Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1047_Библиотеки_им_академика_М_И_Перельмана.pdf
130
P. Chowbey
articial space, it gets obliterated after exsufation of CO2. It should be ensured that the
mesh lies at at the time of exsufation.
• Wound closure
After removal of the Hasson trocar from the
subumbilical port, the two stay sutures on the
anterior rectus sheath are tied to each other,
ensuring complete sheath closure. The skin of
all three ports is closed using skin clips/sutures,
depending on the surgeon’s choice. Complete
exsufation of CO2 from the extraperitoneal
space must be ensured before wound closure.
9.1.6 Post-operative Care
• Patients are ambulated once fully conscious.
• Patients are encouraged to get up and walk
around on the same day.
• Clear uids are given immediately on recovery from anaesthesia. The quantity of oral liquids is gradually increased.
• Patients are discharged the next morning on a
normal diet.
• Oral analgesics are administered for 3 days
post-operatively. Injectable diclofenac is
administered only on demand.
• All port sites are covered with waterproof
dressings and patients are permitted to have a
shower.
• No restriction on normal physical activity is
advised as it is a ‘tension-free’ repair.
• Wound stitches/clips are removed on the rst
post-operative visit, i.e. at 1week post-surgery.
9.1.7 Post-operative Complications
The complication of laparoscopic hernia repair
can be summarized as follows:
1. Seroma/haematoma—This is the most common complication of TEP repair. The incidence varies from 5 to 25% [2]. Seroma
usually occurs in a large hernia, and more
often in an indirect than a direct hernia.
Division of the sac of an indirect hernia without excessive dissection of the sac from the
cord structures decreases the incidence of
cord haematoma and seroma formation. In
direct hernia, the transversalis fascia can be
pulled into the extraperitoneal space and xed
over the pubic bone to decrease the incidence
of seroma formation. If a seroma develops, it
usually subsides automatically in 2–6weeks.
Aspiration is best avoided and the patient
should be reassured. In rare cases in which
aspiration is required, it should be performed
under aseptic conditions as it may lead to contamination and chances of mesh infection. An
ultrasound should be performed to conrm the
diagnosis before performing aspiration.
2. Neuralgia—This is usually transient.
Neuralgic pain over the lateral aspect of the
thigh is the commonest. Pain may also be
referred to the knee joint. Neuralgia is caused
by irritation of the genitofemoral nerve and/or
lateral cutaneous nerve of the thigh, and the
intermediate cutaneous branch of the femoral
nerve. The irritation can be due to the mesh
placed in that region or entrapment of the
nerve in the xation device (tacks used for
staples). To minimize the incidence of neuralgia, the fascia over the psoas muscle should
not be dissected and the mesh should only be
xed medially. No staples should be applied
lateral to the cord structures. If the mesh has
to be xed laterally (in the case of a large,
indirect hernia) it should be xed on the anterior abdominal wall above the iliopubic tract.
3. Testicular swelling and pain—This is usually
present in the immediate post-operative period
and is caused by excessive dissection of the
sac of an indirect hernia from the cord structures. This should be avoided. Scrotal support
for a few days is of help, although the condition usually subsides spontaneously.
4. Wound infection—The incidence of infection
is usually low in the case of TEP repair.
Occasionally, there may be slight discharge
from the subumbilical port because of a small
haematoma in the area. It usually subsides by
drainage of the haematoma and use of antiseptic dressings.
5. Mesh infection—Mesh infection is a rare but
serious complication of TEP repair [3]. The iso-
9 Total Extraperitoneal Repair ofGroin Hernias
131
lated microora in mesh-related infections is
usually associated with the following bacteria:
Staphylococcus species, especially S. aureus;
Streptococcus species, including group B strep-
tococci; and Gram-negative (mainly enterobacteriaceae) and anaerobic bacteria [6]. In addition
to these organisms, mesh infections with pathogenic, waterborne atypical mycobacteria are
being recognized in recent years (Ref). These
organisms include three major pathogenic species: Mycobacterium fortuitum, Mycobacterium
chelonae and Mycobacterium abscessus. M.
chelonae is known to cause nosocomial skin and
soft- tissue infections following contaminated
injections, surgical procedures and laparoscopic
surgery. The source of infection is contamination of the wound directly or indirectly with
colonized tap water. Most cases of mesh infections after laparoscopic surgery can be attributed
to deciencies in the sterilization technique.
In early cases of infection, patients present
with fever, chills or rigor, focal tenderness,
erythema and swelling. Late infections are
more indolent and presentations are varied.
