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F. Köckerling et al.
11
reintroduction of the medial working trocar. Most
cases of “shrunken” meshes reported in the literature may be considered the result of a displacement
that has already occurred intraoperatively.
During the desuation phase, a grasper
placed through the 5mm trocar can be of help, for
example, by elevating the ventral part of the mesh
to facilitate the repositioning of the peritoneal
sac. In particular in the case of young, muscular
patients with a correspondingly at preperitoneal space, it is important that the peritoneal sac
should be seen to “unfold” as far caudally as possible to prevent kinking of the mesh.
If there are any intraoperative doubts as to the
proper placement of the mesh or of proper closure
of the peritoneal lesions, a check laparoscopy can
readily be carried out by opening the posterior
rectus sheath and peritoneum.
Otherwise, when the optic and trocars have
been removed, the fascia at the umbilicus and the
skin are sutured.
For logistical reasons, the drain is removed on
the morning of the postoperative day but could
also be removed in the aernoon or evening of
the day of surgery.
11.3 Specic Risks
clinical relevance [20]. In addition, some authors
have raised the issue of prophylactic repair of a
clinically healthy other side to avoid the second
inguinal hernia repair in the future [21–23].
In an analysis of the Herniamed Registry, 9395
patients with a TEP were enrolled [24]. ese
comprised 6700 patients with unilateral (71.3%)
and 2695 patients (28.69%) with bilateral inguinal
hernia repair. While no signicant dierence was
found in the overall number of intraoperative complications between the unilateral and bilateral group
(p= 0.310), a signicantly higher number of urinary bladder injuries in the bilateral TEP operation
of 0.28% compared with 0.04% for unilateral TEP
(p= 0.008) were noted [24]. e greater probability of complication-related reoperation (0.82% for
unilateral vs 1.78% for bilateral TEP; p<0.001) in
the unadjusted analysis was conrmed in the multivariable model (OR 2.35 [1.504; 3.322]; p=0.001)
[24]. e authors concluded that a signicantly
higher intraoperative urinary bladder injury rate
and reoperation rate because of postoperative surgical complications constituted a dierence in the
perioperative outcome between unilateral and bilateral TEP which warranted attention [24]. Based on
these results, prophylactic operation of the healthy
other groin should not be recommended [24].
11.3.1 Bilateral Inguinal Hernias
e proportion of bilateral inguinal hernias using
diagnostic laparoscopy is 28.5% [17]. For bilateral
inguinal hernias, all guidelines of the international
surgical societies recommend laparo-endoscopic
repair in TAPP or TEP technique [12, 13, 15, 18,
19]. But to date no randomized controlled trials
have been carried out to compare the perioperative
outcome of unilateral and bilateral inguinal hernia
repair using a laparo- endoscopic technique.
A Swiss registry study compared 3457 unilateral with 3048 bilateral inguinal hernia repairs
using TEP technique [20]. e authors identied
an intraoperative complication rate of 1.9% for
unilateral and 3.1% for bilateral TEP (p =0.002)
[20]. Likewise, the postoperative complications
for unilateral TEP at 2.3% and for bilateral TEP at
3.2% were signicantly dierent (p=0.026) [20].
e authors concluded that the absolute dierence between intra- and postoperative complications of unilateral versus bilateral inguinal hernia
repair in TEP technique was small and of minor
11.3.2 Recurrent Inguinal Hernias
e proportion of recurrences in the National
Swedish Hernia Registry is 11.2% [25]. Female
gender, direct inguinal hernias at the time of the
primary procedure, operation for a recurrent
inguinal hernia, and smoking are signicant risk
factors for recurrence aer inguinal hernia surgery [26]. In ve meta-analyses, the outcome of
open repair was compared with that of endoscopic
repair of recurrent inguinal hernias [27–31].
In a meta-analysis and review of prospective
randomized trials comparing laparo-endoscopic
and Lichtenstein techniques in recurrent inguinal
hernia repair, patients who underwent laparoendoscopic repair experienced signicantly less
chronic pain and returned earlier to normal
activities. Operative time was signicantly longer
in laparo-endoscopic operations. No other dierence was found [30].
On the basis of the meta-analyses, the
European Hernia Society recommends endoscopic inguinal hernia techniques for recurrent
Technique Total Extraperitoneal Patch Plasty (TEP): Standard Technique andSpecic Risks
135
11
hernias aer conventional open repair [18].
Likewise, the International Endohernia Society
recommends, with a high level of evidence, TEP
and TAPP for repair of recurrent hernia as the
preferred alternative to tissue repair and to the
Lichtenstein repair aer prior anterior repair [12].
