What New Procedures For Hernia Repair

Open access peer-reviewed chapter

New Laparoscopic Surgery in Inguinal Hernia Repair

Submitted: May 3rd, 2019 Reviewed: August 6th, 2019 Published: September 12th, 2019

DOI: 10.5772/intechopen.89028

Abstruse

Laparoscopic inguinal herniorrhaphy has become widely accustomed every bit an effective alternative to the treatment of hernias with the anterior arroyo. It has success rates identical to those of the conventional method and quickens recovery by decreasing time until return to work or physical activities. With the introduction of single incision laparoscopic surgery (SILS), there has been an exponential increase in the number of SILS hernia repair. Information technology probably represents the single almost exciting innovation in laparoscopic surgery of the final 2 decades. The main premise of SILS is the use of completely blunt ports, which will negate the risks of bowel and vascular injuries, less wound, less postoperative pain, cosmetically more than favorable and lower the recurrent rate.

Keywords

inguinal hernia
laparoscopic
TAPP
TEP
SILS

Reno Rudiman
- Director of Digestive Surgery Department, Padjadjaran University, Indonesia
Andika August Winata*
- General Surgeon in Eka Hospital BSD, Indonesia

*Address all correspondence to: andhika.august@gmail.com

1. Introduction

Surgery to treat diverse diseases has been recorded back to middle ages. For two centuries, large incisions were necessary to perform abdominal surgical procedures. Although effective, several known morbidities were related to this method, including postoperative hurting, wound infection, incisional hernia, and prolonged hospitalization [1]. The nowadays surgical site infection charge per unit is fifteen–25%, depending on the level of contamination [2].

Laparoscopic surgery was introduced in 1983 by Lukichev and 1985 past Muhe who performed laparoscopic cholecystectomy. Their cumbersome techniques did not receive the attention they probably deserved. Interests were started to abound after Mouret in 1987 reported the start acknowledged laparoscopic cholecystectomy by means of four trocars [3]. Since and then, operative laparoscopy has advanced progressively. Several operative procedures take been performed by this new approach. Due to its minimal invasiveness to abdominal wall, laparoscopic surgery is also called minimally invasive surgery. Laparoscopic procedures tin can be performed using modest incisions of effectually 0.v–1.five cm that can be made far away from the surgical site [iv].

I of the main advantages of laparoscopic surgery over traditional open surgery is it often requires a shorter hospital stay than traditional open up surgery. Procedure such every bit appendectomy or cholecystectomy is ordinarily stay at the hospital for but ane night after surgery. This is due to patients are experiencing less pain and bleeding after surgery [5].

Another of import advantage of laparoscopic surgery is that as the incision wound is and so much smaller than open surgery, post-surgical scarring is significantly reduced. Cosmetically, it is more desirable to well-nigh patients. Risks of keloid forming are therefore significantly reduced as well [vi].

In conventional laparoscopic surgery, three to iv small incisions are made. In a more than complex procedure such as big bowel resection or bariatric (obesity) surgery, upwardly to half dozen incisions can be made, allowing more instruments to exist used to aid organ resection [4, 7, 8, 9]. Apparently, the more wounds are made, the more hurting it will eventually be caused to the patients. On the contrary, less wound signifies less pain. This brings almost the concept of unmarried incision laparoscopic surgery [10, 11].

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2. Laparoscopic hernia repair

Transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair are the well-nigh common laparoscopic inguinal hernia repair techniques, since the early of 1990s [half-dozen]. In TAPP, the peritoneal cavity is explored by the surgeon and then a mesh is placed through a peritoneal incision over possible hernia sites. TEP is unlike as the peritoneal crenel is non penetrated and mesh is employed to seal the hernia from outside of the peritoneum [8]. Both techniques endeavour to diminish the hernia and hernia sac within the abdomen and then place a 10 × fifteen cm mesh just deep to the abdominal wall [12].

