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14
ab
ab
. Fig.14.4 a Dissection of hernia sac and cord and b dissection and reduction of cord lipoma
. Fig.14.5 Relaxing incisions in transversalis sling at the 10 o’clock position for incarcerated a direct and b indirect
M. Iskandar and G. Ferzli
standard mesh size (10 × 15cm) was too small.
In large hernia openings, a mesh with less exural
stiness (lightweight) or insucient overlapping
may be pushed into the defect.
Recommendations
14
. Fig.14.6 Presence of the testicle and tunica vaginalis
14.4 Technical Considerations
inTAPP (See
14.4.1 Evidence [3, 4]
7 Chap. 8)
Level 3
TAPP and TEP are possible therapeutic options
in scrotal hernia. Operation time, complication
rate, and frequency of recurrences are higher than
in normal hernia repair. Sero-hematoma forma-
tion is the most frequent complication. Results
will improve with gaining experience. Complete
reduction of hernia sack is possible.
TEP inguinal-scrotal hernia repair remains
an advantageous approach during the dicult
scrotal hernia that requires “conversion” to an
open repair, because the preperitoneal dissection
performed laparoscopically allows for reduction
of the hernia and optimal mesh placement once
the hernia repair has been converted and is performed from the anterior approach.
Level 5
e higher recurrence rate may result in some of
these cases (large hernia openings), because the
14.5 Incarcerated andStrangulated
Inguinal Hernias
Incarcerated hernias may be repaired either by
TAPP or TEP, but TAPP has the advantage of
allowing the surgeon to inspect the bowel to
ensure its viability [5]. If a TEP is performed, the
umbilical port can be moved from a preperitoneal
to a peritoneal location to examine the bowel
in question. Occasionally, incarcerated hernias
reduce spontaneously or with gentle pressure
when paralysis has been achieved with induction
of general anesthesia. e key step to the operation is the reduction of the sac and its contents.
e hernia ring can be enlarged (while preventing injury to the femoral or epigastric vessels)
14
through a ventromedial incision in the case of
direct hernias and through a ventrolateral incision in the case of indirect hernias. If resection of
nonviable tissue is required, it can be done intraperitoneally (for the omentum or appendix) or
extraperitoneally (for small bowel) aer the repair
has been accomplished.
e use of TAPP has been described for the
treatment of incarcerated femoral hernias [6–8].
A relaxing incision in the medial border of the
iliopubic tract as it recurves to form the medial
border of the femoral canal may be made to aid in
the reduction of the hernia sac.
14.6 Evidence: TAPP for
Incarcerated and
Strangulated Hernias [3, 4]
14.6.1 Level 3
Operation time is longer than in uncomplicated
hernia. Complication rate and recurrences are
similar to uncomplicated cases. Advantage of laparoscopy is that bowel viability can be observed
during the whole time of procedure. Frequency
of bowel resection is less compared with open
hernia surgery.
Level 5 Reduction of hernia content or cutting
the hernia ring if necessary for reduction may be
safer when overlooking both peritoneal and preperitoneal spaces.
14.7 Evidence forTEP in
Incarcerated andStrangulated
Inguinal Hernia [3, 4]
14.7.1 Level 3
e conversion rate in the acute setting is high.
Recurrence and complication rates are higher
than in the non-incarcerated hernia.
14.7.2 Level 5
A drawback to the TEP vs. TAPP approach for the
strangulated inguinal hernia is that TEP does not
allow inspection of the bowel without laparoscopy.
Recommendations
14.7.3 Evidence for Incarcerated
Femoral Hernias
Recommendations
Level 5
ere are only few reports of successful treatment of incarcerated femoral hernia. Reduction
of hernia contents requires incision of the lacunar
ligament.
Recommendations
M. Iskandar and G. Ferzli
14
14.8 Recurrent Inguinal Hernias
Recurrence rates aer open primary hernia repair
with mesh range between 1% and 5%. Recurrence
rates aer laparoscopic repair can be as high as
10% [9] or as low as 1% in experienced highvolume centers [10]. However, it is estimated that
17% of inguinal hernia repairs are done for recurrent hernias [11]. Re-recurrence rate aer repair
of recurrent hernias can be as high as 15%–20%
[12–14]. erefore, laparoscopic repair of recurrent inguinal hernias should be performed in
high-volume centers where surgeons are over the
learning curve to select the best approach and
provide the best possible repair with minimal
morbidity. Before an operation for a recurrent
hernia is scheduled, it is imperative to review
the operative report in detail from previous procedures focusing on the type of hernia that was
present, the use of a mesh, and, if so what type and
size, the use of tacks/sutures.
