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428
13.3 Complicated Laparoscopic Hernia Repair
Fig. 13.3.10 Indirect recurrent inguinal hernia with development of the
hernia sac between the deferent duct and the testicular vessels.
Fig. 13.3.11 Right-sided indirect recurrent hernia with displacement of
the testicular vessels medially (very rare!)
of the hernia sac and the sac itself do not require lysis. The size
of the hernia sac alone usually necessitates time-consuming
dissection (Fig. 13.3.12). It is usually possible to dissect the sac
off its bed while reliably sparing the spermatic cord and vessels.
For this reason we do not recommend leaving the large hernia
sac in situ with the subsequent possible development of a hydrocele. By applying gentle tension to disinvaginate the sac inwards it is then possible to easily identify and expose the organs
of the spermatic cord (Fig. 13.3.13).
In cases of a thin hernia sac and dense scarring a complete mobilization is not possible. In such cases dissection is continued
to the inner inguinal ring and the hernia sac is not completely
separated from the cremaster tube. A secure closure is then
achieved by approximating the incised side of the polypropylene mesh around the cremaster tube.
Fig. 13.3.12 Complete detachment of a large, indirect hernia sac in the
case of a scrotal hernia.
Open Vaginal Process
A feature of this situation is the long hernia sac with a large area
of contact to the cremaster tube. The inner inguinal ring is usually only slightly widened and can easily be covered with the
polypropylene mesh. The depth of the hernia sac generally
makes complete mobilization impossible. The dissection is continued into the inguinal canal as far as possible; then the hernia
sac is circumferentially and sharply transected. The intraabdominal part is dissected sharply and bluntly from the
cremaster tube and the spermatic cord organs, respectively. The
distal part remains open and problems are not expected.
Reconstruction Difficulties
429
Fig. 13.3.13 View of the hernia sac margin and the deferent duct in a
left-sided, indirect hernia.
Irreducible Inguinal Hernia
The laparoscopic procedure is possible for small, irreducible
hernias and for freshly incarcerated hernias.
In these cases, reduction is achieved by widening the hernia
ring (Fig. 13.3.14). For both direct and indirect hernias this is ac-
complished by means of a careful anterosuperior incision using
scissors. In the case of indirect hernias the epigastric vessels
must first be identified and protected. Reduction of the hernia
after widening of the hernia ring may be facilitated by external,
manual compression of the abdomen or scrotum. The mesh repair must be sufficient to ensure good coverage of the hernia
defect including the widening incision.
In cases of difficult or unsolvable situations we recommend an
additional, transcutaneous exposure or a conventional, open
procedure.
Fig. 13.3.14 Scarred ring of an incarcerated or, respectively, irreducible
indirect hernia on the left side. The scarred hernia ring is transected.
Reconstruction Difficulties
The principle objective is complete coverage of all hernia defects by an exact placement of the polypropylene mesh. In the
medial region the identification of Hesselbach’s triangle and its
constituent parts is most important. With the normal gas pressure of 10 to 12 mm Hg it is usually possible to expose all essen-
tial structures in the inguinal region reliably and with greater
safety than in a conventional procedure.
The size of the mesh must be chosen so that it overlaps all defects by at least 3 cm (Fig. 13.3.15). This is generally achieved
using a mesh measuring 10 × 15 cm.
Fig. 13.3.15 Fold-free, secure positioning of an intact prolene mesh.
430
13.3 Complicated Laparoscopic Hernia Repair
Fig. 13.3.16 Complete destruction of the posterior wall of the inguinal
canal with large indirect and direct hernial canal.
Fig. 13.3.18 Laparoscopic view of an interparietal hernia.
Fig. 13.3.17 When inserting an incised mesh ensure a clear overlap of
the two halves of the mesh which must be securely fixed together with at
least two clips.
Combined Direct and Indirect Hernias
This form of hernia often extends from medial to far lateral. It
may be necessary for a secure coverage with the necessary
mesh overlap to employ an additional piece of mesh
(Fig. 13.3.16). This is attached to the standard 10 × 15 cm mesh
with a few clips. When a sufficiently large mesh is chosen, additional anchoring superior to the iliopubic tract in the so-called
“triangle of doom” is not needed (nerve injury!).
