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296 VIII Primary Inguinal Hernia
26
13. Bay-Nielsen M, Nordin P, Nilsson E, Kehlet H (2001) Operative
findings in recurrent hernia after a Lichtenstein procedure.
Am J Surg 182: 134–136
14. Johanet H, Cossa JP, Chosidow D, Marmuse JP, Benhamou G
(1999) (Laparoscopic treatment of recurrent inguinal hernia
after only mesh [French]. Ann Chir 53: 29–31
15. Gianetta E, Cuneo S, Vitale B, Camerini G, Marini P, Stella M
(2000) Anterior tension-free repair of recurrent inguinal her-
nia under local anesthesia: a 7-year experience in a teaching
hospital. Ann Surg 231: 132–136
16. Kingsnorth AN (2004) Treating inguinal hernias. BMJ 328:
403–404
17.
Richards SK, Vipond MN, Earnshaw JJ (2004) Review of the
management of recurrent ingunal hernia. Hernia 8: 144–148
18. Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R
Jr., Dunlop D, Gibbs J, et al. (2004) Open mesh versus laparo-
scopic mesh repair of inguinal hernia. New Engl J Med 350:
1819–1827
19. Reid I, Devlin HB (1994) Testicular atrophy as a consequence
of inguinal hernia repair. Br J Surg 81: 91–93
20. Wantz GE (1993) Testicular atrophy and chronic residual
neuralgia as risks of inguinal hernioplasty. Surg Clin N Am
73: 571–581
21. Felix E (1995) Laparoscopic repair of recurrent hernias. Surg
Endosc 9: 135–139
22. Scheurlein H, Schiller A, Schneider C, et al (2003) Totally ex-
traperitineal repair of recurrent inguinal hernia. Surg Endosc
17: 1072–1076
23. Lowham A, Filipi C, Fitzgibbons RJ, et al. (1997) Mechanisms
of hernia recurrence after preperitoneal mesh repair. Ann
Surg 225: 422–431
24. Arregui ME (2005) Groin hernia repair by laparoscopic tech-
niques: current status and controversies. World J Surg 29:
1052–1057
25. Nixon SJ, Kumar S (2005) The totally extraperitoneal ap-
proach (TEP) to inguinal hernia repair. Surgeon 3: 281–287
26. Lau H (2004) Endoscopic totally extraperitoneal inguinal
hernioplasty for recurrence after open repair. ANZ J Surg
74: 877–880
27. National Institute for Clinical Excellence (2001) Technology
Appraisal Guidance No. 18: Guidance on the use of laparo-
scopic surgery for inguinal hernia.
28. Guthy E, Boom H (1983) Multiple recurrences in inguinal
hernia. Langenbecks Arch Surg 361: 316–318
29. Knook MTT, Weidema WF, Stassen LPS, van Steensel CJ (1999)
Endoscopic totally extraperitoneal repair of primary and
recurrent inguinal hernias. Surg Endosc 13: 507–511
30. Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ (2002)
Laparoscopic transperitoneal procedure for routine repair
of groin hernia. Br J Surg 89: 1062–1066
31. Tamme C, Scheidbach H, Hampe C, et al. (2003) Totally extra-
peritoneal endoscopic inguinal hernia repair (TEP). Results
of 5023 hernia repairs. Surg Endosc 70: 190–195
32. Beets GL (1999) Open or laparoscopic repair for recurrent
inguinal hernia. Surg Endosc 13: 323–327
33. Champault GG (1997) Totally preperitoneal laparoscopic
approach versus Stoppa operation: randomized trial of 100
cases. Surg Lap Endosc 7: 445–450
34. Janu PG (1998) Recurrent inguinal hernia; preferred opera-
tive approach. Am Surg 6: 569–573
35. Huang C-S (1999) Surgical treatment of recurrent groin her-
nia. J Formos Med Assoc 98: 122–127
36. Kurzer M, Belsham PA, Kark AE (2002) Prospective study of
open preperitoneal mesh repair for recurrent inguinal hernia.
Br J Surg 89: 90–93
37. Johansson B (1999) Laparoscopic mesh versus open pre-
peritoneal mesh versus conventional technique for inguinal
hernia repair: a randomizes multicenter trial (SCUR Hernia
Repair Study). Ann Surg 230: 225–231
38. Bloor K, Freemantle N, Khadjesari Z, Maynard A (2003) Im-
pact of NICE guidance on laparoscopic surgery for inguinal
hernias: analysis of interrupted time series. BMJ 326: 578
39. Mc Greevy M (1998) Groin hernia and surgical truth. Am J
Surg 176: 301–304
40. Smietanski M, Lukasiewicz J, Bigda J, et al. (2005) Factors
influencing surgeons‘ choice of method for hernia repair
technique. Hernia 9: 42–45
Discussion
Bendavid: This was a very good paper, congratulations.
