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Single-port onlay mesh repair of recurrent inguinal hernias after failed anterior and laparoscopic repairs.

Tran H, Tran K, Zajkowska M, Lam V, Hawthorne WJ - JSLS (2015 Jan-Mar)

Bottom Line: The peritoneum was incised above the pubic symphysis, and dissection was continued laterally and proximally, raising the inferior flap below the previous extraperitoneal mesh while reducing any direct, indirect, femoral, or cord lipoma before placement of antiadhesive mesh, which was fixed to the pubic ramus, as well as superiorly, with nonabsorbable tacks before the inferior border was fixed with fibrin sealant.The umbilical scar length was 23 mm at the 6-week follow-up.There were no intra-/postoperative complications, port-site hernias, chronic groin pain, or recurrence of the hernia during a mean follow-up of 24 months.

View Article: PubMed Central - PubMed

Affiliation: Discipline of Surgery, Sydney Medical School, University of Sydney at Westmead Hospital, Westmead, NSW, Australia.

ABSTRACT

Background and objectives: Despite the exponential increase in the use of laparoscopic inguinal herniorrhaphy, overall recurrence rates have remained unchanged. Therefore, a growing number of patients are presenting with recurrent hernias after conventional anterior and laparoscopic repairs have failed. This study reports our experience with single-incision laparoscopic (SIL) intraperitoneal onlay mesh (IPOM) repair of these hernias.

Methods: Patients referred with two or more recurrences of inguinal hernia underwent SIL-IPOM from November 1, 2009, to June 24, 2014. A 2.5-cm infraumbilical incision was made, and an SIL port was placed intraperitoneally. Modified dissection techniques were used: chopstick and inline dissection, 5.5-mm/52-cm/30° angled laparoscope, and conventional straight dissecting instruments. The peritoneum was incised above the pubic symphysis, and dissection was continued laterally and proximally, raising the inferior flap below the previous extraperitoneal mesh while reducing any direct, indirect, femoral, or cord lipoma before placement of antiadhesive mesh, which was fixed to the pubic ramus, as well as superiorly, with nonabsorbable tacks before the inferior border was fixed with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.

Results: Nine male patients underwent SIL-IPOM. Their mean age was 53 years and mean body mass index was 26.8 kg/m(2). Mean mesh size was 275 cm(2). Mean operation time was 125 minutes, with a hospital stay of 1 day. The umbilical scar length was 23 mm at the 6-week follow-up. There were no intra-/postoperative complications, port-site hernias, chronic groin pain, or recurrence of the hernia during a mean follow-up of 24 months.

Conclusion: Inguinal hernias recurring after two or more failed conventional anterior and laparoscopic repairs can be safely and efficiently treated with SIL-IPOM.

No MeSH data available.


Related in: MedlinePlus

A single-incision laparoscopic intraperitoneal onlay mesh repair of a right inguinal hernia with multiple recurrences. A, Patient with incisions from previous anterior and laparoscopic repair; B, The setup (an extra-long laparoscope was used to prevent clashing of the handles of the conventional straight dissecting instruments with the side arm of the scope) and inset showing close up view of the single-port device.
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Figure 1: A single-incision laparoscopic intraperitoneal onlay mesh repair of a right inguinal hernia with multiple recurrences. A, Patient with incisions from previous anterior and laparoscopic repair; B, The setup (an extra-long laparoscope was used to prevent clashing of the handles of the conventional straight dissecting instruments with the side arm of the scope) and inset showing close up view of the single-port device.