Symptoms can be chronic, recurrent or totally
absent until the progression of sepsis. Sinus
formation, swelling, pain or fever of unknown
etiology may be encountered. The treatment
of mesh infections initially involves administration of antibiotics, local wound care, and
drainage. In deep-seated mesh infections, prolonged antibiotic treatment in combination
with percutaneous or open drainage has been
reported to be effective in restraining the
infectious process [2]. However, in the presence of an extensive infection, caused by biolm formation and limited penetration of the
drug in the area, mesh removal and surgical
cleaning of the wound provide the best possible treatment to eradicate infection. It should
be emphasized that early surgical intervention
is desirable in the presence of extensive infection and abscess formation.
6. Osteitis pubis—It is a rare but reported complication after TEP repair. It can be an
extremely disabling condition with severe
pain and persistent symptoms after surgery.
The use of penetrating xation devices and
excessive cautery on the pubic bone should be
avoided. Osteitis pubis presents as persistent
pain over the pubic bone, which generally
settles with anti-inammatory drugs.
7. Recurrence—Recurrence after endoscopic
hernia repair is low [7]. Factors causing
recurrence in the early post-operative period
are as follows:
(a) Use of a small-sized mesh
(b) Migration or folding of the mesh into the
defect
(c) Displacement of the mesh by a
haematoma
(d) Folding of the mesh
(e) Missed indirect sac in the case of a direct
hernia
(f) Inadequate dissection of the extraperito-
neal space.
8. The incidence of recurrence can be reduced
by taking the following precautions:
(a) Using a mesh that is 15cm×13cm on
both sides
(b) Fixing the mesh medially to the Cooper
ligament
(c) Ensuring complete proximal dissection of
the peritoneum from the spermatic cord
(d) Maintaining proper haemostasis to pre-
vent haematoma formation
(e) Adequate training of surgeons.
9.2 Summary
• Laparoscopic surgery for inguinal hernia is an
advanced laparoscopic procedure. A surgeon
should rst have adequate experience of basic
laparoscopic procedures before attempting a
laparoscopic hernia repair.
• A complete knowledge of the laparoscopic
anatomy of the preperitoneal space is an
important prerequisite for performing a TEP
repair.
• For beginners, proper selection of a case is
important. A small, direct, right inguinal hernia is ideal.
• Creation of the preperitoneal space is the most
important step and all necessary precautions
should be taken.
132
P. Chowbey
• Accessing and enlarging the preperitoneal
space helps in creating adequate space and
ensuring proper haemostasis.
• The urinary bladder should be voided before
surgery.
• In the case of a direct inguinal hernia, an
indirect sac should always be looked for
along the cord structures and treated
accordingly.
• In the case of an indirect hernia, minimum dissection should be performed while separating
the sac from the cord structures.
• The peritoneum should be well reected proximally from the cord structures and laterally
from the psoas muscle so that the mesh can be
placed accurately.
• A mesh of at least 15 cm×13 cm should be
used.
• The mesh should be xed medially over the
Cooper ligament. This prevents migration and
rolling of the mesh, which can cause recurrence of a hernia after surgery.
• Lateral xation below the iliopubic tract
should be avoided, as it may cause
neuralgia.
Key Points
• The proper access between fascia transversalis
and peritoneum is important.
• Pubic bone is the rst landmark in the midline,
which needs to be identied at the start of
dissection.
• As the dissection proceeds laterally to pubic
bone, one should be aware of the presence of
‘corona mortis’.
• Inferior epigastric vessels should be identied
on roof when creating lateral space.
• Dissect laterally till the lateral border of psoas
muscle to create adequate space.
• While parietalization, caution should be exercised while dissecting the triangle of Doom
and Bendavid circle.
References
1. Garren MJ. Laparoscopic inguinal hernia repair total
extraperitoneal (TEP) approach. In: Illustrative handbook of general surgery. Berlin: Springer International;
2016. p.539–45.
2. Chowbey P.Endoscopic repair of abdominal wall hernias. Delhi: Byword Books Private Limited; 2012.
3. Konik RD, Narh-Martey P, Bogen G.Recurrence of an
inguinal hernia containing the dome of the bladder following laparoscopic repair with mesh: a case report.
Int J Surg Case Rep. 2016;25:218–20.
4. Shah T, Shah S, Joshi BR, Karkee RJ, Gupta RK.Total
extraperitoneal approach in large inguino-scrotal hernias: an institutional approach. J Soc Surg Nepal.
2016;18(3):51.
