]. Two of the three meta-analyses found no signicant differences in terms of early postoper­ative pain, recurrence rate or return to work [14,
15]. The reduced incidence of chronic groin pain
is only in one meta-analysis [16] signicantly lower after low-weight mesh implantation.
We usually choose a lightweight syn-
thetic mesh (ENDOLAP
®
by DynaMesh or
ULTRAPRO® by Ethicon).
According to the EHS [17] and the IEHS guidelines [11], today “adequate” mesh size means a 15 × 10 cm or larger mesh. Less than
Fig. 34.13 Introduction of the mesh
Fig. 34.14 The mesh is unfolded
342
D. Cuccurullo and M. Cavalli
The mesh should be placed wrinkle- and fold- free respecting the well-dened anatomic landmarks. Especially the inferior mesh margin has to show a security distance from the lowest lateral dissection area of the “landing zone” in order to prevent its lifting up when closing the peritoneum.
34.3.5 Fixation
This step is still controversial. There is an evidence- based insight that not all preperitoneal hernia repairs require a mesh xation. In fact, preperitoneal mesh placement works according to the physical law of Pascal; thus, xation does not compensate for inadequate mesh size or overlap.
Moreover, mesh xation to the underlying structures of the landing zone by tissue penetra­tion is to be avoided due to the risk of damaging vessels and nerves.
Fixation and non-xation of the mesh are associated with equally low recurrence rates; however, in most studies, the hernia opening was small (<3 cm) or not measured. Consequently, non-xation could be considered in type LI and LII and MI and MII hernias (EHS classication) [20] (grade B). For TAPP repair of big defects (LIII, MIII), the mesh should be xed (grade D).
According the paper previously cited [18], in case of a large medial or combined hernia, xa­tion of the mesh is needed, and the type of xa­tion does not impact the recurrence rate.
We are used to x the mesh in any case with brin glue (Fig. 34.15) or cyanoacrylate. There are some types of self-xating meshes (e.g.,
ProGrip, Medtronic, made with monolament polylactic acid (PLA), reabsorbed in 18months; and Adhesix mesh, Bard Davol, covered by a layer of self-adhering reabsorbable glue).
34.3.6 Peritoneal Closure
Meticulous running suture of the peritoneal ap prevents any contact of prosthetic with the intes­tinal loops and avoids any obstructive event based on incarceration or strangulation within a defect in an incomplete closure. We are used to perform this running suture with a self-locking suture (V-lock 2/0), from lateral to medial, with reverse needle in the right hand, taking rst the lower ap and then the upper ap, so that with a single gesture, it is possible to take both edges (Fig.34.16).
34.3.7 Closure oftheTrocar Incisions
The trocars are extracted under vision as in any laparoscopic procedure, and the working ports of 10 mm or more can cause trocar hernias and therefore should be closed in layers [11].
34.3.8 Antibiotic and Thromboembolic Prophylaxes
According to the International Endohernia Society guidelines [11], antibiotic and thrombo­embolic prophylaxes for elective laparoscopic inguinal hernia repair are not universally recom-
Fig. 34.15 Fixation of the mesh with brin glue
Fig. 34.16 Closure of the peritoneal ap with running
suture
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343
mended. Antibiotic prophylaxis is recommended only in the presence of risk factors for wound and mesh infection based on patient (advanced age, corticosteroid usage, immunosuppressive condi­tions and therapy, obesity, diabetes, and malig­nancy) or surgical complications (contamination, long operation time, drainage, urinary catheter). Despite this, we normally give a one dose of cephalosporin at general anesthesia induction.
References
1. Stoppa R, Petit J, Abourachid H.Procédé original de plastie des hernies de l'aine: l'interposition sand xa­tion d'une porthèse en tulle de dacron par voi médiane sous-péritonéal. Chirurgie. 1973;99:119–23.
2. Wantz GE.Giant prosthetic reinforcement of the vis­ceral sac. Surg Gynecol Obstet. 1989;169:408–17.
3. Corbitt JD. Laparoscopic herniorrhaphy. Surg Laparosc Endosc. 1991;1:23–5.
4. Schultz L, Graber J, Pietrafta J, et al. Laser lapa­roscopic herniorrhaphy: a clinical trial. Preliminary results. J Laparoendosc Surg. 1991;1:41–5.
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