Mentions: After induction of general anesthesia, the patients were prepped and draped with iodine from epigastrium to mid thigh and then draped with an iodine-impregnated adhesive cover (Ioband; 3M, St Paul, Minnesota), to expose the entire abdomen and both groins (Figure 1). A preoperative intravenous dose of cephalosporin was given, and a urinary catheter was routinely placed. After infiltration with bupivacaine 0.5% with 1:200 000 ephedrine in the umbilical area, a 2- to 2.5-cm (depending on the laxity of the skin) crescentic infraumbilical incision was made, the anterior rectus sheath was incised transversely, and the rectus sheath was retracted laterally. The site of entry was on the side contralateral to the previous laparoscopic entry (if a TEP approach was used), to avoid scar tissue. The posterior rectus sheath and the peritoneum were then entered for placement of an SIL port (Covidien, Norwalk, Connecticut). Insufflation with CO2 was maintained at 12 mm Hg. The patient was placed in a Trendelenburg position at 10° to 15° (Figure 1). The procedure was performed with a 52-cm/30° angled laparoscope, to assess the amount of adhesions (Figure 2), and those were meticulously divided by sharp dissection, to avoid electrocautery (Figure 3). Modified dissection techniques, namely, chopstick and inline, were used to overcome the relative loss of triangulation. The pubic symphysis was identified, the peritoneum was incised 2 cm superior to it, and the incision was extended laterally, or superior to a direct sac, if present (Figure 4). No attempt was made to incise (or remove any part of) the previously placed (extraperitoneal) mesh; rather, the dissection was performed from the inferior aspect of the mesh and continued proximally. Care was taken to stay below the inferior epigastric vessels as the dissection continued laterally. The peritoneum was then reflected inferiorly over the pubic symphysis and continued laterally over the spermatic cord and its structures, thus reducing any direct, femoral, and indirect hernia and lipoma of the cord, akin to the dissection during TAPP inguinal hernia repair. Extreme care was taken to prevent damage to the urinary bladder, external iliac vessels, vas deferens, testicular vessels, and femoral nerve and to preserve other retroperitoneal nerves in the vicinity (Figure 4). No attempt was made to dissect the superior flap of peritoneum overlying the previous laparoscopically placed mesh. Often the previously placed extraperitoneal mesh had folded during placement or deflation, causing the recurrence of the hernia, and consequently the inferior peritoneal flap was usually surprisingly easy to lift (Figures 3 and 4). Even so, it had to be assumed that, although the previously placed extraperitoneal mesh had been poorly positioned, there would have been some attempt to dissect the peritoneal space below the pubic ramus; therefore, millimeter-by-millimeter meticulous sharp dissection, with avoidance of electrocautery, was used to minimize damage to the aforementioned retroperitoneal structures and to minimize tearing of the inferior peritoneal flap. After deflation to 8 mm Hg, measurements were taken externally for the size of the mesh (Gore-tex Dualmesh; WL Gore & Associates, Flagstaff, Arizona), which was at least 5 cm longer craniocaudally, extending inferior to the pubic symphysis. A polydioxanone (PDS) 0 suture (Ethicon, Somerville, New Jersey) was placed in the superior medial corner of the mesh to provide transfascial suture fixation, and the mesh was marked 5 cm above its inferior medial corner to correspond to the superior edge of the pubic symphysis (Figure 5). The mesh was rolled inward along its horizontal axis, like a scroll, and placed intraperitoneally via a 12-mm trocar, which temporarily replaced the 5-mm camera trocar. One of the 5-mm trocars was temporarily withdrawn until it was outside the fascial defect, to facilitate insertion of the 12-mm trocar. The mesh was then unrolled and positioned to cover the defect(s). A stab incision was then made in the midline and inferior to the umbilicus, to retrieve the PDS suture in the superior medial corner of the mesh with a suture passer. This method allowed the mesh to be more easily maneuvered into the correct position before nonabsorbable tacks (Protack; Covidien) were placed onto the pubic bone and along the pubic ramus, taking care to avoid the external iliac vein (Figures 2 and 5). The mesh was then tacked medially and superiorly and, cautiously, laterally, to avoid the nerves in the vicinity. The process was aided by the mesh's craniocaudal dimension being of sufficient size that its superior edge was well above the previously placed extraperitoneal mesh and within 2 cm of the umbilical SIL port, so that the tacks were unlikely to pierce the iliohypogastric nerve, ilioinguinal nerve, genital branch of the genitofemoral nerve, or the lateral cutaneous nerve of the thigh. Fibrin sealant (2 ml) (Tisseel Duo; Baxter AG, Vienna, Austria) was sprayed along the inferior edge of the mesh (Figure 5). The inferior peritoneal flap was then reflected up and tacked lightly onto the mesh, with care taken not to leave any significant gaps that would allow herniation of the bowel loops. Fibrin sealant (2 ml) was also sprayed along the mesh–peritoneum interface, on the periphery of the mesh, and over the tacks, to minimize the risk of adhesions (Figure 5). The fascial defect in the umbilical wound was closed in layers, subcutaneously and subcuticularly, with interrupted No. 0 PDS sutures and absorbable sutures. The urinary catheter was left in place overnight and removed before the patient was discharged home. All patients were seen at 1 week and 4 weeks, with plans to see them annually for 5 years.