5. Utiyama EM, Damous SH, Tanaka EY, Yoo JH, de
Miranda JS, Ushinohama AZ, Faro MP, Birolini
CA. Early assessment of bilateral inguinal hernia
repair: a comparison between the laparoscopic total
extraperitoneal and Stoppa approaches. J Minim
Access Surg. 2016;12(3):271.
6. Chowbey PK, Khullar R, Sharma A, Soni V, Baijal
M, Garg N, Najma K. Laparoscopic management of
infected mesh after laparoscopic inguinal hernia repair.
Surg Laparosc Endosc Percutan Tech. 2015;25(2):125–
8. https://doi.org/10.1097/SLE.0000000000000056.
7. Gutlic N, Rogmark P, Nordin P, Petersson U,
Montgomery A.Impact of mesh xation on chronic
pain in total extraperitoneal inguinal hernia repair
(TEP): a nationwide register-based study. Ann Surg.
2016;263(6):1199–206.
Transabdominal Pre-peritoneal
(TAPP) Repair forGroin Hernias
GeorgePeiCheungYang
10.1 Transabdominal Preperitoneal Groin Hernia
Repair
Transabdominal pre-peritoneal (TAPP) groin hernia repair is one of the two mature techniques of
laparoscopic groin hernia repair. Compared to
TEP, TAPP provides an easier correlation between
the pre-peritoneal and peritoneal anatomy for the
surgeon. It involves intraperitoneal diagnostic
laparoscopy, incision of the peritoneum to gain
access to the pre-peritoneal space, creation of the
peritoneal ap, reduction of the groin hernia and
its sac, placement of the synthetic mesh, and closure of the peritoneal ap. The mesh should not
come into contact with the bowel. Therefore any
defect in the peritoneal ap should be closed
properly to avoid bowel adhesion and stulation
to the mesh. (Fig.10.1).
10.2 Operative Set-Up,
Positioning, andPorts
Placement
The patient is placed in supine position. In majority of cases, pre-operative voiding is all that is
necessary to prevent the bladder from obstructing
G. P. C. Yang (*)
Hong Kong Adventist Hospital,
Happy Valley, Hong Kong
e-mail: george.yang@hkah.org.hk
10
Fig. 10.1 Bowel adhesion to mesh leading to bowel
obstruction after previous laparoscopic groin hernia repair
the operative eld. For those patients with history
of cystitis, outow obstruction like prostatic
hypertrophy, or those with previous pelvic irradiation, foley catheter should be considered to
better empty the bladder to improve operative
eld vision. Also with these patients the surgeon
should keep in mind that there might be bladder
adhesion to the anterior abdominal wall such that
caution should be taken during dissection to
avoid bladder injury.
The monitor screen should be place at the
patient’s foot end, with the surgeon standing on
the contralateral side of the hernia. The assistant
to hold the laparoscope can either stand behind
the surgeon or on the opposite side. The anesthetist should be reminded to position the external
tubing of the laryngeal mask on the angle of the
© Springer Nature India Private Limited 2020
P. Chowbey, D. Lomanto (eds.), Techniques of Abdominal Wall Hernia Repair,
https://doi.org/10.1007/978-81-322-3944-4_10
133
134
G. P. C. Yang
patient’s mouth to avoid collusion between the
tubbing and the cable of the laparoscope.
Under general anesthesia, with the patient
supine and in Trendelenburg position 30° or so,
the rst port is inserted at subumbilicus for diagnostic laparoscopy. Pneumoperitoneum is created with carbon dioxide generally at
12–15mmHg pressure.
The operation can be performed with the three
ports approach or single port approach depending
on the surgeon’s preference. The benet of single
port trans-umbilical approach is only for postoperative cosmetic result. The operative steps and
attentions are exactly the same.
With the three ports approach, one can consider the two different methods (Fig.10.2). On
the right side, the laparoscope is placed through
the mid-clavicular line port allowing the surgeon
to have a better vision on the retropubic space of
retzius. On the left side, the laparoscope is placed
through the subumbilical port with two working
trocars on either side. This allows the surgeon to
perform repair on both sides with these three
ports, but the vision at the retropubic space of
retzius may be obscured by the peritoneum and
the median umbilical ligament. With a 30° laparoscope one may rotate the scope to obtain a better vision.
10.3 TAPP Consist
oftheFollowing
Operative Steps
Diagnostic peritoneal laparoscopy is one of the
main advantages of laparoscopic hernia repair. It
allows the surgeon to correctly identify the site
and number of any hernia in the groin region. It is
not uncommon for a patient especially female to
have additional ipsilateral and/or bilateral groin
hernia apart from the clinically obvious one.