Recurrent Hernias with Multiple Orifices
This constellation may be expected in about one of twenty
patients with a recurrent hernia. The orifices are so far apart
that coverage with a standard mesh is not possible; this situation demands the use of two separate meshes. For medial
hernia orifices the mesh should extend across the symphysis
and completely cover Hesselbach’s triangle. If an incised mesh is
used to repair the inguinal ring the overlapping sides of the
mesh must be fitted around the spermatic cords and securely
attached using at least two clips (Fig. 13.3.17). The slit for the
spermatic cord is generally positioned vertically so that this
weaker section of the mesh does not overlap the hernia orifices.
Combined Procedures in Laparoscopic Hernia Repair
431
Fig. 13.3.19 Mesh with vertical incision. Fig. 13.3.20 When inserting an intact mesh always ensure a wide
parietalization so that the caudal edge of the mesh lies clearly in front of
the peritoneal reflexion.
Inguinal Hernia in Combination
with Interparietal Hernia
This situation is rather rare (Fig. 13.3.18). A prerequisite is an ad-
ditional functional disturbance of the musculature of the
abdominal wall due to neural disorders following trauma or
previous operation (e. g., appendectomy).
Laparoscopic repair in these patients requires subperitoneal
dissection over a wide area from the umbilical fold to well past
the margin of the interparietal hernia. This procedure usually
requires introduction of an additional ipsilateral trocar in a me-
dial and superior position; a further contralateral trocar is only
rarely needed.
This broad subperitoneal dissection results in a correspondingly
higher CO
ventilation or by reduction of the CO
9 mm Hg. To close the defect either two standard size meshes or
a double size mesh (20 × 30 cm) are used.
absorption which must be compensated by hyper-
2
pressure from 12 to 8−
2
spreading of the complaints into the scrotum. A disadvantage is
the far more extensive dissection, especially the far proximal
dissection of the peritoneum off the spermatic cords
(Fig. 13.3.20). This additional measure is required to ensure a
flat placement of the mesh on the inner abdominal wall; otherwise it may be lifted off with the spermatic cords on closure of
the peritoneum. An alternative attachment of the mesh below
the inguinal region (triangle of doom) must be avoided because
of the danger of nerve injuries. The mesh for this section is introduced into the abdominal cavity through the 12-mm working trocar by folding it like an umbrella over the laparoscopic
grasper. It is held in the upper third of the grasper or, if incised,
in the lower third (Fig. 13.3.21). It is secured in place with a suture (Fig. 13.3.22) or a few clips (4 to a maximum of 6). For larger
hernias, the anchoring to Copper’s ligament is particularly important. Since it is difficult to place sutures at this position, the
primary use of clips is recommended.
Combined Procedures in Laparoscopic
Further Aspects of Mesh Placement
The former standard procedure to manage hernia orif ices in the
region of the inner inguinal ring involves use of a vertically in-
cised mesh (Fig. 13.3.19). Actually, an unincised mesh may be
used. This has the advantage of a higher stability and avoids
possible complications from spermatic cords passing through
the mesh in the incised region. These include in particular irri-
tations of the genital branch of the genitofemoral nerve with
Hernia Repair
The possibility of treating several organic defects in the course
of one operation is a proven procedure provided that the known
criteria are respected. A prerequisite is necessary experience,
especially the appropriate placement and arrangement of the
working trocars. Frequently seen constellations are discussed
below.
432
13.3 Complicated Laparoscopic Hernia Repair
Fig. 13.3.21 Insertion of the mesh which is folder over a grasper like an
umbrella and so can easily be pushed through the trocar.
Fig. 13.3.22 Fixing the mesh with sutures lateral and medial of the epigastric vessels.
B
A
Fig. 13.3.23 The “triangle of the doom” (A) and the “triangle of pain”
(B).
Fig. 13.3.24 When the anatomic relationships in the region of the inner
inguinal ring are not clear begin the dissection caudal/lateral in the vicinity of the peritoneal reflexion with exposure of the testicular vessels.