Single-port onlay mesh repair of recurrent inguinal hernias after failed anterior and laparoscopic repairs.

Tran H, Tran K, Zajkowska M, Lam V, Hawthorne WJ - JSLS (2015 Jan-Mar)

A single-incision laparoscopic intraperitoneal onlay mesh repair of a right inguinal hernia with multiple recurrences. A, Patient with incisions from previous anterior and laparoscopic repair; B, The setup (an extra-long laparoscope was used to prevent clashing of the handles of the conventional straight dissecting instruments with the side arm of the scope) and inset showing close up view of the single-port device.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4376219&req=5

Figure 1: A single-incision laparoscopic intraperitoneal onlay mesh repair of a right inguinal hernia with multiple recurrences. A, Patient with incisions from previous anterior and laparoscopic repair; B, The setup (an extra-long laparoscope was used to prevent clashing of the handles of the conventional straight dissecting instruments with the side arm of the scope) and inset showing close up view of the single-port device.
Mentions: After induction of general anesthesia, the patients were prepped and draped with iodine from epigastrium to mid thigh and then draped with an iodine-impregnated adhesive cover (Ioband; 3M, St Paul, Minnesota), to expose the entire abdomen and both groins (Figure 1). A preoperative intravenous dose of cephalosporin was given, and a urinary catheter was routinely placed. After infiltration with bupivacaine 0.5% with 1:200 000 ephedrine in the umbilical area, a 2- to 2.5-cm (depending on the laxity of the skin) crescentic infraumbilical incision was made, the anterior rectus sheath was incised transversely, and the rectus sheath was retracted laterally. The site of entry was on the side contralateral to the previous laparoscopic entry (if a TEP approach was used), to avoid scar tissue. The posterior rectus sheath and the peritoneum were then entered for placement of an SIL port (Covidien, Norwalk, Connecticut). Insufflation with CO2 was maintained at 12 mm Hg. The patient was placed in a Trendelenburg position at 10° to 15° (Figure 1). The procedure was performed with a 52-cm/30° angled laparoscope, to assess the amount of adhesions (Figure 2), and those were meticulously divided by sharp dissection, to avoid electrocautery (Figure 3). Modified dissection techniques, namely, chopstick and inline, were used to overcome the relative loss of triangulation. The pubic symphysis was identified, the peritoneum was incised 2 cm superior to it, and the incision was extended laterally, or superior to a direct sac, if present (Figure 4). No attempt was made to incise (or remove any part of) the previously placed (extraperitoneal) mesh; rather, the dissection was performed from the inferior aspect of the mesh and continued proximally. Care was taken to stay below the inferior epigastric vessels as the dissection continued laterally. The peritoneum was then reflected inferiorly over the pubic symphysis and continued laterally over the spermatic cord and its structures, thus reducing any direct, femoral, and indirect hernia and lipoma of the cord, akin to the dissection during TAPP inguinal hernia repair. Extreme care was taken to prevent damage to the urinary bladder, external iliac vessels, vas deferens, testicular vessels, and femoral nerve and to preserve other retroperitoneal nerves in the vicinity (Figure 4). No attempt was made to dissect the superior flap of peritoneum overlying the previous laparoscopically placed mesh. Often the previously placed extraperitoneal mesh had folded during placement or deflation, causing the recurrence of the hernia, and consequently the inferior peritoneal flap was usually surprisingly easy to lift (Figures 3 and 4). Even so, it had to be assumed that, although the previously placed extraperitoneal mesh had been poorly positioned, there would have been some attempt to dissect the peritoneal space below the pubic ramus; therefore, millimeter-by-millimeter meticulous sharp dissection, with avoidance of electrocautery, was used to minimize damage to the aforementioned retroperitoneal structures and to minimize tearing of the inferior peritoneal flap. After deflation to 8 mm Hg, measurements were taken externally for the size of the mesh (Gore-tex Dualmesh; WL Gore & Associates, Flagstaff, Arizona), which was at least 5 cm longer craniocaudally, extending inferior to the pubic symphysis. A polydioxanone (PDS) 0 suture (Ethicon, Somerville, New Jersey) was placed in the superior medial corner of the mesh to provide transfascial suture fixation, and the mesh was marked 5 cm above its inferior medial corner to correspond to the superior edge of the pubic symphysis (Figure 5). The mesh was rolled inward along its horizontal axis, like a scroll, and placed intraperitoneally via a 12-mm trocar, which temporarily replaced the 5-mm camera trocar. One of the 5-mm trocars was temporarily withdrawn until it was outside the fascial defect, to facilitate insertion of the 12-mm trocar. The mesh was then unrolled and positioned to cover the defect(s). A stab incision was then made in the midline and inferior to the umbilicus, to retrieve the PDS suture in the superior medial corner of the mesh with a suture passer. This method allowed the mesh to be more easily maneuvered into the correct position before nonabsorbable tacks (Protack; Covidien) were placed onto the pubic bone and along the pubic ramus, taking care to avoid the external iliac vein (Figures 2 and 5). The mesh was then tacked medially and superiorly and, cautiously, laterally, to avoid the nerves in the vicinity. The process was aided by the mesh's craniocaudal dimension being of sufficient size that its superior edge was well above the previously placed extraperitoneal mesh and within 2 cm of the umbilical SIL port, so that the tacks were unlikely to pierce the iliohypogastric nerve, ilioinguinal nerve, genital branch of the genitofemoral nerve, or the lateral cutaneous nerve of the thigh. Fibrin sealant (2 ml) (Tisseel Duo; Baxter AG, Vienna, Austria) was sprayed along the inferior edge of the mesh (Figure 5). The inferior peritoneal flap was then reflected up and tacked lightly onto the mesh, with care taken not to leave any significant gaps that would allow herniation of the bowel loops. Fibrin sealant (2 ml) was also sprayed along the mesh–peritoneum interface, on the periphery of the mesh, and over the tacks, to minimize the risk of adhesions (Figure 5). The fascial defect in the umbilical wound was closed in layers, subcutaneously and subcuticularly, with interrupted No. 0 PDS sutures and absorbable sutures. The urinary catheter was left in place overnight and removed before the patient was discharged home. All patients were seen at 1 week and 4 weeks, with plans to see them annually for 5 years.