Therefore laparoscopic repair should be offered
for female patients [1]. Figure 10.3 shows an
elderly lady presented with left femoral hernia,
Fig. 10.2 Ports placement for TAPP: Left—camera port
at subumbilical wound with two working ports one on
each side; Right—camera port at mid-clavicular line, one
working port at subumbilical wound and another one lateral to the camera port
10 Transabdominal Pre-peritoneal (TAPP) Repair forGroin Hernias
fold) to avoid injury to this vessel, which can
result with unnecessary bleeding. Some surgeons will create a high ap and some prefer a
low ap. Nonetheless, the peritoneal ap should
be large enough not only to allow proper placement of the synthetic mesh but also to allow
1–2cm gap caudally to avoid exposing the edge
of the mesh after closure of the peritoneal ap.
If the ap is too low with limited pre-peritoneal
space, the surgeon will be forced to shift the
mesh down or crumble up the mesh in order to
accommodate it. This leads to suboptimal mesh
positioning and placement. For high ap the
Fig. 10.3 Left femoral and obturator hernia
incision should start about 5cm below the level
of umbilicus.
During dissection the surgeon should have
clear understanding of the pre-peritoneal anatomy in order to avoid injury to vessels and nerves,
especially the structures that lie in the triangle of
doom and the triangle of pain. Structures including the inferior epigastric vessels and its origin
from the external iliac artery and vein, transverse
vessels over the pubic arch the “corona mortis,”
the genitofemoral nerve and its medial genital
branch, and the lateral femoral cutaneous nerve.
The handling of the spermatic cord and vas deferens require caution to avoid direct trauma to these
structures and their blood supply, in order to pre-
Fig. 10.4 1 indirect inguinal; 2 direct inguinal; 3 femo-
ral; 4 obturator hernias
vent postoperative cord structures related complications like testicular ptosis, testicular atrophy,
dysejaculation, and infertility.
with an additional left obturator hernia.
Laparoscopic preperitoneal mesh placement not
only allows intra-abdominal pressure to spread
out evenly over the mesh, it also allows the mesh
to cover all myopectineal orices where potential
hernia might occur (Fig. 10.4). Currently in both
EHS and Asian hernia guidelines [1, 2], laparoscopic repair is recommended for bilateral inguinal hernia, recurrent inguinal hernia from
previous open anterior repair, and female patients.
The incision of the peritoneum and creation
of the peritoneal ap is the next step. Whether
to start medial or lateral to the medial umbilical
ligament depends on the surgeon’s preference.
With this step, it is vital to rst identify the
inferior epigastric vessels (the lateral umbilical
Mesh placement is one of the vital elements
in determining the success of repair in the long
term. While the debate on mesh xation or not is
forever running, most surgeons agreed that for
high-risk hernia it will be better to x the mesh
[3–7]. These include M1-3 hernia (EHS
Classication) [8], inguinoscrotal hernia, and
sliding hernia. Generally the goals of mesh xation are rst to avoid migration of the mesh, and
secondly to avoid folding up of the mesh. Not
uncommonly we found recurrence after previous laparoscopic repair caused by folding up of
the mesh, either of its inferior medial (Fig.10.5)
or inferior lateral (Fig.10.6) part, which allow
the hernia to recur underneath the mesh. These
areas covered by the mesh also contain vital
135
136
G. P. C. Yang
Fig. 10.7 Dotted line outlines the old mesh
Fig. 10.5 Vascular triangle
Fig. 10.6 Dotted line outlines the old mesh
structure like the iliac vessels and major nerves
(triangle of pain and triangle of doom).
Nonpenetrating type of xation like biocompatible glue or self-gripping mesh may be superior
in these areas to avoid injury to the great vessels
and nerve. Fixing the mesh to the rectus muscle
probably offers no advantages unless in M3 hernia. For bilateral M1-3 hernia, the left and right
meshes should overlap each other in the midline. In male the spermatic cord may also cause
problem by slinging up the medial inferior part
of the mesh, which may allow hernia to slip
through in the future. It is therefore important to
properly lay the mesh down against the psoas
muscle and external iliac vessels. Alternatively
there are meshes available in the market
designed to have a slit open lateral end with
proper overlapping laterally. This allows the
surgeon to place the inferior lateral slip of the
mesh posterior to the spermatic cord to avoid
the mesh being sling up by the cord (Fig.10.7).