I should also like to add the agreement of Prof. Nyhus.
Though he prepared the extraperitoneal approach for
many years, it did not in retrospect favourable, and
rightly so because the recurrences went up to 25 and 30%;
but from the day mesh started being used it became an
absolute success story. Certainly, I support what you are
saying. I personally feel that it’s a much simpler operation
than laparoscopic surgery and certainly a lot cheaper,
and I agree with you that it ought to be done far more
often than it is.
Kurzer:
Thank you, Robert. It’s interesting. Obviously the
published series are very few and they have come from
experts and you could criticize this as a procedure that
has efficacy but not effectiveness. I very much like to hear
from laparoscopic TEP surgeons about whether they are
happy just to try it once or even to use it to teach their
trainees, because I think it does have a place, it could
have a place particularly in hospitals, in countries where
laparoscopic equipment is very expensive. And people
can then move on. I haven’t tried this because I am not
a laparoscopic surgeon, but I have done a lot of open pre-
peritoneal repairs and I would like to try a TEP repair to
see what the differences are. There must be people who
have done both. I don’t know whether this room feels that
open preperitoneal repair should be given a chance?
Bendavid:
That’s a very good appeal and I think Dr. Duh
will comment on this. Something I want to include in
my conclusions eventually is: we started with animos-
ity between the laparoscopic and the open surgeons. I
am glad to see that over the years this has disappeared.
Unfortunately, we still see some individual surgeons who
maintain this animosity. The idea is to develop an opera-
297
VIII
How to Treat Recurrent Inguinal Hernia
tion that adapts to the patient and that the patient adapts
to the technique that the surgeon is doing. There is no
doubt that everyone is excellent in his own technique and
that good results can be obtained with every technique.
Duh:
A great, great paper. The comment you asked for
about the laparoscopic perspective: I find that the TEP
repair is a great repair for every kind of hernia. There is
one population that it is probably better for than the open
preperitoneal repair. In the US we have lots of patients
with a huge, huge belly, big BMI. In these patients any
open repair takes so much more work to get to the space.
If you are able to get into the preperitoneal space with
the scalpel, the operation is so much easier.
Kurzer:
Can I ask you, have you done an open preperi-
toneal?
Duh: I have tried a few and found it difficult enough so
that I stuck with laparoscopic repair.
Franz: I have just lived the question you’re asking. I was
trained to do both, the open and the laparoscopic ap-
proach at the same time. Recently I used an open ap-
proach for a difficult patient. I felt, based on what I had
learned and knowing the TEP approach, that it is a fan-
tastic operation in the current situation, it was much
easier for me to perform an open preperitoneal approach
having the better understanding of the anatomy I had
learned laparoscopically.
Kurzer:
Right. I learned my open preperitoneal from
Georg Wanz when I was with him for about 3 days and
he was a great teacher. I think that with all this, in fact
it has been the mood of this meeting: you can’t learn any
of this from both, even Lichtenstein repair. You have just
got to go to someone who does it well. I think these are
the messages that must emerge. Perhaps not from your
boss who doesn’t do it well but from someone who does
do it well. You just have to go and do it and watch it two
or three times.
Bendavid:
I agree that an obese patient is actually a
totally different patient and I can also understand the
hesitation of many people and I have referred them to
laparoscopic surgery as well.
Introduction
Recurrent inguinal hernia after laparoscopic and endo-
scopic hernioplasty is seldom [1, 2]. Therefore, it is not as-
tonishing that although there are some anecdotal reports,
only very few studies involving larger numbers of patients
describing laparoscopic re-intervention ( re-TAPP) due to
recurrent hernia after transabdominal preperitonal patch
plasty (TAPP) are available [3]. Re-TAPP is considered very
difficult because the operating field can contain extensive
scar tissue, depending on the size and type of mesh that
was implanted primarily. Any amount of dissection that
respects the tissue layers is extremely difficult, and the
risk of complications is high. For this reason, it is said that
posterior access should be used for recurrent hernia fol-
lowing anterior repair (e.g. Shouldice or Lichtenstein), and
anterior access should be used following posterior repair
( preperitonal mesh implantation, e.g. TAPP, TEP or Stoppa
procedure). With this rule, scar tissue is circumvented, thus
decreasing the complication rate (haematoma, infection,
spermatic cord injury).
