Pilot study of selective fixation of mesh in laparoscopic extra-peritoneal inguinal hernia repair (TEP)

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1 Original article: International J. of Healthcare and Biomedical Research, Volume: 05, Issue: 04, July 2017, Pilot study of selective fixation of mesh in laparoscopic extra-peritoneal inguinal hernia repair (TEP) DR. CHINMAY GANDHI, DR. ASHOK DHONDE, DR. DAJIRAM MOTE Name of institute: BHARATI DEEMED UNIVERSITY MEDICAL COLLEGE & HOSPITAL, SANGLI Corresponding author: DR. CHINMAY GANDHI ABSTRACT AIMS / OBJECTIVES: chronic groin pain and recurrences are the concerns of open inguinal hernia repair. Our aim was to find out intra and early postoperative complications associated with TEP repair. Find out chronic groin pain and early recurrences of inguinal hernia after TEP repair. METHOD: This is the prospective observational study of selective fixation of large size mesh in total extra peritoneal inguinal hernia repair. The surgeries were done at Bharati deemed university medical college and hospital,sangli by well experienced laparoscopic team of surgeons. We had followed the patients for minimal 6 months. Data was recorded for intra and early postoperative period. Numerical rating scale(out of 10) was used to record postoperative pain. Each patient was followed up for minimal 6 months for groin pain and recurrence after TEP repair of inguinal hernia. RESULTS: There was no recurrence at 6 month follow up and only one patient had mild pain(3/10) at 3 month follow up, Which disappeared after 6 month. We reconfirmed advantage of TEP for early recovery and return to physical activity, less chronic pain and less wound infection.tep repair has a definite advantage in recurrent and bilateral inguinal hernias. CONCLUSION: Experienced laparoscopic surgeons can reduce learning curve for TEP repair. key words: Inguinal hernia, Laparoscopic inguinal hernia, learning curve in TEP repair. INTRODUCTION: MATERIALS AND METHODS: Inguinal hernia is the most common hernia surgery This is a pilot prospective observational study of 30 performed in the world.. Lichtenstein hernioplasty has laparoscopic extra peritoneal inguinal hernia repair done become gold standard for open inguinal hernia repair with selective fixation of large size lightweight because of less than 1% recurrence after the surgery (1,2). polypropylene mesh (12 by 15 cm). In all the open repair chronic groin pain and wound All patients with unilateral or bilateral inguinal hernia infection is the main concern. To reduce the issue of primary or recurrent, which are fit for general anaesthesia chronic groin pain and wound infection after open are included in study. Patients unfit for general hernioplasty for inguinal hernia, laparoscopic extra anaesthesia, having coagulation defects or with peritoneal mesh repair of inguinal hernia has been obstruction and strangulation of inguinal hernia were developed and evolved since first reported by Ger and excluded. Also patients with previous open colleagues in 1990 (3,4). prostatectomy, having local radiation or infection were excluded. Data was collected after indoor case paper review and postoperative follow up of 6 months. 77