After proper placement of the mesh, the peritoneal ap is then closed. It can be closed with
tacker/ staple devise like absorbable tackers or
running suture. It is again important to note the
position of the inferior epigastric vessel in order
to avoid injury. Injuring this vessel at this stage
without being noticed by the surgeon may lead
to signicant bleeding, because the large perperitoneal space can accommodate large volume
of blood. If using tacker/staple to close the peritoneum, it is important to have less than 1cm
gap between each tacker/staple in order to reduce
the chance of bowel herniating into the peritoneal ap. Running suture may be a better alternative [9].
Towards the end of the operation, it is
strongly advised to check the peritoneal flap
for proper closure and for any defect which
may expose the mesh. These defects in the
peritoneal flap should all be closed by suture
under direct vision rather than tackers to avoid
injury to the vessel and nerve behind the flap.
There is no study to show how small a size of
peritoneal defect will not cause problem such
as bowel adhesion or fistulation. In my opinion, if you can see the mesh through the defect
it should be closed. Mesh-related bowel adhesion and fistulation are major morbidities
which are difficult to manage and treat
(Fig.10.1).
10 Transabdominal Pre-peritoneal (TAPP) Repair forGroin Hernias
137
10.4 Indication forTAPP
As with TEP, TAPP should only be consider
when expertise including surgeon and supporting
nursing staffs are available, as well as equipment
and mesh. For bilateral groin hernia, pelvic oor
hernia (Fig.10.8), recurrent hernia after previous
open anterior repair, female patients with groin
hernia, TAPP can be considered as an alternative
to TEP repair. Laparoscopic repair (TEP/TAPP)
should be seriously considered for patients with
pelvic oor hernia because of the risk of bilateral
occurrence and better coverage and positioning
of the mesh.
For complex groin hernia like sliding inguinal
hernia (Fig. 10.9), incompletely reduced groin
hernia, groin hernia with adhesion around the ori- ce, or when difculty arises during TEP repair,
Fig. 10.10 Obturator hernia
TAPP should be the technique of choice. It is
because TAPP allows the surgeon to have better
correlation between the pre-peritoneal and peritoneal condition, such that inadvertent injury can
be avoided to the herniate content (Fig.10.10).
Fig. 10.8 Overlapping mesh
Fig. 10.9 Cord through mesh
10.5 Postoperative Complications
10.5.1 Recurrence
Proper placement of mesh especially its inferior
ap is important to prevent folding up of the
mesh and recurrence. Inadequate lateral coverage of the hernia orice increases the risk of
recurrence because the mesh will shrink by
20–50% over time which may re-expose the hernia orice. Diagnostic laparoscopy is vital to
identify concurrent ipsilateral hernia to prevent
recurrence (Figs.10.11 and 10.12).
10.5.2 Bleeding
Major bleeding usually comes from inferior epigastric vessel or pubic branches veins injury.
Caution during dissection and early identication
of these vessels is the key to prevent injury.
Patients who are on anticoagulation should be
identied pre-operatively and the anticoagulation medication adequately stopped before the
138
Fig. 10.11 Sliding right indirect inguinal hernia
Fig. 10.12 TAPP view allows correlation reference
between pre-peritoneal structures with peritoneal
condition
G. P. C. Yang
10.5.4 Mesh Infection
Wound infection in laparoscopic repair is
extremely rare, so is mesh infection. Prophylactic
intravenous antibiotic is not required from evidence base [1, 2, 11], but nonetheless it is still
commonly given by many surgeons. What is
more important is the handling of the mesh during surgery. The surgeon’s gloves should be
changed when it comes to the placement of the
mesh. The surgeon should employ a non-touch
technique, keeping the mesh in the factory sterile packing if possible, using forceps to grasp
it, removing from the packing, and placing it
through the 10mm trocar.
10.5.5 Postoperative Pain
Postoperative pain should be minimal and mostly
subside completely within 1–2 weeks. Most
patients complain of swollen sensation of the lower
abdominal wall and scrotum, this also should subside completely over 1–2weeks postoperatively.
To minimize the risk of chronic pain, tacker
should be avoided especially inferior to the
pectineal line (Triangle of pain). Alternatively
anatomical mesh, self- adhesive mesh, or nontraumatic xation with glue can be an alternative.
operation. They should be warned of possible
bruising that may track down into the scrotum
after the operation.