Hematoma and Seroma
433
Bilateral Inguinal Hernia
This is found in about every fifth patient, sometimes as an unex-
pected secondary finding. In contrast to the conventionally
used, sequential procedures in open operations, the bilateral la-
paroscopic hernia repair may be performed through the same
approach with only a small increase in operating time. There are
no disadvantages for the patients with regard to the results or
the risk profile.
The laparoscope/camera trocar is always introduced at the su-
perior margin of the umbilicus. The position of the surgeon is
contralateral to the operation site, i. e., it must be changed
during the procedure. The patient’s arm with the intravenous
access is either placed above the head or a central venous catheter is used.
Postoperative, the periods of hospitalization and convalescence
are not longer than those for a unilateral procedure.
Management of Secondary
Intraabdominal Problems
The simultaneous treatment of all secondary complaints that
can be managed under aseptic conditions seems reasonable.
These include, in particular: lysis of adhesions, closure of
abdominal wall hernias, cholecystectomy, vasectomy. Preoperative single-dose antibiotic prophylaxis is recommended in every
case. Careful attention must be paid to the placing of the lateral
and epigastric trocars; if necessary further trocars may be used.
The most important prerequisite to avoid these complications is
knowledge of the local anatomy and topography as well as of
the possible variations in the courses of the mentioned nerves
(Fig. 13.3.23). Although all of the nerves in question are usually
in the triangle of pain (B), they may also occur as much as 1 cm
superior to the inguinal ligament or beneath the fascia.
In addition to knowledge of standard anatomy and it variations,
the following basic rules should be observed:
1. Never use clips on the iliopubic tract or the inguinal liga-
ment, maintain superior and inferior safety margins of 1 cm.
2. Use only blunt dissection in the region inferior to the iliopu-
bic tract and lateral to the spermatic cords. Control bleeding
extremely carefully, using electrocautery only as single
bursts.
Intraoperative Bleeding
Intraoperative bleeding can usually be detected and controlled
under direct vision.
More severe bleeding is possible in particular, from the epigastric artery which may be injured during placement of the
working trocar, the region of the aberrant arterial branches near
Cooper’s ligament, and the spermatic cords. For management,
we recommend removal of the working trocars under vision
and, after release of pressure, control of the bleeding.
If laparoscopic control of bleeding is not possible or not certain,
we convert to a conventional, open procedure. Uncontrolled
electrocautery or deep penetrating sutures are not recommended to control the bleeding.
Prevention of Complications
and Hernia Recurrences
Pneumoperitoneum and
Trocar Placement
Reliable measures to avoid complications in these procedures
are, above all, to follow the established rules and safety tests for
establishing the pneumoperitoneum and introducing the
camera trocar. In cases of doubt and, especially, after previous
surgery the open procedure should be preferred.
The use of the so-called “safety trocar” does not automatically
provide protection from feared complications and does not release the surgeon from his or her duty to use proven techniques
and safety procedures. For the working trocars in the right and
left mid abdomen we recommend blunt tapered reusable tro-
cars. The procedure for adhesions corresponds to the generally
accepted rules.
Nerve Injuries
Injuries to or irritations of the following nerves and branches
are also possible in laparoscopic procedures: ilioinguinal nerve,
genital and femoral branches of the genitofemoral nerve, and
the lateral femoral cutaneous nerve. The spectrum of symptoms
ranges from sensory deficits to severe pain in the area supplied
by the respective nerve. Causes of injury may be transection
during dissection, electrocautery, or pressure irritation on use
of clips.
Hematoma and Seroma
Bleedings in the region of the testicular vessels cannot always
be avoided on extensive dissection along the spermatic cords.
When extensive scarring is present and the situation in the region of the inner inguinal ring is not clear, we move the dissection inferior to the iliopubic tract along the iliopsoas muscle in
order to expose the clearly visible testicular vessels
(Fig. 13.3.24). From here the dissection continues superiorly to
the inner inguinal ring.
Palpable or ultrasonically detected but clinically silent hematomas in the region of the spermatic cords may be observed and
are left alone. They subside spontaneously.
More frequent is the occurrence of serohematomas in the region of previous hernias, especially direct hernias. The causes
are probably undetected bleeding in the hernia bed which slips
back inward through fine tearing during development of the
hernia.