The following study investigated whether recurrent
hernia following TAPP can be treated with the same type of
access (re-TAPP), provided that the surgeon has adequate
experience. Also, the complications that can be expected
and factors influencing the rate of these complications
were analyzed.
Patients and Methods
Between April, 1993 and December, 2005 12,687 lapa-
roscopic hernia repairs were performed in the Marien-
hospital, Stuttgart (
⊡
Table 26.4
). 1577 patients who
presented with recurrent hernia had primary anterior
repair, and 135 patients had preperitoneal mesh repair.
Of the latter group 73 had TAPP repair at our institution
and 62 came from other hospitals.
⊡
Figure 26.2
shows
the change in recurrence rate per year for our patients.
Re-operation for recurrent hernia was performed us-
ing the laparoscopic approach in all 73 patients who
had been treated in our hospital. This provided us with
precise information regarding the cause of recurrence.
Insufficient overlapping of the hernial defect during the
primary operation was the cause in 18 (20.9%) patients,
because initial meshes were too small (8×12 cm). Insuf-
26.3 TAPP
R. B, J. S
298 VIII Primary Inguinal Hernia
26
ficient occlusion of the keyhole mesh was the cause for
recurrence in 16 (18.6%) patients who received meshes
with slit, which were also used in the beginning years.
The most frequent cause of recurrence (39 patients,
45.3%) was mesh dislocation due to either inadequate
fixation or lateral parietalization. The remaining 13
patients have not yet been operated on, so the cause
cannot be determined. Our operative technique is de-
scribed in the book Laparoscopic Hernia Surgery by
Karl LeBlanc [4]. The important features of the opera-
tion are listed below:
1. The peritoneal incision must be performed clearly
above the upper rim of the mesh or region of scar tis-
sue, which is usually easily discernible. Usually, the
dissection is made between the mesh and abdomi-
nal wall, strictly along the anatomical land marks
(rectus muscle, symphysis and Cooper‘s ligament,
transverse fascia).
2. When necessary, the medial umbilical plica is sev-
ered in order to gain access to the symphysis through
a region that is free of scar tissue.
3. The same applies to the epigastric vessels, which
usually cannot be left undamaged when dissection
proceeds strictly along the rectus muscle and trans-
verse fascia.
4. The correct direction of dissection is from normal
tissue to scar tissue.
5. The dissection should proceed from familiar struc-
tures to scar tissue.
6. Thorough haemostasis should always be per-
formed.
7. Usually the mesh is not removed.
8. There is usually no scar tissue in the region of the
hernia, which makes dissection here comparatively
easy.
9. The dissection is usually finished by completely de-
picting the anatomic structures, including the large
blood vessels and psoas muscle, as is also the case
during primary surgery.
10. A second mesh is implanted with sufficient overlap-
ping of the defect.
11. If it is not possible to completely separate the sper-
matic cord from the lateral-caudal region of the
mesh, then a mesh with a slit should be implanted
and the slit should be secured with an adequately
sized mesh using the double-buttress technique.
Results
The results of primary laparoscopic hernioplasty, re-
current hernia repair after anterior access and recur-
rent hernia repair after preperitoneal access are pre-
⊡
Table 26.4. Laparoscopic hernia repair (TAPP)
Patients (n = 10,250) Hernia (n = 12,678)
Unilateral repair
n = 7813 (76.2%)
Primary hernia
n = 10,962 (86.4%)
Bilateral repair
n = 2473 (23.8%)
Recurrent hernia
n = 1725 (13.6%)
0
year
5
4
7
9
1995
1996
1997
1998
1999
2004
2000
2001
2002
2003
percentage
8
6
3
2
1
2005
1994
1993
n=15
n=16
n=7
n=10
n=10
n=7
n=7 n=7
n=2
n=0
n=3 n=3
n=2
causes (73 re-operated):
mesh to small n= 18 (20.9%)
slitted mesh n= 16 (18.6%)
mesh dislocation n =39 (45.3 %)
⊡
Fig. 26.2. Recurrence after TAPP
299
VIII
How to Treat Recurrent Inguinal Hernia
sented in
⊡
Table 26.5
. While the results of the first
two groups differ only slightly, the operating time and
morbidity rate are significantly longer and higher for
the last group. The list of complications is presented
in
⊡
Table 26.6.
