Repeat Laparoscopic Totally Extraperitoneal HerniaRepair After Primary Laparoscopic Totally

Extraperitoneal Hernia Repair for Inguinal Hernia

Hiroki Uchida, MD,1,2 Toshifumi Matsumoto, MD,1,2 Yuichi Endo, MD,1,2

Tetsuya Kusumoto, MD,1,2 Yoichi Muto, MD,1,2 and Seigo Kitano, MD, FACS3

Abstract

Introduction: Although laparoscopic totally extraperitoneal hernia repair (TEP) is reported to have a low re-currence rate, few reports address treatment for contralateral occurrence after primary TEP. Most studies onsurgical treatment for recurrent inguinal hernia reported on laparoscopic transabdominal preperitoneal repair.The aim of this study was to evaluate the efficacy of repeat TEP for contralateral occurrence after primary TEPfor unilateral inguinal hernia.Methods: We retrospectively reviewed the medical charts of 215 patients undergoing TEP performed betweenApril 2003 and May 2009. We employed a similar approach to that of standard TEP for primary hernia.Results: Twenty eight of 215 patients who underwent unilateral TEP also underwent repeat TEP for contra-lateral-side hernia occurring after primary TEP. The initial hernia was on the right side in 15 patients and on theleft side in 13. The initial hernia was indirect in 26 patients and direct in 2. Mean duration of primary TEP tocontralateral occurrence was 54.4 months. Mean operation time for the contralateral occurrence was 73.3 min-utes, and there was little intraoperative blood loss. Three patients were converted to an anterior approachbecause of insufficient surgical field due to injury of the peritoneum. Although the inferior epigastric artery andvein were divided in 4 patients, there were no difficulties during surgery. The postoperative course in all patientswas uneventful.Conclusions: TEP after primary TEP for contralateral occurrence is feasible. Repeat TEP might be an alternativetechnique for new occurrence of contralateral inguinal hernia after primary TEP.

Introduction

After the introduction of endoscopic hernia repair byGer in 1982, the number of laparoscopic totally extra-peritoneal hernia repairs (TEPs) has been constantly rising.1

The laparoscopic approach has been associated with lesspostoperative pain, shorter hospital stay, and low recurrencerate.24 Some studies reported that recurrence rates rangedfrom 0.3% to 8.5%,5 and the rate of contralateral occurrencewas about 1%.6,7 As the period of postoperative surveillance isextended, it is thought that the number of patients with re-currence or with a new hernia on the contralateral side willincrease.

Laparoscopic technique as the treatment for recurrenthernia has been reported to be superior to open anterior

repair.811 Although laparoscopic transabdominal preperi-toneal repair (TAPP) for recurrence after primary TEP orTAPP has also proven feasible,8,12,13 only a few studies havereported on TEP for recurrence after primary TEP. Felix et al.reported that TEP after primary TEP is virtually impossible.12

Therefore, the purpose of this study was to review our ex-perience with TEP of contralateral hernia recurrence after aprimary TEP.

Patients and Methods

From April 2003 to May 2009, 215 TEPs had been per-formed for inguinal hernia in Beppu Medical Center. Ofthese, 30 TEPs were performed for bilateral inguinal her-nia, 157 TEPs for primary inguinal hernia, and 28 TEPs for

1Department of Surgery, National Hospital Organization Beppu Medical Center, Beppu, Japan.2Clinical Research Institute, National Hospital Organization Beppu Medical Center, Beppu, Japan.3Department of Gastrointestinal Surgery, Oita University Faculty of Medicine, Yufu, Japan.

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contralateral occurrence. We retrospectively reviewed thecases of the 28 patients who underwent TEP for contralateralhernia occurrence (Table 1). Twenty-three of those 28 patientshad undergone primary TEP before April 2003 and 5 haddeveloped contralateral inguinal hernia from April 2003 toMay 2009.14 The follow-up period was between 1 and 72months (median 35.9 months). The surgeons, each experi-enced over 10 years, were considered to be experienced inlaparoscopic gastrointestinal surgery.

Our approach to these contralateral occurrences was notmarkedly different from that of standard TEP. A small para-umbilical incisionwasmade and the ipsilateral anterior rectussheath was opened. The extraperitoneal space was createdwithout exposing the primary repair using a PDB 1000(Covidien). There was no additional dissection. Carbon di-oxide gas was insufflated to an intraperitoneal pressure of10mmHg to create a surgical field. The ENDOPATH XCEL5-mm port (Ethicon Endo-Surgery) was made on the ipsilat-eral rectus or lower midline. We used polypropylene three-dimensional mesh to cover the inguinal bed and ProTackTM

(Autosuture; Tyco Healthcare) to fix the mesh.

Results

A total of 28 TEPs were performed for inguinal herniaoccurring on the contralateral side after primary TEP. Thepatients comprised 26 men and 2 women with a mean age of63.7 years (range: 2388 years) (Table 2). Of the contralateralhernias, 27 were indirect hernias and 1 was a direct hernia.The mean period to contralateral occurrence was 54.6 months(range: 2131 months) after primary surgery. The mean op-eration timewas 73.8minutes (range: 25217minutes) and theconversion to anterior repair was made in 7 of 157 patientswho had undergone primary TEP for unilateral inguinalhernia. There were no significant difference in operation timeand rate of conversion by using MannWhitney U test and w2

test.