2 Smokers were advised to stop smoking 3 weeks prior to surgery. All patients were given preoperative antibiotic prophylaxis. All surgeries were done under general anaesthesia with self retaining bladder catheter in place. Patients were given 10 to 15 degree trendelenberg position with both upper limbs tucked by the side of body. The monitor was placed at the foot end of bed, surgeon stands opposite the side of hernia to be operated and camera person at the head end on the same side of operating surgeon. In cases of bilateral hernia surgeon and camera surgeon had changed the side simultaneously. 12 mm transverse infraumblical incision is given to the same side of hernia, Pre-peritoneal space was entered needs sharp dissection to create more extra peritoneal space. Indirect hernia sac identified as white glistering structure lying anterolateral to cord and lateral to inferior epigastric vessel. After reducing sac content, incomplete hernia sac was dissected off the cord and completely reduced, where as in complete hernia sac after reducing it content, sac was separated from cord structure, ligated proximally and cut distally, keeping distal sac open. Parietalization of the cord proceeds till the vas deference turns medially towards bladder in visceral compartment of extra peritoneal space and gonadal vessel enter psos muscle laterally. This dissection exposes triangle of after opening anterior rectus sheath.10 mm Hassan's doom bounded by vas deference medially, testicular cannula with blunt tip trochar and cone was inserted into preperitoneal space.co 2 insufflations with 12mm. of hg pressure and to and fro movement of 10 mm 30 degree telescope created the midline pre-peritoneal space. Next two working ports were placed in preperitoneal space one just 2 cm above the pubic symphysis and other between 10 mm camera port at infraumblical and 5mm suprapubic port. vessel laterally and peritoneal reflection inferiorly, apex of triangle was formed by deep inguinal ring and base by peritonea reflection inferiorlly.external iliac vessels which lie in this triangle of doom needs to be protected. Lipoma of the cord removed. After creation of adequate extra peritoneal space 12 by 15 cm polypropylene light weight mesh was introduced from camera port in rolled cigar configuration. Mesh was spread open to cover all Dissection was started in visceral extra peritoneal space, myopectineal orifices.it covers all hernia sites like until landmarks such as symphysis pubis, coopers direct, femoral and Obturatore medial to inferior ligament, inferior epigastric vessel with anterior epigastric vessel and indirect lateral to inferior epigastric abdominal wall were seen. Dissection progressed to two cm. below pubic symphysis in the space of retzius. vessel. We had used non absorbable tackers selectively. In small Possible direct, femoral and Obturatore sac were ( <1.5 cm) direct sac a single tacker was used to fix mesh dissected in visceral extra-peritoneal space. The lateral plane of dissection in parietal compartment of extra peritoneal space was progressed between cord structures below and anterior abdominal wall above, just lateral to inferior epigastric vessel. Adequate dissection in space of bogros(parietal compartment) was carried out up to anterior superior iliac spine laterally and psos muscle postero inferior. Dulucq's fascia was excised in lateral space. Cranially the peritoneum was seen densely adherent to arcuate ligament on anterior abdominal wall, at cooper ligament or we should be able to give 4 cm medial cover of mesh over direct defect. In large direct hernia sac (>1.5 cm) we did two to three point fixation of the mesh. One over cooper ligament, other just above pubic bone to anterior abdominal wall or last fixation at medial superior edge of mesh to anterior abdominal wall. We had not done any fixation for small indirect inguinal hernia (<1.5cm)as mesh could cover 5 to 6 cm all round the defect, for large indirect inguinal hernia we had done two or three point fixation,one over cooper ligament, 7876

3 other medial superior edge of mesh to anterior abdominal postoperatively catheter was removed on first wall or last over superior lateral edge of mesh to anterior abdominal wall. Once the mesh was spread over the defects we released the co2 insufflations, anterior sheath defect was closed with vicryl 1.0 suture and trochar defects with ethilone postoperative day. All patients required one or two injections of tramadol on first day. All patients were mobilized next day. Patients were on mild oral analgesics from day two. Patients were discharged on 2nd postoperative day. On day two NRS (numerical rating 2.0 suture. On the first post operative day catheter was score) pain score of all patients was between removed and patients were mobilised. All patients were discharged on second postoperative day with mild analgesics. RESULTS: 2&3/10.Patients were followed on 7th postoperative day.28 patients were pain free on 7th postoperative day.2 patients had persistent NRS pain score of 3/10.It was found that these patients were having inguinal or scrotal All 30 patients were male. Intraoperative hernia was seroma. On postoperative day 14 seroma disappeared and classified according to European hernia society they wear pain free. One patient complained of chronic classification.(figure. 1) Out of these 30 patients one had recurrence and four had bilateral inguinal hernia repair. PM1: 9 Patients, Primary medial hernia about 1.5 cm defect. groin pain 3 month after surgery. He required mild oral analgesic. None of our patient had wound infection, mesh infection or groin haematoma.two of our patients had seroma. These patients were having either large direct hernia or PM2: 1 Patient, Primary medial hernia about 3 cm defect. complete indirect inguinal hernia. The seroma RM1: 1 Patient, Recurrent medial hernia with 1.5 cm defect.. PL1: 18 Patients, Primary lateral hernia with 1.5 cm defect. PL2: 1 Patients, Primary lateral hernia with 3 cm defect. Surgery duration was 45 to 60 minutes for unilateral hernias and up to 90 minutes for bilateral cases. Intraoperative complications like vascular, intestinal or bladder injuries were not observed in our series. There were no cases of surgical emphysema in these series. Intraoperative peritoneal tear was observed in seven cases. Minor tear was managed with intracorporial suturing with 2.0 vicryl or endo loop catgut suture. Major peritoneal tear in one case required conversion to transabdominal procedure (conversion to TAPP) and suturing of peritoneum with continuous intracorporial 2.0 vicryl suturing. 23% patients had peritoneal tear. There were no anesthesia related complications like hypercarbia and hypotension.(figure.2) disappeared on 2 weeks postoperative on its own with mild oral analgesic and anti-inflammatory drugs. There were no patients with testicular swelling due to Orchitis. post operatively all patients were able to do routine normal activity from day seven and they were advised routine normal physical activity afterwards. There were no recurrence of hernia at the end of 6 month postoperative.(figure.3) DISSCUSION: Since the introduction of tension free Lichtenstein hernioplasty in 1989 the recurrence of inguinal hernia has drastically reduced below 1%. Chronic groin pain and wound infection remained the major concern after open inguinal mesh repair. First total extra peritoneal laparoscopic inguinal mesh repair was described by McKernan and Law in 1993 (5). Main principle of laparoscopic inguinal hernia is to keep large size mesh in extra peritoneal space overlapping the hernial defects. Pascal's hydrostatic force which causes 7977