10.5.3 Seroma
Most surgeons will agree that seroma is present
in all patients after laparoscopic groin hernia
repair; the size determines its clinical presentation. It is considered as a normal physiological
body response to a dead space which was previously occupied by the hernia. Almost all seromas
will resolve over several months’ time. It is recommended not to aspirate asymptomatic seroma
which may increase the risk of infection [2, 10].
10.6 Special Considerations
10.6.1 Contraindication forTAPP
TAPP requires the patient to undergo general
anesthesia and pneumoperitoneum, so for those
who are not suitable for general anesthesia and
pneumoperitoneum open groin hernia repair
should be considered.
Age itself should not be a contraindication [2],
since even for 90-year-olds, as long as their cardiac function is optimal, laparoscopic groin hernia repair can be performed safely.
Previous abdominal surgery no longer is an
absolute contraindication, because of the advancement in laparoscopic surgical technique and
10 Transabdominal Pre-peritoneal (TAPP) Repair forGroin Hernias
139
improvement in endoscopic vision technology.
More and more laparoscopic surgeries are being
performed for patients who had previous open
abdominal surgery, such as laparoscopic repair of
incisional hernia.
Previous pelvic irradiation may cause problem
because of the induced brosis and adhesion in
the pelvis. One should consider open repair if
there is dense adhesion around the iliac vessel and
myopectineal orices in the pre-peritoneal space.
10.7 Strangulated
andIncarcerated
Groin Hernia
This is no longer a contraindication for laparoscopic repair. However for these conditions the
surgeon should be experienced. Diagnostic laparoscopy should be performed rst to clearly identify the site of strangulation and whether there is
any other concurrent hernia present in the ipsilateral or contralateral side. Having the strangulated
hernia reduced, the surgeon can proceed to laparoscopic repair. Reduction of the strangulated
herniated content should be done very carefully;
our experience showed that external compression
under laparoscopic guidance may be safer than to
rely only on laparoscopic pulling by grasping
instrument, which may cause bowel injury. The
stretching and distension of the abdominal wall
by pneumoperitoneum, together with the external
compression of the herniated content to decrease
its oedema, will allow most of the strangulated
hernia to be reduced. Some author suggested
incising the posterior fascia to release the strangulated content [12]; this should be done by an
expert in this eld with extreme caution.
Compared to open repair for strangulated hernia,
laparoscopic repair results in lower wound infection rate, relatively lower laparotomy, and lower
bowel resection rate. The use of mesh in these
conditions did not show any increase in mesh
infection rate. In open repair for strangulated hernia many surgeons will also choose Lichtenstein
repair [13].
Another frequently asked question for laparoscopic repair in strangulated or incarcerated groin
hernia is shall we perform TAPP or TEP after
reduction of the strangulated content? I would
suggest TEP, because in TAPP, having the dissecting instruments especially endoscopic scissor
goes through the port in and out of peritoneum
many times with distended bowel imposes a
higher risk of injury to the bowel. Incising and
closing the peritoneum in TAPP with the presence of distended bowel also creates additional
risk. So after reduction of the strangulated herniate content, if the surgeon proceeds to TEP repair,
it seems to be safer.
10.8 Conclusion
Laparoscopic groin hernia repair is a technically demanding operation; it requires a thorough understanding of the pre-peritoneal
anatomy. The attitude to the operation, together
with the handling and placement of mesh, plays
a vital role in determining the success of the
surgery. It has great benets in managing recurrent, bilateral, and pelvic oor hernias.
Especially for pelvic oor hernia like femoral
and obturator hernias, the undoubtable superiority of diagnostic laparoscopy plus the accurate placement of mesh in the pre-peritoneal
space to cover all potential hernia orices in the
groin make it the technique of choice. A surgeon should not only acquire one technique,
both TAPP and TEP should be acquired and
under certain situations one should adjust their
approach accordingly.
References
1. Simons MP, Aufenacker, Bay-Nielsen M, Bouillot
JL, Campanelli G, Conze J, Lange D, Fortelny R,
Heikkinen T, Kingsnorth A, Kukleta J, Morales-Conde
S, Nordin P, Schumpelick V, Smedberg S, Smietanski
M, Weber G, Miserez M. European Hernia Society
guidelines on the treatment of inguinal hernia in adult
patients. Hernia. 2009;13:343–403.
2. Lomanto D, Cheah WK, Faylona JM, Huang CS,
Lohsiriwat D, Maleachi A, Yang GPC, Li MKW,
Tumtavitikul S, Sharma A, Hartung RU, Choi YB,
Sutedja B.Inguinal hernia repair: toward asian guidelines. Asian J Endosc Surg. 2015;8:16–23.