Repeat TEPwas applied to repair the contralateral inguinalhernia after primary TEP in these patients. In 3 patients,conversion to an anterior open procedure was made becauseof injury to the peritoneum due to adhesions on the midlinepreperitoneal space in 1 patient and due to difficulties indissecting the preperitoneal space with a blunt balloon-tipcannula at the beginning of surgery in 2 patients. However,these converted 3 cases had occurred in first 10 cases and therewere no convert after these sequential cases. The inferiorepigastric artery and vein were divided in 4 patients becauseof bleeding in 2 cases and strong adhesion to peritoneum in 2cases during the dissection of PDB 1000. There were nopostoperative complications (Table 3). There were no recur-rences in these 28 patients after secondary TEP. The follow-upperiod was between 1 and 70 months.

Discussion

Laparoscopic repair of recurrent hernia has been shown tobe effective.811 Many studies concerning the repair of recur-rent hernia were reported after 1999, and most of the proce-dures reported were TAPP for recurrent hernia. In thesereports, several authors reported the feasibility of TAPP repairfor recurrence after primary laparoscopic hernia repair byTAPP or TEP.8,12,13 Leibl et al. reported TAPP repair of therecurrence in 46 of 5005 patients, and the total complicationrate was 10.9%.8 Felix et al. reviewed 35 recurrences in 10,053hernias in 7661 patients, of which 29 were repaired by TAPP.Four patients were converted to an open approach. They as-serted that it was virtually impossible to reexplore an extra-peritoneal repair extraperitoneally.12 However, Tamme et al.reported on 5203 TEPs in 3868 patients, in whom 29 recurrenthernias had been detected in 28 patients.15 Among these pa-tients, 26 had primary hernia and 3 had recurrent hernias.Reoperation had been performed for 23 recurrent hernias intheir institution, 18 by Lichtenstein technique, 3 by TAPP, and2 by TEP. Ferzli et al. reported the repair of 1059 inguinalhernias in 804 patients bymeans of TEP.7 Twenty patients hadrecurrent hernia and underwent TEP. In these patients, 12hernias were on the ipsilateral side, and 8 were on the con-tralateral side. Only 1 patient converted to an anterior ap-proach, and there were no postoperative complications. Theyconcluded that TEP for recurrent inguinal hernia after pri-mary TEPwas entirely feasible aswell as safe. In our cases, theoperation time for TEP after primary TEP was not prolongedcompared with that of the primary TEP, and there were nopostoperative complications in any patient. These resultssuggest that, in general, reexploration of the extraperitonealspace after primary TEP appears to be feasible.

We do not routinely perform bilateral examination to ruleout contralateral occult inguinal hernia because of low rate

Table 1. Distribution of Laparoscopic TotallyExtraperitoneal Hernia Repairs

No.

Primary TEP 187Bilateral 30Unilateral 157

Repeat TEP 28

Total 215

TEP, laparoscopic totally extraperitoneal hernia repair.

Table 2. Patient Characteristics

Characteristic No. Range

Age (years) 63.7 2388SexMale/Female 26/2

Type of primary herniaRight/left 15/13

Direct/indirect 2/26Duration of contralateraloccurrence (months)

54.6 2131

Table 3. Operative Results

Parameter No. Range

Operative time (minutes) 73.3 27157Blood loss (g) 8.6 190Conversion to anterior approach 3Resection of the inferiorepigastric artery and vein

4

Postoperative complications 0

234 UCHIDA ET AL.

of contralateral occurrence. In our institution, only 5 (3.2%)patients developed contralateral hernia in our 157 patientsundergoing primary TEP for unilateral inguinal hernia be-tween 2003 and 2009.14 Koehler reported observing occultcontralateral hernia in 13% of patients when examined bytransabdominal diagnostic laparoscopy,16 and Thumbe andEvans reported finding incidental defects in 22% of patientsduring TAPP.17 However, Saggar and Sarangi reported that ahernia developed on the contralateral side after only 6 of 446unilateral repairs,6 and Ferzli et al. noted that 4 contralateralhernias occurred after a primary unilateral endoscopic repairin 549 patients.7 The contralateral occurrence rate after TEP islow, and few reports mention laparoscopic repair for newcontralateral hernias. We start all contralateral occurrences asTEPs; however, if we have some trouble, it is thought tochoose open method, not TAPP, because of possibility of in-traoperative injury of intestinal tract and postoperative ileus.In our patients, 3 (11%) of 28 patients converted to an anteriorapproach because of difficulties in reexploring the pre-peritoneal space. The remaining 25 patients underwent TEPwithout injury to the peritoneum, including division of theinferior epigastric artery and vein in 4 patients. However,none of our patients suffered ipsilateral recurrence after pri-mary TEP. Reexploration of the ipsilateral peritoneal spaceafter primary TEPwhen the contralateral peritoneal space hadbeen created with a blunt balloon-tip cannula could be per-formed in only a few patients. Reexploration of the ipsilateralperitoneal space after primary TEP is controversial, and fur-ther accumulation of data on ipsilateral recurrence after pri-mary TEP is necessary.

Conclusions

Repeat TEP had no longer operation time and no higherconversion rate compared with primary TEP. It is thought tobe feasible for contralateral occurrence. Although it has somedifficulty during the dissection of the preperitoneal space,repeat TEP might be an alternative method for contralateraloccurrence after primary TEP.

Disclosure Statement

No competing financial interests exist.

References

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Address correspondence to:Hiroki Uchida, MD

Department of SurgeryNational Hospital Organization Beppu Medical Center

1473 UchikamadoBeppu 874-0011

Japan

E-mail: ucchy@med.oita-u.ac.jp

REPEAT TEP FOR INGUINAL HERNIA 235

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