The formation of serohematomas in the hernia sac bed generally does not require active treatment, we recommend a regular
sonographic follow-up (Fig. 13.3.25). As a rule, spontaneous absorption can be expected within about 6 weeks.
Extensive serohematomas and those that are clearly visible on
account of external swelling require treatment by percutaneous
puncture. In the rare cases of excessive bleeding a reoperation is
needed. The hematoma is cleared through an inguinal access.
Regular sonographic follow-ups of the operation site and the
scrotum are recommended after laparoscopic hernia repair in
order to check for seroma formation and the correct positioning
of the mesh coverage (e. g., on the 1
days).
st,3rd
, and 5thpostoperative
434
13.3 Complicated Laparoscopic Hernia Repair
Fig. 13.3.25 Postoperative sonographic control of the position of the
mesh, showing hematoma anterior and posterior from the mesh.
Fig. 13.3.26 Secure closure of the peritoneum with sutures.
a b
Fig. 13.3.27a Recurrent hernia after laparoscopic hernioplasty, the edge
of the implanted mesh is clearly visible. The hernia region itself is free of
adhesions.
b Recurrence after laparoscopic hernioplasty. After exposure of the in-
guinal canal a second mesh is implanted to overlap the old mesh which
is left in place.
13.4 Comments on Laparoscopic Hernia Repair
435
Testicular Atrophy
Causes of this complication are transection of the testicular vessels or compression of the spermatic cords in the region of passage through the mesh with edema and restricted passage.
Postoperative swelling of the testes requires wearing an athlete’s support and close sonographic monitoring. In cases of
doubt the opening in the mesh must be enlarged surgically.
Peritoneal Closure and Danger of Ileus
The security of the peritoneal closure can be increased by use of
a Lahodny suture (Fig. 13.3.26). It is preferred over closure with
clips and at the same time helps to avoid possible irritations of
nerve branches that can occur when a clip is placed deep in the
muscle. If unexpectedly, a rare defect does occur in the peri-
toneal closure there is a danger of bowel incarceration. Primary
clarification and revision should be attempted by laparoscopy.
Hernia Recurrence
The rate of recurrences after laparoscopic repair should correspond to the situation after conventional procedures; however,
isolated, short-term studies provide indications for the better
results.
Most situations involve a medial recurrence which is diagnosed
clinically. In cases of firm suspicion laparoscopic correction is
carried out. However, the peritoneal plane may be obliterated
and the hernia orifices only become visible after the peritoneum has been opened. Technically, the dissection is started
medially with exact exposure of the local anatomic structures.
Adhesions are rare so the dissection is usually easily performed
(Fig. 13.3.27 a + b). The hernia orifices are closed with an additional mesh. This is attached to Cooper’s ligament, to the symphysis region, and to the edge of the exposed, primary mesh.
The operation site is carefully reperitonealized. The more
heavily scarred lateral section of the inguinal region is usually
not affected and is left alone.
An open procedure is recommended for recurrent hernias with
complications (e. g., incarceration).
The most important steps in avoiding a recurrent hernia include:
1. Precise exposure of the hernia orifices, especially in the me-
dial segment of Hesselbach’s triangle past the symphysis and
retrovesical exposure extending to the opposite side.
2. Use of a large mesh, at least 10 × 15 cm, so that all possible
hernia orifices are covered by at least 2−3 cm.
3. In the presence of a large, direct hernia, the mesh must b e
fastened to Cooper’s ligament or to the symphysis pubis.
4. If an incised mesh is used to cover the inner inguinal ring, the
slit should be positioned vertically. Both sides of the mesh
should overlap and be securely joined by at least two clips.
5. If an intact mesh is used, the peritoneal sac must be broadly
dissected off the spermatic cords in a parietal dissection so
that the mesh will lay flat in the inguinal region and remain
so even after closure of the peritoneum.