Recurrent hernias aer a primary open
repair can be approached by either TEP or
TAPP. Initially most recurrences were done via
the TAPP approach, but as surgeons became more
familiar with TEP, it became the predominant
procedure. Data from multiple nonrandomized
studies show re-recurrence rates ranging from
0.5% to 11% with similar outcomes between TEP
and TAPP [12, 13, 15, 16].
Repair of recurrent inguinal hernias aer a
prior laparoscopic procedure can be approached
either open or with a redo TEP or TAPP. A
number of studies have looked at TAPP repair
for recurrence aer TAPP as the primary repair
modality (TAPP aer TAPP). In a large series of
TAPP aer TAPP by Bittner (n=135), the overall
re-recurrence rate was 0.74%. is study emphasized the learning curve and experience needed to
achieve good outcomes [17].
TEP aer TEP is a challenging procedure
requiring procient knowledge in anatomy and
meticulous dissection. e challenges arise from
adhesions, leading to obscuring of normal anatomical landmarks and loss of working space with
diculty in developing the spaces of Retzius and
Bogros. e key features of a TEP aer TEP are
as follows:
5 Development of the working space should be
done in a plane between the old mesh and the
anterior abdominal wall to keep the perito-
neum intact.
5 Identication of the epigastric vessels will
lead to the identication of the hernia.
Hernias don’t normally have adhesions, and
subsequently the presence of dense adhesions
means that there is probably no hernia.
5 Ligation of the epigastric vessels or their
branches is done routinely to achieve
adequate hemostasis because bleeding will
compromise the exposure.
5 Dissection of the hernia sac is done sharply
without electrocautery, whereas in primary
hernias, most dissection is blunt with traction
and countertraction.
5 External palpation and pulling of the testicle
will aid in the identication of the cord
structures.
5 Although the working space is limited and
may only allow placement of a smaller-sized
mesh, every attempt must be made to place
a large mesh. Failing to place a large mesh
increases recurrence rates, and in that case,
an anterior approach is preferred [18].
In our own experience, TEP aer TEP was
attempted in 21 patients [19]. Five were converted
to open because of inability to open the space of
Retzius (3) or bleeding obscuring the operative
eld (1) and peritoneal violation leading to loss of
working space(1). Mean OR time was 47minutes
(31–120min), and there were no blood transfusions or complications. All patients were discharged home the same day.
14.8.1 Evidence: TAPP forRecurrent
Inguinal Hernia Repair [3, 4]
Level 2
TAPP is advantageous in terms of dening
anatomy and providing improved mechanical
strength. Re-recurrence rate is equal or
improved when compared with open techniques.
Complication rate at 1 week aer surgery is
less, and sick leave is shorter compared with the
Lichtenstein repair. Acute and chronic pains are
less compared with open mesh repair.
Level 3
Eectiveness of TAPP repair in recurrent hernia
is equal compared with TAPP repair in primary
hernia.
14
Recommendations
14.8.2 Evidence TEP forRecurrent
Inguinal Hernia Repair [3, 4]
Level II
TEP is advantageous in terms of dening anatomy
and providing improved mechanical strength. Rerecurrence rate is equal or improved compared
with open techniques.
Level IIC
Reoperation rate is less compared with open
techniques.
14.10 Obturator Hernia
Obturator hernias are rare and account for less
than 0.1% of all hernias, such that limited data
on laparoscopic repair exists and is mostly in
small case series [21]. ey typically occur in
older emaciated females. e usual presentation
is that of obstruction without a bulge on exam.
Pain in medial thigh with extension, abduction,
and medial rotation of the hip, the HowshipRomberg sign, is pathognomonic but rarely present. Imaging with CT scan is needed to make
the diagnosis, and prompt surgical treatment is
necessary to avoid strangulation and the high
mortality rate in this elderly population. And
considering that up to 20% of obturator hernias
are bilateral, it is mandatory to explore the other
side. Laparoscopic repair oers the advantage
of exploring both sides and covering the whole
myopectineal orice with mesh. Both TEP and
TAPP can be done keeping in mind that in TEP,
the viability of the bowel should be assessed with
conversion of the umbilical port from a preperitoneal into a peritoneal position.
Recommendations
14.9 Femoral Hernias
Femoral hernias are more common in women and
account for 2%–4% of groin hernias [20]. When
diagnosed, femoral hernias should be repaired
electively even if asymptomatic due to the high
risk of strangulation and associated morbidity.
Information regarding laparoscopic treatment of
isolated femoral hernias is limited to small case
series. However, the laparoscopic repair has the
advantage of covering the entire myopectineal
orice with a mesh to avoid complications associated with plug placement in the femoral canal in
the open repair. Such complications include plug
migration and venous thrombosis. erefore, the
authors advocate for all femoral hernias to be
repaired laparoscopically [1].