Bottom Line: The peritoneum was incised above the pubic symphysis, and dissection was continued laterally and proximally, raising the inferior flap below the previous extraperitoneal mesh while reducing any direct, indirect, femoral, or cord lipoma before placement of antiadhesive mesh, which was fixed to the pubic ramus, as well as superiorly, with nonabsorbable tacks before the inferior border was fixed with fibrin sealant.The umbilical scar length was 23 mm at the 6-week follow-up.There were no intra-/postoperative complications, port-site hernias, chronic groin pain, or recurrence of the hernia during a mean follow-up of 24 months.

View Article: PubMed Central - PubMed

Affiliation: Discipline of Surgery, Sydney Medical School, University of Sydney at Westmead Hospital, Westmead, NSW, Australia.

ABSTRACT

Background and objectives: Despite the exponential increase in the use of laparoscopic inguinal herniorrhaphy, overall recurrence rates have remained unchanged. Therefore, a growing number of patients are presenting with recurrent hernias after conventional anterior and laparoscopic repairs have failed. This study reports our experience with single-incision laparoscopic (SIL) intraperitoneal onlay mesh (IPOM) repair of these hernias.

Methods: Patients referred with two or more recurrences of inguinal hernia underwent SIL-IPOM from November 1, 2009, to June 24, 2014. A 2.5-cm infraumbilical incision was made, and an SIL port was placed intraperitoneally. Modified dissection techniques were used: chopstick and inline dissection, 5.5-mm/52-cm/30° angled laparoscope, and conventional straight dissecting instruments. The peritoneum was incised above the pubic symphysis, and dissection was continued laterally and proximally, raising the inferior flap below the previous extraperitoneal mesh while reducing any direct, indirect, femoral, or cord lipoma before placement of antiadhesive mesh, which was fixed to the pubic ramus, as well as superiorly, with nonabsorbable tacks before the inferior border was fixed with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.

Results: Nine male patients underwent SIL-IPOM. Their mean age was 53 years and mean body mass index was 26.8 kg/m(2). Mean mesh size was 275 cm(2). Mean operation time was 125 minutes, with a hospital stay of 1 day. The umbilical scar length was 23 mm at the 6-week follow-up. There were no intra-/postoperative complications, port-site hernias, chronic groin pain, or recurrence of the hernia during a mean follow-up of 24 months.

Conclusion: Inguinal hernias recurring after two or more failed conventional anterior and laparoscopic repairs can be safely and efficiently treated with SIL-IPOM.

No MeSH data available.


Related in: MedlinePlus