In the Consensus Development Conference
of the European Association for Endoscopic
Surgery, TEP and TAPP are preferred in patients
with a recurrent groin hernia aer open repair
[15]. Repeat endoscopic repair is only feasible
when the surgeon has a high level of experience
in repeat endoscopic groin hernia repair [15].
To date, there are no prospective randomized
studies that compare the outcome of endoscopic
repair of primary versus recurrent inguinal hernias [32].
In an analysis of the Herniamed Registry,
20,624 patients with male unilateral inguinal hernia were enrolled. 18,142 (88.0%) had primary and
2482 (12.0%) had recurrent laparo- endoscopic
repair [32].
Unadjusted analysis did not reveal any signicant dierences in the intraoperative complications
(1.28% vs 1.33%; p= 0.849). However, there were
signicant dierences in the postoperative complications (3.20% vs 4.03%; p=0.036), the reoperation rate due to complications (0.84% vs 1.33%;
p=0.023), pain at rest (4.08% vs 6.16%; p<0.001),
pain on exertion (8.03% vs 11.44%; p < 0.001),
chronic pain requiring treatment (2.31% vs 3.83%;
p < 0.001), and the recurrence rates (0.94% vs
1.45%; p = 0.0023). Multivariable analysis conrmed the signicant impact of laparo- endoscopic
repair of recurrent hernia on the outcome [32]. e
authors concluded that laparo-endoscopic repair
of recurrent inguinal hernias called for particular
competence on the part of the hernia surgeon [32].
11.3.3 Scrotal Hernias
In the guidelines of the European Association for
Endoscopic Surgery [15], scrotal hernia is classied
as being a complex condition. For scrotal hernia,
only highly experienced laparo- endoscopic hernia surgeons should opt for a laparo- endoscopic
technique [12]. e challenge in scrotal hernia is
ensuring complete dissection of the large hernia
sac from the inguinal canal and scrotum. Failure to
remove a large section of the hernia sac will generally result in formation of a persistent seroma [12].
Endoscopic control of bleeding during scrotal hernia repair is also oen very dicult when dissecting
the hernia sac from the spermatic cord structures.
erefore, there is oen a higher incidence of postoperative secondary hemorrhage and hematomas
[33]. Accordingly, the European Hernia Society
Guidelines recommend the open mesh techniques
(Lichtenstein, Plug and Patch, and PHS) as the
techniques of choice for scrotal hernia [18, 19].
11.3.4 Incarcerated Hernias
In the presence of an incarcerated inguinal hernia,
a diagnostic laparoscopy should be performed
rst of all [12, 15]. e incarcerated bowel or
greater omentum can then be withdrawn from the
hernia sac, if necessary making an incision into
the cranial hernia ring [33]. Next, a decision must
be taken as to whether parts of the omentum and/
or intestines should be resected. In approximately
90% of cases, the data show that this is not necessary as the organs recover aer reposition into the
abdominal cavity [33]. en inguinal hernia repair
can be carried out using a TEP or TAPP technique
[34–38]. If there is transmural peritonitis, the her-
nia sac can be rst closed with a suture and the
inguinal hernia mesh repair performed later [33].
11.3.5 Previous Lower Abdominal,
Pelvic, andUrological
Surgery, Vascular Operations,
andAscites
Faced with these complex situations, the guidelines of the International Endohernia Society [12]
and of the European Association for Endoscopic
Surgery [15] also recommend that only very
experienced laparo-endoscopic hernia surgeon
should opt for a minimally invasive procedure
[33]. Following major lower abdominal and pelvic surgery, the European Hernia Society therefore recommends the open mesh techniques
(Lichtenstein, Plug and Patch, and PHS) as the
preferred techniques [18, 19]. e open mesh
approach, no doubt, also presents the least risk in
the presence of cirrhosis of the liver with ascites
or for patients on peritoneal dialysis [33].
A right-sided or bilateral TEP procedure may
be performed safely in patients aer previous
appendectomy [39]. In a comparative study, the
136
F. Köckerling et al.
11
conversion rate aer previous open appendectomy was at 10% signicantly higher as at 1%
in the group without previous appendectomy
(p=0.005) [39].
e authors concluded that despite a higher
conversion rate, the vast majority of patients
could be operated endoscopically [39].