The more superior surgical approach and technique for inguinal hernia repair is nevertheless widely argued. TAPP laparoscopic inguinal hernia repair improved clinical consequence and associated with a better quality of patient's life in numerous written report [13]. The advantages of this arroyo are adequacy to audit intestinal crenel, excellent exposure and enabling bilateral repair if necessary. The disadvantages are the possibility of intraperitoneal structures injury, adhesion formation and possibility of belatedly bowel obstruction [14] (Figures 1 and 2).

Figure 1.

Positioning the mesh in inguinal area.

Peritoneal integrity preservation is the chief reason for TEP laparoscopic inguinal hernia repair is preferred to the TAPP repair. Still, the peculiarity of beefcake and working area restriction in general made information technology to be more hard [fifteen]. In TEP, the surgeon is able to create a space only deep to the abdominal muscles without entering the peritoneal cavity and minimizing adhesion formation [fourteen, xvi].

It has been more than 20 years since TAPP and TEP were introduced to clinical routine [17]. TEP is considered to be more difficult than TAPP but may accept fewer complications [8].

Rhambia et al. in 2016 also conducted a comparative study betwixt these techniques; they establish that in that location is no pregnant difference betwixt them in the variable of duration of surgery, serious adverse outcome, persisting postal service-operative pain, hematoma, seroma, persisting numbness, hernia recurrence, port site of hernia and length of infirmary stay. TEP gave the patients less pain after 24 hours of surgery in this research [18].

Former research past McCormack revealed that TAPP has slightly increased the number of hernias developing close by and injuries to internal organs. TEP has been associated with more conversions to another type of surgery. These are widely consistent results. Comparing these 2 techniques, the number of vascular injuries and deep and mesh infections is infrequent and there were no overt difference [eight].

Apart from that, bold a comparable patient grouping, identical indication and adequately experienced surgeons, similar results can be achieved with the TEP and TAPP technique. That is borne out by the comparable reoperation rate for postoperative complications [17].

ii.1 SILS in hernia repair

An effective alternative to care for hernias is SILS that was introduced in 2007 later a port by Covidien was released. It is at present probably represents the single most exciting innovation in laparoscopic surgery of the last 2 decades [nineteen]. In hernia repair, SILS also accommodates TAPP or TEP to repair the defect. Early outcomes of this novel technique testify information technology to exist viable, safe and with potentially better cosmetic outcome [20].

With this technique, the surgeon operates exclusively through a unmarried entry point, typically at the patient's omphalus. Dissimilar a traditional multi-port laparoscopic approach, SILS leaves simply a single minor scar [10, 21, 22]. During the introduction years on SILS in 1997, enthusiasm was limited because of lack of technical support and poor equipment [3]. In 2005, Hirano et al. reintroduced the technique with some advancements compared to previous technique. Since then, the applied science was progressing steadily. Among advancements created were articulating instruments, laparoscope adjustments, several trocars next into each other through a single incision [23].

SILS is gaining popularity due to its advantages in minimizing the invasiveness of surgical incisions. With the reduced number of incisions, the associated possible wound morbidities volition also exist reduced. This includes the reduced risks of wound infection, pain, bleeding, organ injury, and port site hernia [24]. In addition, one of import feature of SILS is since the wound is at umbilicus, it leaves a single modest scar that is well-hidden, it is well-nigh unseen when the wound is healed, thereby it is almost "scarless" [10, 21, 25, 26].

In general, SILS techniques take almost the same amount of fourth dimension to exercise as traditional laparoscopic surgeries. However, SILS is recognized every bit to be a more complicated process because it involves manipulating three articulating instruments through i admission port [22, 27, 28]. SILS performed with a similar technique to the conventional laparoscopic through a single umbilical port. The SILS-Port was introduced through a single 2.0–iii.0 cm transverse transumbilical skin and facial incision. After creation of pneumoperitoneum at pressure level of 12 mmHg, ii v-mm working ports and a x-mm photographic camera port was inserted. The peritoneal flap was prepared. A mesh was placed, and the peritoneum was closed with standard laparoscopic instruments or tackers. After releasing the pneumoperitoneum, the umbilical fascia was routinely closed with polypropylene loop suture and the skin was sutured with 4-0 absorbable intradermic sutures [29].

