LAPAROSCOPIC HERNIORRHAPHY FOR PATIENTS WITH RECURRENT INGUINAL HERNIAS FOLLOWING ENDOSCOPIC INGUINAL HERNIA REPAIRS.

FITZGIBBONS, R. J Jr.
Professor of Surgery. Creighton University, Department of Surgery. Omaha, Nebraska.

e-mail: fitzjr@creighton.edu

Enough time has passed that there is now a substantial number of patients with failed preperitoneal laparoscopic hernia repairs needing treatment. We all know the reasons-limited experience of the original surgeon, incomplete dissection, missed hernias, missed lipomas of the cord, insufficient size of the prosthesis, insufficient overlap of the prosthesis over the hernia defect, improper fixation in cases where fixation was needed because of the size of the hernia, lifting of mesh laterally and mesh migration especially in medial recurrences (1). Most surgeons feel that the logical approach to such a patient is to perform a conventional herniorrhaphy in the conventional inguinal space. Makes sense! The conventional operation is safe and effective and the surgeon is able to work in undissected tissue. So should laparoscopic re-repair ever be considered?

Well, there are two groups of patients in whom the question is legitimate: 1) The multiply recurrent hernia patient where both spaces have already been dissected and 2) The patient who insists on an endoscopic re-repair by virtue of personal preference. The latter most commonly comes up when the patient has had a previous conventional repair on the opposite side.

One might make a case that surgeons should simply refuse the patient’s request. However, several groups have devised specific surgical strategies for approaching recurrent preperitoneal hernias laparosocpicaly (2-4). These include general anesthesia, transabdominal approach (no place for the TEP here!), three laparoscopic cannullae at the level of the umbilicus, redissection of the preperitoneal space leaving the old prosthesis in situ followed by completion of the coverage of the myopectineal orifice with a new prosthesis. If no hernia is evident from the laparoscopic vantage point, a pseudo recurrence consisting of a lipoma of the cord or an encapsulated seroma may account for the clinical findings.

Felix has suggested that a small counter incision in the groin is best in this situation to avoid the difficult preperitoneal dissection but others prefer to address these from the preperitoneal space (2). Medial recurrences which are invariably near the pubic tubercle are treated by opening the peritoneum at least 3 cm above the hernia defect in unscarred tissue. Dissection proceeds medially and inferiorly widely opening the space of Retzius to the opposite tubercle. It is necessary to identify the opposite tubercle because this will assure sufficient overlap by a new prosthesis. By staying in unscarred tissue while identifying and freeing the bladder one avoids injury to the structure which is the major complication. Once the space of Retzius is opened, dissection proceeds laterally across the ipsilateral pubic tubercle and the hernia defect. It is difficult to separate the peritoneum from the old prosthesis but nevertheless is relatively safe because there are really no structures in harms way until the internal ring is reached. Once sufficient overlap is achieved, a new prosthesis is fastened in place. Lateral recurrences are more difficult because of the scarring at the internal ring caused by the old prosthesis and the recurrent sac. Bittner opens the preperitoneal space above the hernia defect and gets behind the previous prosthesis so that an en bloc mobilization of peritoneum and prosthesis from the transversalis fascia can be accomplished (3). Dividing the inferior epigastric vessels facilitates this. The identification and mobilization of the lateral hernia sac can then be safely done after separation of the cord structures. A new mesh is then slit and positioned around the cord in the opposite direction of the original. A second unslit mesh is placed over the first again reinforcing the entire myopectineal orifice. Finally, the prosthesis must be covered. Peritoneum is best but sometimes it is so shredded that an omental flap is necessary.

So just who should be performing these operations? Any surgeon who has attempted this difficult procedure knows the significant risk for complications including bladder injury, damage to the cord structures and even major vascular injury. Indeed the most experienced group in the world with this procedure reported two bladder injuries and one cord damage in 46 patients (6.5%). Although admittedly self-serving, I believe this procedure should only be performed in specialty centers with sufficient experience.

1. Lowham AS, Filipi CJ, Fitzgibbons RJ Jr, Stoppa R, Wantz GE, Felix EL, Crafton WB. Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic. Ann Surg 1997 Apr;225(4):422-31.
2. Félix EL. A unified approach to recurrent laparoscopic hernia repairs. Surg Endosc 2001 Sep;15(9):969-71.
3. Leibl BJ, Schmedt CG, Kraft K, Ulrich M, Bittner R. Recurrence after endoscopic transperitoneal hernia repair (TAPP): causes, reparative techniques, and results of the reoperation. J Am Coll Surg 2000 Jun;190(6):651-5.
4. Knook MTT, Weidema WE, Stassen LPS, van Steensel CJ. Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy. Surg Endosc 13:1145-1147 (1999).