⊡
Table 26.7
shows a reduction in complication rate
with increasing experience of the surgeon. The most
important complication was bladder injury in the first
observational period. One of these patients had a re-
current inguinoscrotal hernia due to mesh slit insuf-
ficiency, one had the fourth recurrence after previous
anterior, and posterior repair as well. The first patient
was treated laparoscopically after 5 days, and there were
no further complications. The other two were treated
conservatively. Adhesiolysis caused both cases of bowel
injuries. One patient had the fourth recurrence (three
anterior and one posterior repair) and the other patient
had the eighth recurrence after multiple conventional
and laparoscopic operations. Both patients had exten-
sive abdominal adhesions of small intestine or sigmoid
colon with the inguinal region.
A medial recurrence can be repaired much faster
and without as many complications as a lateral recur-
rence, as can be seen in
⊡
Table 26.8 .
⊡
Table 26.9
shows that there is a certain connec-
tion between the cause of recurrence and complication
rate.
Discussion
Laparoscopic surgery of recurrent hernia following
laparoscopic/endoscopic repair (re-TAPP) is a difficult
operation. Operating time and complication rates are
significantly longer and higher than for both primary
hernia repair and recurrent hernia after anterior repair.
Our experience indicates that the most important com-
⊡
Table 26.5. Laparoscopic hernia repair (TAPP) – results
Primary hernia
(n = 10,962)
Recurrence after
anterior repair (n = 1590)
Recurrence after preperito-
neal mesh repair (n = 135)
Operating time (median) [min] 40 45 75
Morbidity [%] 12.8 13.5 18.1
Re-operation rate [%] 10.3 10.6 12.2
Recurrence rate [%] 10.7 11.0 10.74
Return to work (median) [days] 14 17 17
Age (median) 59 (17–97) 61 (18–92) 59 (29–90)
BMI (median) 25 25 25
⊡
Table 26.6. TAPP after posterior repair – complica-
tions
Total complications
n (%) Therapy
Bladder injury 3 (2.2) 1x lap. rev.,
2x cons. ther.
Bowel injury 2 (1.5) 1x lap. rev.,
1x open rev.
Mesh infection 1 (0.73) Ant. + post.
rev. drain
Orchitis/testicular
atrophy
1 (0.73) Conservative
Urinary retention 1 (0.73) suprapubic cath.
Wound infection 1 (0.73) Conservative
Trocar-site hernia 1 (0.73) Operative
Ileus 1 (0.73) Operative
external hosp.
Total 11 (8.1)
300 VIII Primary Inguinal Hernia
26
plication is bladder injury. Bowel injuries occur only
when extensive adhesions are present between bowel
and inguinal region after multiple previous operations.
Surgery of recurrent direct inguinal hernia is easier than
for recurrent indirect hernia. A correlation between the
type and size of mesh that was implanted during the
first operation and the amount of scar tissue could be
seen in isolated cases. Scarring was less pronounced for
smaller, lighter meshes than it was for heavier meshes,
which were used in the early phase. Noteworthy is that
despite all of these difficulties, only one patient had
testicular atrophy. The results are clearly dependent
⊡
Table 26.9. TAPP after preperitoneal mesh repair
Slit insufficiency n = 16 Mesh dislocation n = 62
Operating time (median) [min] 98.5 89.5
Morbidity [%] 16.25 11.2
Re-operation rate [%] – 13.2
Recurrence rate [%] – 11.6
Return to work (median) [days] 14.0 19.0
Hospital stay 17.0 16.0
⊡
Table 26.7. TAPP after preperitoneal mesh repair. Results (n = 135), “learning curve”
n (Prof.) 1–45 (1–20)
(6/1993–12/1998
46–90 (21–40)
(12/1998–02/2002)
91–135 (41–56)
(02/2002/–11/2005)
Operating time (median) [min] (Prof.) 82.5 (87.5) 71.0 (85) 77.0 (57.5)
Morbidity [%] 14.0 18.0 12.0
Re-operation rate [%] 12.2 12.2 12.2
Recurrence rate [%] – – 12.2
Return to work (median) [days] 18.0 17.0 17.0
⊡
Table 26.8. TAPP after preperitoneal mesh repair
Medial (direct) n = 57 Lateral (indirect) n = 78
Operating time (median) [min] 60.0 92.5
Morbidity [%] 15.2 10.2
Re-operation rate [%] – 12.6
Recurrence rate [%] – 11.3
Return to work (median) [days] 16.0 17.0
301
VIII
How to Treat Recurrent Inguinal Hernia
on the experience of the surgeon. With adequate sur-
gical experience, the complication rate is not higher
than for primary operation. Since the re-recurrence
rate and length of time off work does not differ signifi-
cantly from primary hernia surgery, the indication for
at least diagnostic laparoscopy is justifiable. There is
no question that conversion is necessary when serious
difficulties arise or when conditions in the operating
field are too complex.