In a comparative study, Le Page et al. [40]
found no signicant dierences in patients with
compared with patients without previous prostatectomy in terms of rates of postoperative complications, length of stay, or recurrence. Only the
operation time was longer. ey concluded that
in experienced hands TEP inguinal hernia repair
for patients who had previously undergone prostatectomy was safe and had equivalent outcomes
to patients who had not undergone prostatectomy
and was an alternative to open repair [40].
Chung etal. [41] reported about 23 patients
with TEP inguinal hernia repair aer previous abdominal surgery compared to 46 patients
without such surgery. No dierence was observed
between the two groups in terms of operative
times, analgesic use, hospital stay, return to daily
activities, or postoperative complications [41].
In a study by Paterson et al. [42], 35 unilateral and 12 bilateral TEP hernia repairs were performed in the presence of 20 appendectomy, 10
lower midline, 18 suprapubic, and 5 paramedian
incisions. ere were no major complications
and no early or late recurrences [42]. e authors
stated that TEP hernia repair could be carried out
safely in the presence of scars from previous lower
abdominal surgery.
11.3.6 Patients withCoagulopathy
or Antithrombotic Therapy
for careful perioperative risk benet assessment
with regard to the use of such therapeutics [43].
If it is possible to suspend platelet aggregation
inhibitors for 7 days or discontinue oral anticoagulant therapy and eect bridging with heparin,
inguinal hernia surgery can be performed without increased risk of postoperative bleeding [43].
But if, based on multi-disciplinary consensus,
antithrombotic medication cannot be dispensed
with, a higher risk of bleeding complications must
be countenanced [43].
Out of the 82,911 patients from the
Herniamed Registry, who had undergone inguinal hernia repair, 9,115 (11%) were operated on
while receiving antithrombotic therapy or with
existing coagulopathy [43]. e rate of postoperative secondary bleeding, at 3.91%, was
signicantly higher in the risk group with coagulopathy or receiving antithrombotic therapy than
in the group without that risk prole at 1.12%
(p<0.001). Multivariable analysis revealed other
inuence variables which, in addition to coagulopathy or antithrombotic therapy, had a relevant
inuence on the occurrence of postoperative
bleeding. ese were open operation, a higher
age, a higher ASA score, recurrence, male gender,
and a large hernia defect [43].
e authors concluded that patients receiving
antithrombotic therapy or with existing coagulopathy who undergo inguinal hernia operation
have a fourfold higher risk for onset of postoperative secondary bleeding. Despite the extensive
dissection required for laparo-endoscopic (TEP,
TAPP) inguinal hernia repair, the risk of bleeding complications and complication-related reoperation appears to be lower compared to open
surgery [43].
Against a background of a progressively aging
population, candidates for inguinal hernia
repair are oen elderly and have comorbidities.
erefore, it is not uncommon for the patients to
be on antiplatelet or anticoagulant therapy [43].
Because antithrombotic agents are associated
with longer bleeding time, the risk of postoperative hemorrhage is increased [43]. Prophylactic
or therapeutic use of anticoagulants and platelet
aggregation inhibitors confronts the treating surgeon with the challenge of protecting patients
against thromboembolic complications without
inducing bleeding complications [43]. at calls
11.3.7 Patients Older Than 65Years
Outcome studies demonstrate that morbidity and
mortality are increased following surgery in the
elderly as compared with the younger population
[44].
In the Swedish Hernia Registry, there was
a signicant and substantial increase in risk
of a postoperative complication with laparoendoscopic and open preperitoneal procedures in
older patients (aged>65years) [45].
In the Danish Hernia Registry, complications
aer groin hernia repair were more frequent in
Technique Total Extraperitoneal Patch Plasty (TEP): Standard Technique andSpecic Risks
137
11
patients >65years (4.5%) compared with younger
patients (2.3%) (p=0.001) [46].
In the National Surgical Quality Improvement
Program (NSQIP) of the American College of
Surgeons, the risk of onset of perioperative complications in patients >65years is expressed with
a signicant higher odds ratio of 1.418 [1.206–
1.666] [44].
In the Herniamed Registry, 24,571 patients
with a primary inguinal hernia operated in TAPP
and in TEP technique are documented [44].
17,214 patients (70.06%) were in the age group
≤65 years and 7357 (29.94%) in the age group
>65years [44].