From fiscal point of view, the apply of a single-port device and the increased skills needed to perform, SILS is slightly more than costly to conventional multi-port laparoscopic surgery [25, 26, 27]. By and large, the length of stay in the hospital is shorter and the demand of medical aid is bottom than traditional laparoscopic surgeries [30].

Although SILS offers benefits for patients undergoing abdominal surgery, not everyone is an applicant for the procedure. Obesity, severe adhesions, or scarring from previous surgeries are a few of the factors that would prohibit patients from getting the surgery [26]. Nonetheless, new technologies are evolving continuously [27].

2.1.one SILS versus conventional laparoscopic hernia repair

A concordant development and improvement of the laparoscopic method has occurred when the advantages of minimally invasive surgical techniques are continuing to be divers. The less scar initiative has driven to a reduction in the number of port sites. Consequently, SILS is more popular and widely being used. As the findings show, repair of intestinal wall defects, specifically inguinal hernias, is feasible via SILS besides [31].

In that location are many studies comparing these two methods now. In Rajapandian et al. study, they assess the potential benefits of SILS without using specialized ports or instruments and compare the same with the conventional laparoscopic surgery in terms of operative time, post-operative pain, complications, cost and scars. They institute that the mean duration of surgery was significantly longer in SILS for unilateral every bit well as bilateral hernia repair than its conventional counterpart. While the mean claret loss was comparable in either groups, various complications like vascular injury, peritoneal tear, cord and nerve injuries had not significant differences. In SILS, two patients were converted to conventional laparoscopy, but without any open conversion [26].

Ece et al. did a inquiry from 148 patients, 88 underwent conventional laparoscopic repair and lx underwent SILS repair. All SILS procedures were completed successfully without conversion conventional laparoscopic or open repair, and no additional port was required in both groups. At that place were no differences in operative time, length of hospital stay and VAS scores of patients 24 hours afterward the operation. No intraoperative major complications were observed such as vessel, intestine, or bladder injury. One patient in each group had a complaint of hurting for longer than 3 months. Brusque-term complexity rates were similar in each group. Several small seroma and hematomas were reported in both groups, and all of them were resolved with conservative treatment. As well, iii patients treated with oral antibiotics for port site infection. Long-term complications such as mesh infection and recurrence were non detected in both the groups. Three patients in the SILS-TAPP group experienced port site hernia. All of the port site hernias were confirmed by ultrasound, and elective mesh hernioplasty was performed [29].

Another research by Buckley in 2014 described a slightly different outcome. SILS for unilateral cases was significantly shorter statistically than for conventional 1. For bilateral cases, the average operative times for both were similar. No conversions from SILS to conventional laparoscopic were performed. There were five conversions from SILS (3.88%) and iii conversions from other group (3.95%) to open Kugel or Lichtenstein repairs, but the deviation was not significant statistically. The recurrence charge per unit during one-half year flow follow upward was ii.3% (3 of 129) for SILS and i.4% (i of 76) for conventional one. The chronic pain rate was four.7% for SILS and v.2% for other grouping. Both groups reported only one wound infection. Incisional hernia was rare (only one) in the SILS arm of the report, which occurred at the site of an umbilical hernia. At that place was no widely divergence between the two cohorts in complication rate [31].