14.11 Hernias inWomen
Hernias in women deserve special attention as
they follow a dierent pattern than in their male
counterparts. It is more common to have small
femoral hernias in women and very rare to have
large direct hernias. is dierence in presentation stems from the anatomical dierences of the
female and male inguinal canals, mainly the defect
in the external oblique aponeurosis in males [22].
e diagnosis of hernias in women can be challenging depending on the location of the hernia
and the presenting symptom. If the presentation
is associated with a bulge, then the management
is straightforward. More oen than not, when a
female patient presents with groin pain, the physical exam is non-revealing, and the dierential
diagnosis is wide and involves many organ systems such as musculoskeletal, genitourinary, gastrointestinal, and vascular to name a few. e risk
of occult hernias in women is not to be undermined. Imaging is necessary to make a diagnosis
in the absence of a bulge, and MRI can be very
helpful in diagnosing potential causes of groin
pain besides hernias [23]. Forty-one percent of
recurrent groin hernias in women are attributed
M. Iskandar and G. Ferzli
14
to femoral hernias that were not present at the
initial operation [20]. is high frequency argues
for a laparoscopic repair in all women to cover the
inguinal and femoral spaces simultaneously.
14.11.1 Evidence [3, 4]
Level 4
Women are at increased risk of having an occult
synchronous femoral hernia.
Grade C
When performing inguinal hernia repair in
women, extra eort should be undertaken to
reveal and treat occult synchronous femoral hernia.
14.12 TEP andTAPP After Previous
Radical Prostatectomy and
Lower Abdominal Surgery
An almost fourfold increase in the incidence of
groin hernia repair was observed aer retropubic
and minimally invasive prostatectomy compared
with a control cohort, and men who underwent
radiation had an almost twofold increase in incidence [24].
ese observations suggest that in addition
to postoperative changes in the abdominal wall,
increased vigilance for groin hernia also contributes to the observed increase in the incidence of
groin hernia repair in men with prostate cancer.
In general an anterior open approach would be
the preferred treatment for of inguinal hernias
in patients that had undergone prostatectomies. However, both TEPP and TAP have been
described for such hernias. It is generally accepted
that an anterior approach seems to be the best
choice aer previous preperitoneal surgery.
Only two studies report the results of TAPP
[26] and TEP [25] in hernia patients aer previous transabdominal radical prostatectomy.
During a 1-year period, Dulucq operated
on a total of ten patients aer prostatectomy
with TEP. Operation time was longer than in
uncomplicated repairs, and two patients were
converted to TAPP, but overall complication
rates and outcomes were similar. Wauschkuhn
etal. reported approximately 264 patients who
underwent surgery during a 10-year period.
ey found a longer operation time and a higher
morbidity (5.7 vs. 2.8), but time of sick leave
and recurrence rates were similar. Analysis of
subgroups with respect to the time period during which they were operated on showed a steep
learning curve.
Patterson also described 47 TEPs in patient
with a variety of lower abdominal scars including
appendectomy and paramedian and Pfannenstiel
incisions [27]. ere were two conversions to open
procedure without any signicant complications.
14.12.1 Evidence [3, 4]
Level 3
TAPP and TEP are possible treatment options.
Operation time is longer and morbidity higher
compared with repair of primary hernia, but time
of sick leave and re-recurrence rate are similar.
ere is a steep learning curve. In TEP, there is a
signicant conversion rate to TAPP.Level 5 TAPP
seems to be easier to perform.
Grade D
TAPP or TEP repair may be performed, but it
should only be attempted by experts in TAPP or
TEP inguinal hernia repair.
14.13 Bilateral Hernia
In comparison to open surgery in patients
presenting a bilateral inguinal hernia, laparoendoscopic repair oers the possibility of repair
of both sides without any increase of the access
trauma to the abdominal wall. Furthermore a
large prospectively documented case series could
show that short-term and long-term outcome
was equal to the repair of a unilateral hernia [28],
except operation time was about 20 min longer.
e incidence of bilateral hernias is high. In a
prospective study of 1010 hernia repairs consecutively performed with a long follow-up, the rate
of bilateral hernias was 28%, but in the patients
operated on because of a unilateral hernia, 13.8%
of these patients developed a contralateral hernia aer 5years [29]. To grant the advantages of
laparo-endoscopic repair, it is recommended to
always carefully evaluate both sides clinically and
when in doubt by ultrasound. Furthermore, it is recommended to get informed consent for repair of both
sides in the case that intraoperatively (esp. in TAPP) a
contralateral (clinically occult) hernia is found.