Unadjusted analysis revealed signicantly
dierent results for the intraoperative (1.19% vs
1.60%; p=0.010), postoperative surgical (2.27%
vs 4.59%; p < 0.001), and postoperative general
complications (0.85% vs 1.98%; p > 0.001) as
well as for complication-related reoperations
(1.07% vs 1.37%; p = 0.044), which were more
favorable in the ≤65 years age group. e age
limit for increased onset of perioperative complication rates tends to be more than 80 rather
than 65years. In patients over the age of 80 [44,
47, 48], laparo-endoscopic hernia repair is pos-
sible, but preoperative analysis of risk factors and
their correction if possible should be mandatory.
Moreover, careful intraoperative monitoring by
the anesthesiologist is essential, and the possibility to stay for some hours in an ICU should be
provided [44].
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Technique Total Extraperitoneal Patch Plasty (TEP): Complications, Prevention, Education, and Preferences
FerdinandKöckerling, PradeepChowbey, DavideLomanto,
andMauriceArregui
12.1 Intraoperative Complications – 143
12.1.1 Injury oftheExternal Iliac Vessels – 143
12.1.2 Injury oftheEpigastric Vessels – 143
12.1.3 Bleeding – 143
12.1.4 Bleeding fromtheRectus Muscle – 143
12.1.5 Bleeding fromVessels over thePubic Symphysis – 143
12.1.6 Bleeding fromSpermatic Vessels – 143
12.1.7 Bladder Injury – 144
12.1.8 Bowel Injury – 144
12.1.9 Injury totheVas Deferens – 144
12.1.10 Conversion – 144
12.1.11 Accidental Tearing ofPeritoneum with
Pneumoperitoneum – 144
12.1.12 Subcutaneous Carbon Dioxide Emphysema – 145
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12.2 Postoperative Complications – 145
12.2.1 Hematoma/Bleeding – 145
12.2.2 Seroma – 145
12.2.3 Wound Disorders andDeep Infection – 146
12.2.4 Postoperative Urinary Retention – 146
12.2.5 Impairment ofSexual Activity – 146
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_12
12.3 Pitfalls andPrevention – 146
12.4 Education andLearning Curve – 148
12.4.1 Aftercare andPain Management – 148
References – 149
Technique Total Extraperitoneal Patch Plasty (TEP)
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12.1 Intraoperative Complications
e rate of intraoperative complications in 6833
TEP for primary unilateral inguinal hernia repair
in men is 1.17% [1]. e intraoperative vascular
injury rate is 0.28% in 6833 male primary unilateral inguinal hernia repairs in TEP technique in
the Herniamed Registry.
12.1.1 Injury oftheExternal Iliac
Vessels
Injury of the external iliac vessels is an emergency
and leads to major bleeding [2–4]. Immediate
conversion to open surgery must be done to control the bleeding. An iliac abdominal wall incision
is made to immediately convert to open surgery
[2]. Pressure is applied to the exposed vessels
to control the bleeding. A vascular surgeon, if
available, should be called to repair the vessels.
Proximal and distal control should be gained
before removing compression from the bleeding point, and repair is done using 5–0 Prolene
sutures or a patch [2].
12.1.2 Injury oftheEpigastric
Vessels
In particular in the case of older patients, when
creating the preperitoneal space, connective tissue degeneration may result in dorsal displacement of the epigastric vessels from the abdominal
rectus muscle. In the majority of cases, this can be
seen with the 30° optic in the dissection balloon,
so that further use of the balloon is foregone in
favor of manual dissection via the 5mm working
trocar. If there is complete displacement of the
epigastric vessels, they can be temporarily secured
to the rectus muscle with either an endoclip suture
or a suture passed transcutaneously, around the
vessels, and endoscopically back through the
abdominal wall. Clipping of the epigastric vessels
is not indicated. e result of displacement is usually minor bleeds from epigastric branches which
aer identication can be coagulated selectively.
Only in the event of bleeding directly from the
epigastric vessels is management with absorbable
clips justied.
12.1.3 Bleeding
e intraoperative bleeding rate in the Herniamed
Registry in 6833 TEP procedures for primary unilateral inguinal hernia in men is 0.72% [1].
12.1.4 Bleeding fromtheRectus
Muscle
Bleeding of the rectus muscle can occur from
muscular branches of the epigastric vessels when
the Hasson cannula or blunt-tip trocar is positioned. In this situation, blood ows down along
the cannula, stains the camera, and obscures
vision [2]. e bleeding vessel should be coagulated using cautery aer removal of the cannula. A
compress can be inserted along the side of the
cannula to achieve hemostasis [2].
12.1.5 Bleeding fromVessels over
thePubic Symphysis
During dissection of the medial preperitoneal
space, the veins over the pubic symphysis may
bleed and should be controlled properly by monopolar cautery [2].