Conclusions
The recurrence rate following laparoscopic hernia re-
pair is low. The classic approach for repair is an ante-
rior reparation. Re-TAPP is difficult and technically
demanding. The morbidity rate is dependent on the
experience of the surgeon and the location of the defect
as well. Furthermore, the morbidity rate appears to be
dependent on the type and size of mesh and individual
scar tissue formation. In experienced hands, re-TAPP
can be performed with the same effectiveness and ef-
ficiency as primary repair.
References
1. Bittner R, Schmedt CG, Schwarz J, et al. Laparoscopic trans-
peritoneal procedure for routine repair of groin hernia. Br J
Surg 2002; 89: 1062–1066
2. Schmedt CG, Sauerland S, Bittner R. Comparison of endo-
scopic procedures vs Lichtenstein and other open mesh
techniques for inguinal hernia repair. A meta-analysis of ran-
domized controlled trials. Surg Endosc 2005; 19: 188–199
3. Leibl BJ, Schmedt CG, Kraft K, et al. Recurrence after endo-
scopic transperitoneal hernia repair (TAPP): causes, repara-
tive techniques, and results of the reoperation. J Am Coll
Surg 2000; 190: 651–655
4. Bittner R, Schmedt CG, Leibl BJ. Transabdominal pre-peri-
toneal approach. In: LeBlanc K (ed) Laparoscopic hernia
surgery – an operative guide. Arnold, London, 2003
Discussion
Duh:
You obviously have fantastic experience in laparo-
scopic repair. I just have a comment and I want to ask you
your opinion about this. I have done about 20 re-TAPPs,
but I have done them differently from what you recom-
mended here, because always almost the mesh migrated
towards the head, and the defect is frequently lateral and
inferior. So I just cut only the inferior border of the previ-
ous mesh and I find it easy to leave the other mesh, not
even to dissect it. What do you think of that technique?
Bittner:
I am sorry that I didn’t comment on this during
your talk. We discussed it with Kukleta. The problem is, as
demonstrated in your video, that you didn’t do lateral pari-
etalization. So far, it must come to a recurrence. And your
question is the right answer. In our opinion, it is not neces-
sary to make a slit; moreover it is better to do no slit.
Introduction
There has never been a shortage either of technical cre-
ativity or of methodology for treating inguinal hernia. In
De Medicina, Cornelius Celsus (circa 25 B.C. to A.D. 50) [1]
described his approach to this condition (bubonocele).
Even before that, the mummy of Pharaoh Merneptah
(1224–1214 BC) showed evidence of a wound in the groin,
with the scrotum separated from the body, indicating that
surgery may have been performed [2]. Since Bassini’s pro-
cedure was developed, more than 70 techniques have
been described [3]. Among them is the preperitoneal
approach described by Stoppa [4]. It provides direct ac-
cess to the entire myopectineal orifice of Fruchaud, and
reinforces the transversalis fascia through the placement
of a large mesh. Over the past 15 years, meanwhile, the
laparoscopic management of inguinal hernia has evolved
from a simple plug and patch to the transabdominal pre-
peritoneal repair (TAPP) and the totally extraperitoneal
approach ( TEP) [5–7], which essentially reproduces the
Stoppa repair. Results of the TEP have been quite satisfac-
tory, and it is often recommended for bilateral and recur-
rent inguinal hernias (8). However, recurrences after TEP
are inevitable [3, 6, 9–12], with treatment for them being
either the open standard approach, a TAPP, or another
TEP. This report describes the management of these re-
currences and our 10 years of experience with TEP after a
first TEP.
26.4 TEP
G.S. F, G. E A-K
302 VIII Primary Inguinal Hernia
26
Methods
The approach to TEP after TEP does not vary from the
standard TEP repair [7, 13]. The patient is placed in a
supine, slightly flexed position, with arms tucked in.