A systematic review by Sajid et al. analyzed from fifteen comparative studies on 1651 patients evaluating the surgical outcomes of inguinal hernia repair using SILS versus conventional laparoscopic techniques. Recovery fourth dimension after the surgery was significantly more rapid in SILS compared to the other process. Nonetheless, from the perspective of length of hospital stay, operative time both for unilateral and bilateral hernias, post-operative pain score, one-week pain score, hernia recurrence conversion and post-operative complications between 2 approaches showed an equality. The sub-grouping analysis of four included randomized, controlled trials showed similarities between outcomes post-obit SILS and conventional laparoscopic procedure except slightly higher postoperative pain score in conventional group [27].

SILS inguinal hernia repair offers better cosmetic results with slightly longer operative time compared to conventional laparoscopic inguinal hernia repair. Notwithstanding, this approach is technically demanding and should be reserved for experienced unmarried incision hernia surgeons [32]. The invention of new surgical tools volition hopefully overcome the current obstacles in SILS in the future [27].

iii. Complication of laparoscopic hernia repair

Fifty-fifty the complications in endoscopic inguinal hernia surgery are more dangerous and more frequent compared to those in open surgery; they could be avoided especially in experienced hands [33]. The complication charge per unit for laparoscopic repair of inguinal hernia ranges from less than iii% to as high as 20% [34].

Complications and the diverse precautions to exist taken in hernia surgery can exist divided into:

Preoperative
Intraoperative
Postoperative

3.one Preoperative precautions

Patient with large hernias, obese patients and irreducible, obstructed hernias are best avoided. Strangulated hernia is an absolute contraindication. Elderly patients require a detailed work-up to assess cardiorespiratory status to ensure a safe outcome.

3.2 Intraoperative complication

3.ii.i Vascular injury

The iliac vessels, inferior epigastric vessels, spermatic vessels, muscular branches, vessels over the pubic arch (including corona mortis vein) or other vessels in the region are susceptible to injury [33].

three.ii.2 Visceral injury

The well-nigh common injury occurs is bladder injury. Elimination the float prior to an inguinal hernia repair is a must to prevent a trocar injury. It is desirable to catheterize the bladder. When urine is seen in the extraperitoneal space then the diagnosis of this float injury is evident. Repair with vicryl in two layers and insert a urinary catheter for 7–10 days are recommended [33].

Bowel injuries take identify when trocar insertion or while dissecting hernia or utilizing an electrodiathermy. The incidence of bowel injuries is greatly reduced, but sadly not completely eliminated [35].

3.2.three Pneumoperitoneum

It is a common occurrence in TEP. The patient is placed in Trendelenburg position and escalating the insufflation pressures to 15 mmHg helps. Insertion of a Veress needle at Palmer's point can be used if the problem withal persists [33].

three.2.iv Nerve injuries

In that location are several fretfulness, viz., ilioinguinal nerve, iliohypogastric nerve, genito-femoral nerve with its medial and lateral branches (external spermatic nerve and lumboinguinal nerve) which are coursing in the myopectineal orifice of Fruchaud. These are prone to injury especially when a lateral dissection or mesh fixation is being performed. Patient might be suffering from a long-term hurting and discomfort [36].

3.2.5 Injury to cord structures

The cord structures might be harmed while dissecting the hernial sac from it. It leads to an eventual fibrotic narrowing of the vas. In a immature patient, a complete transection of the vas needs to be done. Finding the vas before releasing any construction near the deep ring or flooring of the extraperitoneal infinite can help to avoid this injury. It should be done gentle and direct and not grasping vas deferens with forceps [33].

3.two.6 Bowel obstacle

A water-tight peritoneal closure should reduce the hazard of postoperative intestinal obstruction. Laparoscopy is the process of option to diagnose and treat this complication [37].

A risk reduction strategy is required to better the clinical outcome and this must be adopted during the following surgical steps:

Placement of the trocar and working port

Identify and repair a pneumoperitoneum as a outcome of reckless insertion of the kickoff trocar. If there any previous surgical scarring, a surgeon must be more than attentive and alert in placing the trocar [33, 38].