4 the hernia also keeps the mesh in place after TEP. Most of the inguinal hernia recurrences with TEP will be prevented by mesh in extra peritoneal space as per Pascal's hydrostatic law. (6) Laparoscopic inguinal hernia repair requires relearning of new anatomy and advanced laparoscopic skill. Enough knowledge and experience is published in literature, so the learning curve can be reduced (7,8). Our team of surgeons had enough basic laparoscopic skills and are doing advanced laparoscopic surgery. Over the years literature had mentioned various causes of recurrence after laparoscopic inguinal hernia, these are insufficient size of mesh, defective material, incorrect placement, immediate and early mesh folding and displacement, lifting of mesh due to hematoma and urinary retention, late displacement by insufficient tissue in growth, mesh protrusion, shrinkage and collagen disease (8,9,10,11,12). literature has mentioned recurrence rate was lower with large size well anchored mesh (12 by 15 cm). 60% recurrence were due to small size mesh, 30% recurrence due to insufficient mesh fixation, 20% recurrence due to missed hernia. Use of lightweight, macro porous mesh reduces foreign body sensation, mesh shrinkage and infection (8). We have selectively fixed mesh because flat mesh in preperitoneal space is in constant danger of displacement by abdominal forces. (7) Large direct defects should have 4 cm overlap with fixation to coopers ligament, superior and medial to defect (4). In large direct defects medial edge can be within 2 cm of midline, so mesh should cross midline and fixed (4). For the same reason we had fixed large indirect defects. Knowing well that excessive tacks with wrong placement (laterally below illiopubic tract) can cause chronic groin pain. We had used nonabsorbable tacks because of unavailability of fibrin glue and economical issue at rural hospital. Hence our early results had no recurrence after laparoscopic inguinal hernioplasty. Postoperatively NRS pain score showed less score of 3/10 on second postoperative day and on day seven 28 patients were without pain. Two patients had NRS scale of 3/10 due to seroma. Seroma disappeared on day 14 and then pain score also reduced to zero. So it showed less pain for laparoscopic inguinal hernia repair compared to open inguinal hernioplasty. Patients were doing regular activity from day seven. Only one patient complained of mild 3/10 NRS scale pain at 3 month postoperative, which was relieved with mild analgesic. So early return to work, smaller loss of productivity and less postoperative medical care requirement (no wound infection) after laparoscopy repair were advantages for the patient. For recurrent inguinal hernia we confirmed advantage of laparoscopic repair because it bypassed scarred tissue plane, it prevented Orchitis and testicular atrophy, less chronic inguinodynia (13). In bilateral inguinal hernias laparoscopy allowed both hernia to be repaired in a single set of 3 ports, doesn t need additional ports. So there was cosmetic advantage along with less morbidity of two incisions of open repairs. (13) In females along with direct and indirect inguinal hernia 40% will have femoral hernia. laparoscopic hernioplasty had the advantage that it can cover all myopectoneal orifice (13). We reconfirmed less chronic pain after laparoscopic repair, because minimal access, no use of tacks in parietal compartment below illiopubic tract, visualization of genitofemoral nerve trunk and lateral femoral cutaneous nerve and avoiding mesh contact with nerve, because nerves in this space had no investing layer of fascia cover. (14) 80 78