A slight Trendelenburg position is helpful. A general
endotracheal anaesthesia is used, and the video moni-
tor is positioned at the patient’s feet. A small incision
is made in the inferior aspect of the umbilicus at the
site of the old scar. Dissection is continued down to
the rectus fascia, which is incised horizontally over ei-
ther the left or the rectus muscle. The rectus muscle
is bluntly separated from the midline linea alba, and
blunt and sharp dissection is done medial to the rectus
muscle in the direction of the pubic symphysis on the
midline. Further blunt finger dissection is performed
extraperitoneally on the midline toward the pubic sym-
physis, and must not be forced. (Blunt finger dissection
across the midline would not be feasible.)
This process allows the placement of a 10-mm blunt-
tip trocar, which is secured in place. CO
2
insuflation
tubing is attached to the cannula, with a pressure of
10 mm of mercury being maintained. A 10-mm 30o
operative scope is introduced in the trocar. It is impor-
tant to stay in the midline parallel to the rectus muscle
and as anterior as possible, in order to avoid bleed-
ing or peritoneal tearing. Rectus muscle fibers will be
visible. The thin, translucent, filmy fascial layer that
represents the posterior lamina or the inner portion
of the transversalis will be absent. The scope is gently
advanced on the midline, tangential and parallel to the
rectus. It is best to choose the least resistant pathway
toward the bone (the pubic symphysis on the midline).
This process is carried out above, meaning anterior, to
the old mesh.
In some cases, the CO
2
insufflation pressure must
be increased to 12 or 15 in order to increase the volume
of working space, which is small at best. As soon as there
is room enough to make it possible, an additional 5-mm
trocar is introduced at the old infraumbilical trocar site.
Once the space is further developed, a second 5-mm
trocar is introduced, also on the midline (
⊡
Fig. 26.3).
Adhesions are taken sharply without cautery. Small
branches of the epigastric vessels are divided. Excellent
hemostasis should be maintained, and the epigastric
vessels ligated to avoid bleeding and to provide a slightly
larger working area. If possible, Bogros’s space should
be accessed first, rather than the midline. It is important
to remember that if there is a hernia, there will be no
adhesions around it. Therefore, if the midline is much
scarred, there is no direct hernia.
The usual anatomical landmarks present in a pri-
mary TEP (midline pubic symphysis, Cooper’s liga-
ment, Hesselbach’s triangle, and the transverse abdomi-
nis muscle) will not be visible. What can be seen are
the epigastric vessels. These will lead to the hernia,
either medially (direct) or laterally (indirect). The as-
sistant should reach across to the scrotum and pull on
the cord structures. This helps the surgeon recognize
where these structures are. Everything is to be fibrosed
and sclerosed. Applying pressure from the outside at
the level of the anterosuperior iliac spine or on the cord
structures will help with orientation. At any point when
the surgeon feels that a bladder injury might have oc-
⊡
Fig. 26.3. Trocar placement
303
VIII
How to Treat Recurrent Inguinal Hernia
curred, a Foley catheter should be inserted. The bag will
be automatically distended with CO
2
. The surgeon may
also choose to administer methylene blue for further
identification of possible urine leakage, and a close suc-
tion drain should be left in the preperitoneal space. If
bowel injury is identified at any time during this dis-
section, conversion is mandatory.
Contrary to what is expected during a primary TEP,
the contralateral space will not open up. Likewise, the
Retzius space will not open, which leaves the working
area extremely small. There are several cardinal rules
that serve as guides during primary TEP, such as: in-
ability to see the Cooper femoral canal indicates a direct
hernia, and inability to see the vas deferens indicates
an indirect hernia. Neither of these is applicable in the
TEP after a TEP. Also, if a peritoneal tear occurs and
pneumoperitoneum follows, it should not be vented.
In cases where the working space cannot be main-
tained, conversion is advisable. After the Retzius
space is developed in primary TEP, the weight of the
bladder keeps it open despite a pneumoperitoneum;
but in TEP after TEP this is simply not the case. It is
always advisable to scan the cord for the possibility
of a lipoma. For an indirect hernia, dissection of the
cord structures is done in a direction perpendicular
to these structures, sweeping them gently, medially
and posteriorly, while holding the sac with the other
grasper laterally and superiorly (
⊡
Fig. 26.4). An alter-
native procedure is to pivot the hernia sac medially and
posteriorly, dissecting the cord structures in a perpen-
dicular fashion while sweeping in a lateral and posterior
direction (
⊡
Fig. 26.5). An advantage of this approach
is easy identification of a cord lipoma and the margins
of the indirect sac, as well as avoidance of injury to the
vascular structures.