The underlying intraperitoneal organs like bowel and bladder should not be damaged in trocar insertion procedure. In midline area, beware of the inferior epigastric vessels which crusade copious haemorrhage. A laparotomy conversion might be considered if whatever visceral injury is found [39].
Autopsy of the hernial sac

Identifying the right anatomical landmarks is the side by side most decisive stride, which is difficult for beginners. The get-go point is to recognize the pubic bone. Afterward this, the rest of the landmarks can be discovered by putting this as reference point. Continue abroad the triangle of doom, which contains the iliac vessels and do non place tacks in the triangle of hurting laterally [33, 39].
Mesh placement and fixation

Cull the advisable size of the mesh to prevent a after recurrence due to an eventual "shrinkage" of the prosthesis [xl]. Slashing the mesh is hindered because information technology can lead to a recurrence [33].

Several studies have recommended no fixation but have been found wanting. Tissue glues are being used to secure the mesh in identify [39, 41, 42].

three.3 Post-operative complication

iii.iii.1 Seroma/hematoma formation

It is a mutual complication after laparoscopic hernia surgery and the incidence is inside 5–25%. It resolves spontaneously around iv–six weeks. A drain tin can be considered if in that location is an excessive haemorrhage or afterward extensive autopsy [33].

iii.3.2 Urinary retentiveness

The reported incidence for this complication is ane.iii–5.eight%, normally establish in elderly patients with prostatism. Put a catheter before the surgery and remove the adjacent day morning [33, 43, 44].

iii.3.3 Neuralgias

The incidence is reported to exist between 0.v and iv.vi% and intra peritoneal onlay mesh had the highest incidence [43]. The nigh commonly involved nerves are lateral cutaneous nervus of thigh, genitofemoral nerve and intermediate cutaneous nervus of thigh. This complication can be prevented by avoiding fixing the mesh lateral to the deep inguinal ring in the region of the triangle of pain, safe dissection of a big hernial sac and no autopsy of fascia over the psoas [33].

3.3.4 Testicular pain and swelling

Reported incidence is of 0.9–1.5%. Near are short-term. Orchitis was plant occasionally only testicular cloudburst was not a complication [33, 43, 44].

three.three.5 Mesh infection and wound infection

Wound infection rates are very low. Mesh infection is a very serious complication and care must be taken to maintain strict hygienic precautions during the entire procedure [33].

3.3.half-dozen Recurrence

The run a risk of the demand for repair for recurrent hernia following these initial hernia operations was lower for patients with open up mesh repair and for patients with laparoscopic mesh repair [33, 45].

Laparoscopic has advantages in treating recurrent inguinal hernia including emptying of the missed hernia, identify a circuitous hernias, covering unabridged myopectineal orifice with mesh that buttressing the intrinsic collagen arrears so ane of the crusade of recurrent hernia could exist overcome [14].

Advertizing

four. Conclusion

Laparoscopic inguinal hernia repair shows more benefits compared to open hernia repair. SILS inguinal hernia repair offers better cosmetic results; mail-operative recovery time was significantly quicker and less painful. Nonetheless, this approach is technically enervating and should be reserved for experienced single incision hernia surgeons. The invention of new surgical tools will hopefully overcome the current obstacles in SILS in the future.

Acknowledgments

We would also similar to show our gratitude to the Grace Ika Yuwono of Western Sydney University for writing assist and language editing.

Conflict of involvement

The authors declare no conflict of involvement.

Appendices and classification

SILS

single incision laparoscopic surgery

TAPP

trans-abdominal pre-peritoneal

TEP

totally extra peritoneal

CDC

The Centers for Disease Command

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Written By

Reno Rudiman and Andika August Winata

Submitted: May third, 2019 Reviewed: August 6th, 2019 Published: September twelfth, 2019

© 2019 The Writer(s). Licensee IntechOpen. This affiliate is distributed under the terms of the Creative Commons Attribution 3.0 License, which permits unrestricted utilize, distribution, and reproduction in any medium, provided the original piece of work is properly cited.

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