Laparoscopic Repair of Inguinal Hernia
By definition a hernia is a protrusion of an internal organ through a tear, hole or defect in the wall of a body cavity. Most often it is the abdominal wall which is defective or weak and hernias are classified anatomically with inguinal hernias being the most prevalent. In the history of medicine groin hernias were depicted as far back as 1552 BC in ancient Indian writing and there are even some findings in mummies of Egypt that surgery was attempted. For many centuries the anatomic detailing greatly improved but concrete and feasible surgical technique lagged. Recently Laparoscopic repair of inguinal hernias is usually achieved by totally extra peritoneal (TEP) or trans abdominal pre peritoneal (TAPP) techniques. The intra peritoneal onlay mesh (IPOM) for inguinal hernia could be an interesting alternative as it is much easier to perform and faster to execute without fear of damaging delicate and dangerous structures. This technique is subject to correct selection of indications and to demonstration of its safety.
Hernias occur fairly frequently all over World and are more common in adult males. Occasionally these can be life threatening if get strangulated or more frequently simply a painful nuisance. Nonetheless, the only true remedy of inguinal hernia is surgical repair. In the history of surgery over centuries different surgical techniques have evolved until the present whereby laparoscopic approaches predominate. Several various methodologies have been introduced for laparoscopic inguinal hernia repair.
IPOM technique of Inguinal hernia repair with fibrin glue :
From February 20010 to January 2012 we performed 21 laparoscopic hernia procedures on selected patients with simple small inguinal hernia with an IPOM technique combining the Vipro mesh 15cm X 15 Cm and a fibrin glue (Tissel) and tackier combined technique for its fixation. The glue was diluted to increase fixation time and applied once the mesh was primarily fixed with tackier to positioning on the hernia defect. Procedure is done under general anesthesia in the following sequence;
- Inserting a standard 10 mm trocar at umbilicus using semi-open technique.
- Inserting only one 5 mm working port for tackier and tissue fibrin glue applicator
- Intra peritoneal anatomical landmarks involved in inguinal hernia repair were identified; Triangle of Doom or Square of Doom, Symphysis pubis, Cooper ligament, Iliopubic tract and Anterior superior iliac spine. There was no dissection of the peritoneum carried out.
- The upper half of mesh is fixed with autosuture protack at the level of 2 cm above transverses abdominis arch, medially at abdominal midline, laterally near anterior superior iliac spine and the middle at between the medial and lateral ligament.
- One tacker was also fixed over cooper ligament which was nicely identified before putting the mesh by tactile feedback of tip of tacker.
- Fixation of the lower half of the mesh was done by using fibrin glue.
- Care was taken not to place hernia tacker at Triangle of Doom
RESULTS: Mean operative time was 15 minutes. Mean hernia diameter was 2 cm (+/- 0.5 cm). 9 hernias were direct, 8 were indirect and 4 out of 21 were recurrent. At World Laparoscopy Hospital we did not convert any of the laparoscopic procedures to open. All the patients were having mean hospital stay one day; mean recovery time for working and general physical activities was six days. All the patients were checked after one week, then one months and 1-2 years. Average follow up time was 20 months. 1 % of patients showed short-term complications. No any additional complications were reported in any of this IPOM technique; particularly, we had no recurrence as was feared about, interestingly no seroma, no mesh migration, and no bowel obstruction or fistula was observed in any case. One video of simple case is showing above which we have uploaded to youtube.
Noninvasive surgical treatment or Keyhole surgery utilizing laparoscopy is often a procedure conceptualized to supply effective standard surgical treatment in the patient of hernia yet decreasing access related morbidity to abdominal wall. The potential advantages that were reported are less postoperative pain, decrease blood loss, quicker recovery, superior cosmetic results, less surgical trauma to unrelated organ and surrounding tissue with decreased immunological and metabolic trauma on the patient. In the short 20 year history of laparoscopic surgery we perceive an elevated worldwide acceptance and progression from multi-port (4 incisions) to single port one incision. Concurrent using this trend has been improvement in equipment permitting more compact entry sites which range from 25 mm to 2 mm port and placing the incision wound into anatomic hidden areas for improved cosmetic results.
Laparoscopic IPOM is an optional operation for inguinal hernia and is much easier to be performed. Benefits include operative time saving, better cosmesis, early discharge and early return to work compare to TAPP and TEP. Bio-resorbable composite mesh or Vipro mesh prevents bowel adhesion, however, is much more expensive use of fibrin glue is required together with tacker over cooper ligament and all over mucles above the inguinal ligament. Long term follow up study for complications and recurrence is needed for this technique but ease of doing hernia without the fear of damaging important structures in triangle of Doom, Triangle of pain and Trapezoid of disaster makes it an attractive technique of laparoscopic hernia repair.
Conclusion of laparoscopic IPOM technique of inguinal hernia repair?
Our initial results of IPOM technique of this study show intra peritoneal (IP) tolerance to this kind of vipro mesh and the safety of its fixation with fibrin glue. The absence of recurrence and any complications due to lack of aggressive dissection could be a good reason to extend the indication of Laparoscopic IPOM inguinal hernia repair. However, these preliminary results of World Laparoscopy Hospital should be confirmed by longer follow-up.