The surgeon can also alternate dissection between
the medial and lateral approaches. A window is thus
created between the cord structures and the sac. The
latter is either totally invaginated and reduced or else
transsected, leaving the distal end in situ and closing the
proximal end, after ensuring that the contents are not
injured. The cord structures must be totally parietalized
with the posterior wall, so that no element crosses the
preperitoneal prevesical space. In a direct hernia, the
contents are always freed with gentle traction and coun-
ter traction, a process rarely requiring sharp dissection.
A rolled edge or fold nicely demarcates the separation
between the redundant thickened transversalis and the
peritoneal sac (
⊡
Fig. 26.6
). Dissection continues along
this fold, reducing the entire contents of the defect. The
margins of the direct hernia defect should be cleansed
of all tissue.
⊡
Fig. 26.4. Indirect hernia dissection
⊡
Fig. 26.5. Lipoma of the cord
⊡
Fig. 26.6. Direct hernia dissection
304 VIII Primary Inguinal Hernia
26
Polypropylene mesh was used in all our patients.
A Jackson Pratt drain was left in one, and he also re-
quired a Foley catheter. Small peritoneal tears occurred
in seven cases. In one patient, pneumoperitoneum man-
dated conversion to an open Lichtenstein repair, while
in another case bleeding obscured the field, mandating
a conversion.
Results
From September 1991 to September 2005 we repaired
1526 inguinal hernias in 1156 male patients, using a
totally extraperitoneal TEP approach, with 786 of them
being unilateral and 370 bilateral. Of these, 141 patients
were operated on for recurrence (12.2%), including 21
after a previous TEP. In our early experience we ap-
proached recurrence via the conventional anterior
method, but after 1995 as we gained experience with the
procedure, we began to perform TEP after TEP repair.
Of the 21 TEP repairs after a primary TEP approach,
18 were indirect hernias and three direct. All patients
were male. The mean operative time was 47 minutes
(31 to 120). The mean age was 52 (29 to 79). We also
operated on 22 patients who presented with primary
hernias contralateral to a TEP repair done between 13
months and 12 years before. The mean operative time
was 36 min (20 to 100). The mean age was 56 (35 to 84).
In three patients with TEP after TEP, the space could
not be opened and the cases were converted to an open
preperitoneal Lichtenstein repair. Seven patients had
peritoneal tears, with one of them obliterating the space
and requiring conversion to the open Lichtenstein [13].
The epigastric vessels were ligated in seven patients,
and one had excessive bleeding in the field, leading to
conversion. There were no complications, no bladder or
bowel injuries, and no fatalities. In one patient a Jackson
Pratt drain was left owing to the possibility of a bladder
injury (though none was found). No patient required
transfusion or developed a preperitoneal haematoma,
and all were discharged on the day of surgery.
Discussion
Re-operation by the inguinal approach is the method
of choice for recurrence after an open preperitoneal
Stoppa repair [15, 16]. Thus it would be intuitive that
a recurrence after TEP be repaired by an open tension
free Lichtenstein repair [17]. While this method is fol-
lowed by most surgeons, reports concerning use of the
TAPP for these recurrences are frequently found in the
literature (
⊡
Table 26.10
) [10, 18–23]. Leibl et al. [18]
and Felix et al. [19] concluded that endoscopic re-re-
pair is only possible by the transperitoneal approach.
In 2003, Tamme et al. [20] reported on 29 recurrences
following 5023 TEP procedures, with 18 treated by open
repair, three by TAPP, two by TEP, and six being done
at another institution.
There is no question that re-entry into the preperito-
neal space is challenging. Wide cleavage and dissection
of the Retzius space may be particularly difficult, so
much so that in three of our patients the space could not
be opened at all. In addition, mesh placement behind
⊡
Tab le 26 .10. Repair of recurrence after endoscopic hernia repair
Study Recurrent hernias after
endoscopic repair
TEP original operation Repair
Felix 1998 [19] 34 11 TAPP 29, Open 4
Knook 1999 [21] 34 19 TAPP
Leibl 2000 [18] 46 10 TAPP
Chowbey 2003 [23] 16 16 TAPP 4
Tamme 2003 [20] 23 23 TEP 2, TAPP 3, Open 18
Richards 2004 [22] 18 10 TEP 1, Open 7
Ferzli 2004 [10] 12 12 TEP
305
VIII
How to Treat Recurrent Inguinal Hernia
the transversalis fascia in the preperitoneal space has
led to growing concern among urologists and vascular
surgeons. This centres on the extreme risk and diffi-
culty, if not impossibility, of performing urological and
vascular operations, in particular radical prostatectomy
and lymph node dissection, subsequent to open and
laparoscopic preperitoneal hernia repair [3, 24–26].