14.13.1 Evidence [3]
Statement
Recommendations
14
References
M. Iskandar and G. Ferzli
14
Mesh Technology at Inguinal Hernia Repair
FerdinandKöckerling, DirkWeyhe, ReneH.Fortelny,
andBruceRamshaw
15.1 Biocompatibility – 184
15.1.1 Synthetic Nonabsorbable – 184
15.1.2 Synthetic Absorbable – 185
15.1.3 Biological – 186
15.2 Size – 186
15.3 Slit: Yes or No? – 186
15.4 Fixation (René H. Fortelny) – 187
15.4.1 Non-xation – 187
15.4.2 Glue Fixation – 188
15.4.3 Nonabsorbable andAbsorbable Clips/Tacks – 190
15.4.4 Self–Fixating Mesh – 190
183
15
15.5 Summary – 190
References – 190
© 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_15
184
F. Köckerling et al.
15
15.1 Biocompatibility
15.1.1 Synthetic Nonabsorbable
In a meta-analysis of Currie etal. [1], eight trials
were included in the analysis of 1667 hernias in
1592 patients. Mean study follow-up was between
2 and 60months. ere was no eect on recurrence or chronic pain. Lightweight and heavyweight mesh repair had similar outcomes with
regard to postoperative pain, seroma development, and time to return to work.
e authors concluded that both mesh options
appear to result in similar long- and short-term
postoperative outcomes [1].
In a systematic review and meta-analysis,
Sajid etal. [2] studied 11 randomized controlled
trials (RCTs) encompassing 2189 patients. In a
xed-eects model, operating time, postoperative
pain, and recurrence rate were statistically similar
between lightweight mesh and heavyweight mesh.
Lightweight mesh was associated with fewer perioperative complications and a reduced risk for
developing chronic groin pain. ere was also a
reduced risk for developing other groin symptoms, such as foreign body sensations, but it was
not statistically signicant.
In conclusion, the use of lightweight mesh for
laparoscopic inguinal hernia repair is not associated
with an increased risk for hernia recurrence.
Lightweight mesh reduces the incidence of chronic
pain, groin stiness, and foreign body sensation [2].
erefore, Sajid etal. [2] recommended to use
lightweight meshes routinely in laparoscopic
inguinal hernia repair. In the update [3] with level
1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult
patients [4], it is pointed out that insucient data
are available on the potential advantage of lightweight meshes in laparo-endoscopic inguinal hernia repair. Advantages of lightweight meshes have
not been shown in endoscopic repair [3].
In the update [5] of the guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment
of inguinal hernia of the International Endohernia
Society [6], a statement on level 1A is made that
the statistical signicance about lighter meshes
with larger pores results in improvement of quality of life is not consistent in the published metaanalyses. Subset analysis revealed no higher risk
of recurrence aer using lightweight meshes in
laparoscopic inguinal hernia repair [5].
. Table15.1 Meshes on the market for inguinal
hernia repair
PP (g/m2) Rigidity
Prolene 108 ++++
Marlex 95 ++++
Surgipro 95 ++++
Atrium 83 ++++
Premilene 55 +++
Parietene light 38 ++
Optilene mesh LP 36 ++
TiMesh light 35 ++
Vypro II (multil.)+
polyglactin
Ultrapro+
polyglecaprone
TiMesh extralight 16 +
31 +
28 ++
On evidence-level grade B, the guidelines of the
International Endohernia Society recommend the
use of a monolament synthetic nonabsorbable
implant (polypropylene) with a pore size of at least
1.0–1.5 mm (usually meaning low weight)
. Table15.1, . Figs.15.1, 15.2, and 15.3) consisting
(
of a minimum tensile strength in all directions of
16N/cm appeared to be most advantageous [5, 6].
e consensus development conference on
endoscopic repair of groin hernias of the European
Association of Endoscopic Surgery (EAES) has
made the statement with a level of consensus of
86% that there is currently not enough evidence
supporting the general use of lightweight mesh
over heavyweight mesh in endoscopic groin hernia repair [7].
In 2016 the long-term results of a randomized
double-blinded prospective trial of a lightweight
(Ultrapro) versus a heavyweight mesh (Prolene)
in laparoscopic total extraperitoneal inguinal hernia repair (TULP-trial) were published [8].
Between March 2010 and October 2012, male
patients who presented with a primary, reducible
unilateral inguinal hernia who underwent
day- case TEP repair were eligible. During the
study period, 950 patients were included. One
year postoperatively the presence of relevant pain
(Numeric Rating Score 4–10) was signicantly
higher in the lightweight mesh group (2.9%)