12.1.6 Bleeding fromSpermatic
Vessels
Bleeding from spermatic vessels is controlled by
using electrocautery [2].
12.1.7 Bladder Injury
Bladder injuries in TEP are extremely rare [5].
In the Herniamed Registry with 6833 unilateral inguinal hernia repair, three cases (0.04%)
are reported [1]. In a series of 3868 patients,
injuries to the urinary bladder were seen in just
eight cases, the majority of whom had previously
undergone suprapubic catheterization [5, 11].
Bladder injuries related to balloon dissectors were
oen limited to only those patients with previous
abdominal surgery [5]. In a series of 500 patients,
two cystotomies were noted during balloon dissection of the preperitoneal space. Both patients
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F. Köckerling et al.
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had previous lower abdominal surgery [6]. But
this can also happen in patients without any previous, lower abdominal operation or suprapubic
catheter placement [5].
Bladder rupture is possible during balloon dissection of TEP even in patients without prior
abdominal surgery [5]. But the bladder is especially prone to injury during TEP if the preperitoneal space has previously been dissected [13], e. g.,
previous preperitoneal hernia repair or prostatectomy. To avoid that complication, the guidelines of
the International Endohernia Society recommend
that the bladder should be decompressed either by
having the patient void immediately preoperatively or by the use of an indwelling catheter [13].
Bladder injury detected during endoscopy
should be repaired endoscopically provided the
surgeon is suciently experienced. is should be
followed by bladder drainage for 7–10days [13].
Bladder injury may present in a delayed fashion with hematuria and lower abdominal discomfort. Contrast-enhanced computed tomography,
cystography, and cystoscopy are the primary
imaging techniques used to evaluate patients for a
suspected injury [13]. Small defects may be managed with postoperative decompression with an
indwelling catheter for urinary drainage, whereas
large defects necessitate repair.
12.1.8 Bowel Injury
Bowel injury is rare in TEP repair as the procedure is done extraperitoneally. In the Herniamed
Registry, four cases out of 6833 unilateral inguinal
hernia repairs in TEP technique are reported
(0.06%) [1]. In the case of large, irreducible hernias, bowel injury can occur during reduction of
the hernia contents. Injury to the sigmoid colon or
cecal colon can occur in the case of a large sliding
inguinal hernia, when the colon may slide to form
a part of the sac [2]. Identication of this situation
and prevention of injury are crucial [2].
Also aer previous open appendectomy and
right-sided inguinal hernias, the lateral dissection
needs to be performed very carefully, not injuring
the cecal colon which might be adherent to the
peritoneum due to adhesions.
In case of a bowel injury, whether problem can
be handled laparoscopically depends on the extent
of the lesion and the experience of the surgeon. If
there is any doubt, conversion is always justied.
12.1.9 Injury totheVas Deferens
e vas deferens is identied as a thick, white,
cord-like structure that enters the deep inguinal
ring along with the spermatic vessels. e vas may
be injured while dissecting an indirect sac from
the cord structures. If the vas deferens is divided
in a young patient, it should be repaired immediately by end-to-end anastomosis. In old patients,
the cut ends should be clipped to prevent collection of seminal uid [2].
12.1.10 Conversion
Conversion to either the transabdominal preperitoneal patch plasty (TAPP) or open procedure
depends upon the situation and experience of the
surgeon [2].
Initially, if there is diculty in creating an
extraperitoneal space, the anatomy is not clear,
there is bleeding from small vessels causing a continuous ooze, or dissection of the sac/cord structures is dicult, it is better to convert to the open
surgical technique [2]. In case there is an intraoperative complication, it is important to rst treat
the complication by either the endoscopic or open
technique. A decision regarding the approach for
repair of the hernia should be taken only aer the
intraoperative complication has been adequately
tackled. Conversion to the TAPP technique may
be done, if it is not possible to reduce the contents
of the hernia sac [2].
12.1.11 Accidental Tearing of
Peritoneum with
Pneumoperitoneum
If during manual or balloon dissection a peritoneal tear results in a pneumoperitoneum, singlehand dissection via the medial 5 mm trocar is
made appreciably more dicult. In such a case, an
additional 5mm trocar placed suprapubically in
the midline may be useful to permit bimanual
working. If pneumoperitoneum occurs aer placement of both working trocars during dissection of
the hernias, it is normally readily manageable.
By steepening the head-down position, adequate exposure of the preperitoneal space is usually achieved. Tiny peritoneal lesions resulting in
escape of CO2 into the abdominal cavity may be