Recently, however, Stolzenburg et al. [27, 28] re-
ported on 750 patients who underwent endoscopic
extraperitoneal radical prostatectomies (EERPE). Of
these, 14 had had previous laparoscopic hernia repair
with mesh placement, eight had had prior TEP (two bi-
lateral), and six had had prior TAPP. In one of the cases
with prior bilateral TEP, the space could not be created
and the procedure was performed by a transperitoneal
approach. Their conclusion was that previous mini-
mally invasive hernia repair with mesh placement made
EERPE more demanding, but was not a contraindica-
tion. In a different study, Patterson et al. [29] discussed
the problem of re-entering the preperitoneal space after
prior lower abdominal surgery. They found that TEP
could indeed be carried out safely in the presence of
scars from such procedures, including lower midline
suprapubic and paramedian incisions.
At this institution, our experience with TEP repair
after a primary TEP has been documented in the Re-
sults section. In addition to the 21 successful procedures
noted, we were also able to operate on 22 patients who
presented with primary hernias contralateral to a TEP.
The incidence of peritoneal defects associated with
TEP depends on the presence of adhesions and prior
scarring [11]. These defects are reportedly as high as
46% in this group [30]. In our series, seven patients
(33%) developed peritoneal tears. During primary TEP,
pneumoperitoneum should not lead to conversion, nor
does it occlude the working space. However, in TEP
after TEP, the occurrence of peritoneal tears may lead
to conversion, as happened in one of our patients owing
to loss of the working space. Venting the pneumoperi-
toneum transperitoneally is not helpful. As previously
noted, in primary TEP the weight of the bladder will
keep the Retzius space open, maintaining a working
space despite a full pneumoperitoneum. This is not the
case in TEP after TEP.
Arregui [6] concluded that the overall complication
rate for laparoscopic repair is the same as for the open
procedure, with the potential for serious injury being
higher in laparoscopy. There were no complications in
our series, but in one patient the possibility of a bladder
injury led to the placement of a Jackson Pratt drain,
the injection of methylene blue, and the use of a Foley
catheter. There was in fact no demonstrable injury. In
another study, Stolzenburg [27] reported two bladder
injuries in 14 patients who underwent EERPE after pre-
vious laparoscopic hernia repair. None of those in our
series required transfusion, nor was there any haema-
toma formation, but we found it essential to maintain
proper haemostasis during the entire procedure because
the presence of minute bleeding can obscure the clarity
of vision. This results in difficult identification of the
anatomy and possible conversion, as occurred in one
of our cases. That brought the total conversion rate in
our series to five out of 21 patients (24%).
TEP has a prolonged learning curve for the gen-
eral surgeon [31, 32], with some stating that it is in
the range of 30 to 50 procedures [9]. The cooperative
Veteran Affairs study [33] suggests that the number is
much higher. Indeed, the recurrence rate associated
with laparoscopic repair was greater than 10% for the 58
surgeons who had performed 250 or fewer such repairs
in any category. Recurrence was less than 5% for the 20
surgeons who reported having performed more than
250 laparoscopic repairs. The causes of recurrence have
been clearly identified as missed hernia, missed lipoma,
migration of the mesh, slit in the mesh, and one poorly
shaped or too small [6, 23, 34, 35]. In our series, 18
patients had an indirect hernia resulting from missed
hernias and migration of the mesh (especially in recur-
rent large scrotal hernias). The three direct hernias also
resulted from displacement of the mesh.
Arregui [6] was quite correct in stating that it is im-
perative to remove all excess preperitoneal fat and cord
lipoma, to reduce the sac, and to identify the anatomical
structure properly prior to mesh placement. The size of
mesh used in TEP after TEP is certainly much smaller
than in primary TEP, yet it must be as large as the work-
ing space. It should be fluffy and fairly redundant, be-
cause of the shrinking process over time [3].
Conclusions
The key to successful hernia repair is mastery of the
anatomy. It is easy for urologists to learn endoscopic
extraperitoneal pelvic lymph node dissection, because
they are familiar with the anatomy and have only to
learn the technique. The same applies to general sur-
geons learning laparoscopic cholecystectomy. They
are familiar with the terrain, and need only learn the
method. TEP has a very prolonged learning curve for
general surgeons because they have to learn the anat-
omy as well as the procedure, both at the same time.
It has been recommended that they perform ten open
Stoppa repairs before undertaking TEP [36]. In fine,
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