Laparoscopic Inguino-Femoral Hernia Repair  PART I PART II PART III PART IV PART V

THE LEARNING CURVE PHENOMENON

The TAPP repair remains a difficult surgical repair. It is best demonstrated by the analysis of our mean operating time versus the number of cases performed. Our mean operative time was 1 hour and 39 minutes for our first ten patients. For the last 50 patients, it was 32 minutes. We strongly believe these repairs are best done by surgeons who have performed at least 40 procedures assisting other laparoscopic surgeons well-trained in this procedure. Neophyte operators performing this repair without the proper training or guidance may generate an inordinate and inappropriate morbidity rate.

 

MANAGEMENT OF ACCEPTABLE COMPLICATIONS

• Pneumoscrotum: Almost all male patients will develop an ipsilateral pneumoscrotum. The operator should remember this is a  painless complication which will resolve within six hours after the surgery. It does not require any intervention.
• Seromas: When we started to meticulously dissect the inguinal hernia sac from the spermatic cord instead of cutting it, the rate of postoperative seromas dramatically decreased. It now stands at approximately 3 - 4 % of all cases. This is a painless complication which does not impair the performance status of these patients. If not properly instructed, the patient will think he has an early recurrence of his hernia. He should be reassured and observed for the first 15 days without any restrictions of his physical activities. If the seroma has not resolved, it should be aspirated in the office on a weekly basis. Most seromas will be tapped dry after two aspirations. We should disclose that out of 1700 patients studied, one patient developed a persistent seroma resistant to all aspirations.
• Neuropathy: Since the initiation of this technique, this complication has been subject to intense scrutiny. Injuries to the  genitofemoral nerve, lateral femoral cutaneous nerve and ilioinguinal nerve have been reported in the literature. In summary, almost all patients undergoing this procedure will complain that for the first 72 hours after the procedure they have experienced some form of temporary neuropathy. Very few persist beyond five days. In 1700 patients, only two permanent neuropathies requiring some form of intervention have been reported. One was questionable, the other one occurred when the patient underwent this procedure using an altered position on the operating table. These complications are rare, and patients with complaints compatible with a postoperative neuropathy are observed for one month and asked to exercise daily. Although the literature supports a re-exploration and removal of the staples, to date we have never done so. There are technical maneuvers which are essential for the prevention of such complications, namely avoiding trans-abdominal counter-pressure when stapling the mesh and not placing staples or tacks too low below the spermatic cord to avoid the path of the genitofemoral nerve.
• Non Performing Postoperative Patients: Each patient who undergoes this procedure and remains bedridden during the postoperative period, his recovery will be significantly impaired. This is a dynamic repair and patients have to be remain physically active after this procedure. They are instructed to walk at least one mile per day starting on post operative day one. They are encouraged to go back to their exercise routine and work as soon as possible. Our office policy is to call these patients on post operative day one, three and seven to reiterate the need to be active.

THE FUTURE

We strongly believe this procedure has found its place in the surgical management of inguino-femoral hernias. However, there is significant room for improvement. This procedure is  constantly maturing and the rapid evolution of instrument technology is mandating we revise our technique several times a year. 

As such, we are currently studying the feasibility of performing these procedures under local anesthesia. Our technique to date has not been standardized and is not recommended. Of note, we have also performed a significant number of these procedures using 2 mm micro-instruments. It is a feasible option which can be offered to the discriminative patient who opts for a "no scar" hernia repair.

References:

• Quilici PJ et al: Laparoscopic Inguinal Hernia Repair: Results in 509 Cases - Am Surg 1996 Oct;62(10):849-5
• Quilici PJ et al: Laparoscopic Inguinal Hernia Repair: Results in 131 Cases - Am Surg 1993 Dec;59(12):824-3
• Quilici PJ et al: Laparoscopic Inguinal Hernia Repair: Results in 367 Cases - World Congress 1995 EAES - Luxembourg
• Quilici PJ: New Developments in Laparoscopy (1992) USSC Press - Norwalk USA
• Quilici PJ: Second Generation Laparoscopic Procedures (1990) TMN Press - Los Angeles USA
• Quilici PJ et al: Laparoscopic Inguinal Hernia: 1700 cases - Results and optimal technical variations. Am Surg 2000 Sept;66-9:848-853
• Felix EL et al: Laparoscopic Hernioplasty: TAPP vs TEPP. Surg Endosc (1995) 9: 984-989
• Khoury N: A comparative study of laparoscopic extraperitoneal and transadbominal preperitoneal herniorrhaphy: Journ Laparo Endosc Surg 1995, 5, 349-355
• Tucker JG et al: Laparoscopic herniorrhaphy: Technical concerns in prevention and complications of early recurrence. Am Surg Jan 95:61(1):36-39
• Toy KF et al: Toy-Smoot Laparoscopic Hernioplasty. Del Med J Jan 1992; 4-11
• McGillicuddy JE: Prospective Randomized Comparison of the Shouldice and Lichtenstein Hernia Repair Procedures. Arch Surg.1998;133-974-978
• R J Rosenberger et al: The cutaneous nerves encountered during laparoscopic repair of inguinal hernia. Surg Endosc (2000) 14:731-735