13.4 Comments on Laparoscopic Hernia Repair
V. Schumpelick
In the last decade, minimally invasive surgery has undergone a
dramatic development. After the initial phase of pioneering interventions and the search for innovative methods, today those
procedures with a high degree of standardization, reliability, as
well as medical and economic benefits have become estab-
lished. Typical examples of these include laparoscopic cholecys-
tectomy, laparoscopic fundoplication, laparoscopic sigmoid resection, and thorascopic therapy for pneumothorax. Less
successful procedures are laparoscopic lysis of adhesions, appendectomy, and rectum resection. The latter methods have not
emerged from the shadows of the alternative, open procedures.
Important innovations of the currently expanding indication
fields are the laparoscopic splenectomy and the retroperitoneal
appendectomy.
During this period, laparoscopic hernia operations (Schumpelick and Wantz, 1995) have remained, at a first glance, simple
but on a second look problematic. The idea of closing the well
visible hernia orifices from the inside was confronted with un-
expected difficulties. At first clips and sutures were used for closure then because of the lack of success the hernia sac was filled
with non-absorbable plastic material. The next stage was to
cover the hernia orifice with a mesh which was initially applied
intraperitoneally and finally preperitoneally. At first an absorbable mesh material was chosen, only to be changed to a
non-absorbable material on account of the high rate of recurrences. At first the mesh was small—just covering the hernia
orifice—later it could not be large enough. For fear of causing intraperitoneal injuries and placing sutures with their inherent
danger of adhesions, in the last few years a change to an extraperitoneal procedure has occurred. Now we have reached a
technique that utilizes the proven route of extraperitoneal mesh
reinforcement according to Stoppa and can for the first time report on lasting and reproducible results. Even so, the procedure
is as yet only successful in the hands of a few experienced specialists (Schumpelick et al., 1994).
The 10-year journey was tedious, full of complications and not
without disappointments for surgeons and patients. By use of
the extraperitoneal placement of the mesh, the reservations
about safety which have accompanied laparoscopic hernia repair from the very beginning and classified it as a risky, unnec-
436
13.4 Comments on Laparoscopic Hernia Repair
essarily transperitoneal intervention have been overcome. A
potential standard procedure is in sight, is realizable, relatively
low in risk, and is being increasingly employed. One must now
ask how reasonable is it? The necessity for general anesthesia
and the use of alloplastic meshes remain unsatisfactory. The
operation is technically difficult, time-consuming, and still accompanied by potential complications.
Even if these arguments against the method could be tolerated
under the aspects of innovation and surgical challenge, laparo-
scopic hernia repair today meets its strongest criticism from the
economic points of view. There are now numerous studies
proving that laparoscopic hernia repair is not the method of
first choice, also for reasons of cost. The additional costs as compared to the conventional, open techniques amount to about
$ 1500 due to more expensive materials, apparatus, and longer
operation times. The often expressed counter arguments of a
shorter convalescence, shorter period off work, and less pain
have been examined in controlled prospective studies and
shown to be almost negligible in comparison with an open pro-
cedure.
On the whole, a certain stratification in hernia surgery seems to
be apparent in that small to medium-size hernias (classification L1−2 and M1−2) are best treated under local anesthesia
using the Shouldice technique. Larger hernias (classification L3
and M3) should be more often treated by an alloplastic mesh re-
inforcement which can, as a rule, easily be performed in an
open repair technique under local anesthesia (Schumpelick,
1996). Only multiple recurrences with destroyed, scarred ventral anatomy are suitable for the retroperitoneal approach
which should be applied as an open procedure according to
Stoppa or Wantz or alternatively as a laparoscopic procedure.
From the viewpoint of current hernia surgery, only this situation constitutes a potential indication for a laparoscopic hernia
repair.
In summary we may conclude that the excellent possibilities of
laparoscopic surgical technique should not be overexploited.
Even the most devoted supporter of laparoscopic surgery
should admit that the technically possible is often not reasonable. Laparoscopy has more important and more valuable
fields of application than the extension of a 20-minute, extraperitoneal operation under local anesthesia to a higher-risk,
abdominal procedure under general anesthesia. “Less is more.”
Bibliography
Schumpelick V, Hernien. 3rdedn. Stuttgart: Enke; 1996.
Schumpelick V, Wantz GE. Inguinal hernia repair. Basle: Karger; 1995.