5 CONCLUSION: Experienced laparoscopic surgeons can give excellent results in laparoscopic Total extra peritoneal inguinal hernioplasty. We reconfirmed advantages of laparoscopic TEP for less chronic groin pain, early return to activity, less wound infection. There is definite advantage of laparoscopic TEP in recurrent anterior inguinal hernia repairs, bilateral primary inguinal hernias and in females. Conflict of interest: none declared Ethical clearance: Institutional ethical clearance was taken for the study Patient No. 0 EHS type of Hernia PL 1 PL 2 PM 2 RM 2 PM 1 Patient No. DISTRIBUTION OF PATIENTS ACCORDING TO EUROPEAN HERNIA CLASSIFICATION P Primary R Recurrent L Lateral M Medial 1 Near 1.5 cm defect 2 Near 3 cm defect 8179

6 Table 1 INTERAOERATIVE COMPLICATIONS OF TEP NO. OF Patient VISCERAL INJURY BOWEL NIL URINARY BLADDER NIL SURGICAL EMPHYSEMA NIL PERITONEAL TEAR MINOR 7/30 PATIENT 21 % MAJOR 1/30 PATIENT 3.30% ANESTHESIA COMPLICATIONS HYPERCARBIA NIL HYPOTENSION NIL VASCULAR INJURY INFERIOR EPGASTRIC NIL ILLAC VESSEL NIL 82 76

7 Table 2 POSTOPERATIVE COMPLICATIONS OF TEP NO. OF Patient MESH INFEACTION Nil Wound Infection Nil Groin hematoma Nil Groin Seroma 1 week post op. 3/30 10% 2 weeks Nil Post-operative groin pain 2 nd Day NRS Scale 3/10 in patients - 7 th Day NRs Scale 3/10 in 3 Patients 3 months NRS Scale 3/10 in 1 Patients 3.3% 6 Months NRS Scale 0 in All Patients 0% Recurrence of Inguinal Hernia Nil REFERENCES: 1) F. H. Hetzer, T. Hotz, W. Steinke, F. Largiader. Gold standard for inguinal hernia repair: Shouldice or Lichtenstein?. Hernia September 1999, 3(3): ) D.K.Chaitanya, D. Srihari. Inguinal hernia repair using standard mesh- Our experience.iaim,2016;3(7): )Ger G,Laparoscopic hernia operation. Chirurg 1991;62(4) )Viney K. Mathavan and Maurice E. Arregui. Fixation Versus No Fixation in Laparoscopic TEP and TAPP. B.P. Jacob and B. Ramshaw, Edited. The SAGES manual of hernia surgery, New York, Springer. 5)McKernan and Law. Laparoscopic repair of inguinal hernia using a totally extra peritoneal prosthetic approach. Surg. Endosc January.7(1):26-28, 6)Jan F.Kukaleta. TEP.The logic of hernia repair. Revista Portuguesa de Cirugia.Setember 2009;(10):

8 7) Davide Lomanto and Avinash N Katara. Managing Intra-operative complications during totally extra peritoneal repair of inguinal hernia. J Minimal Access Surg Sep;2(3): )J.F.Kukleta. Causes of recurrences in laparoscopic inguinal hernia repair. J Minimal Access Surgery.2006 Sep;2(3): )Tetik C, Arregui HE, Dulucq's JL, McKernan JB. Complications and recurrences associated with laparoscopic repair of groin hernias, A multi-institutional retrospective analysis. Surg. Endosc.1994;8: )Kes E. Lange J, Bonjer J, Stoeckart R, Mulder P.et.al. Protrusion of prosthetic mesh in repair of inguinal hernias. Surgery.2004; 135: )Knook MT, Van Rosmalen AC, Yoder BE, Looman C.W. Optimum mesh size for endoscopic inguinal hernia repair. A study in a porcine model. Surg. Endosc: 2001;15: )Zheng H, Si Z, Bhardwaj RS. Schumpelick V. Klinge U.et al. Recurrent inguinal hernia: disease of the collagen matrix. World J. Surg.2002 April;26(4): )Jonathan Carter & Quan Yang Duh.Laparoscopic repair of inguinal hernia. World J. Surg.2011 Jul;35(7): )David Chan, Parviz Amin. Chronic pain & quality of life after trans inguinal pre peritoneal (TIPP) inguinal hernia repair, A few tips of TIPP. Hernia 2013;17(6):