Schumpelick V, Treutner KH, Artl G. Inguinal hernia in adults. Lancet 1994;
344:375−379.
14. Closing Commentaries
14.1 Analysis and Prevention of Untoward Ev ents in Laparoscopic Surgery
H. Troidl
437
“As we learn from our errors, our errors become increasingly valuable.” Sir Karl Popper
Error Analysis: A Rarely Used Method
Today, there is a wide variety of methods to assess the results
and effectiveness of surgical interventions.
Controlled clinical studies provide the most reliable data; they
have a recognized higher degree of objectivity. Less reliable al-
ternatives are observational studies without controls, retro-
spective data analyses, and, more recently, “consensus confer-
ences,” “quality assurance measures,” and “quality audits”.
The information is then publicized at meetings, symposia, and
in textbooks and journals. High “scientific content” is regarded
as the best sign of quality in a medical journal. A clear listing of
positive and negative events of clinical relevance is equally important.
We should keep two facts in mind when considering this sys-
tem:
1. It is rare for colleagues from small and medium-sized surgi-
cal departments to present their experience to a scientific
forum, although they perform over 80% of all surgical treatments.
2. Most authors prefer to report positive results, particularly at
professional meetings and in scientific publications.
Negative results, poor outcomes, or even disasters are rarely
presented, and published even more rarely. Scientific publica-
tions seem to thrive on accounts of success.
The world of communications—written and spoken—in medi-
cine does not necessarily represent reality.
In the sixth principle of his twelve principles of new professional ethics, Sir Karl Popper writes: “The new fundamental
law is that to avoid errors as much as possible we must learn
from precisely these errors; covering up errors is thus the
greatest intellectual sin”. He calls for precise and detailed error
analysis as a prerequisite for the continued development of effective art and science in medicine.
A registry of negative events has immense significance for eval-
uating surgical interventions and is part of the basis upon which
therapy is chosen.
The widespread cataloguing of negative events is important for
the systematic analysis of errors. Becoming aware of errors and
complications makes the surgeon more attentive; at the very
least, it is the beginning of a systematic error analysis.
Publications and textbooks with detailed and clear instructions
on how to correct errors abound. However, I am not aware of
any book that addresses the prevention of errors as its primary
topic in a similarly structured, systematic manner.
There are definite reasons for this, and some of them are cer-
tainly plausible. Yet, the absence of such a text is regrettable.
One can examine the multitude of terms used in different languages to refer to negative events. In English, we speak of “complications”, “adverse events”, “critical incidents”, “mishaps”,
and “errors.” The word “mistake” is rarely mentioned.
Referring openly and candidly to “mistakes” has three negative
aspects that should make the surgeon take notice: Open and
possibly overly frank discussion of the error can negatively influence the trust that the patient places in the physician. Disturbing a patient in a life-threatening situation by discussing or
providing information about errors is not conducive to obtaining the patient’s consent to treatment. This applies equally to
the strong placebo effect in specific situations that surgery has
and ought to exploit. For a responsible surgeon, the phrase “excruciating pain” is hardly sufficient to describe honest and clear
analysis of an error.
Yet the fact is that error analysis is able to help avoid errors, and
particularly those with severe and irreparable consequences,
i. e., disasters.
Note: Error analysis makes surgical intervention safer. It represents a tremendous advantage for the patient.
Error Analysis, A Method for Clinical
Practice and Research
By error analysis I mean a systematic, rigorous, objective investigation of:
− The medical, clinical, and individual situation.
− The decision-making process.
− The action.
− The general and specific circumstances underlying the un-
desired result.
Careful determination of the cause of an error is important, yet
its only purpose is to provide practical, relevant information for
avoiding the error next time.
This careful analysis must lead to structured, practical, relevant
action and thus to avoiding the error. The individual steps in
strategy and technique must be clearly listed in writing or at
least suitable for listing.
Note: Avoiding errors on the basis of this information is the core
of error analysis.
Note that the primary intention of error analysis is not to correct
errors.
Concept and Purpose of Error Analysis
(See Fig. 14.1.3 and Table 14.1.1).
Error analysis is not a new concept in surgical practice. Every
surgeon performs his or her own rigorous analysis, often uncon-