Avoiding Recurrence

Avoiding recurrence

Introduction

Causes of recurrence after laparoscopic hernioplasty A multicenter studyE. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7

Surg Endosc (1998) 12: 226–231

Retrospective review of patients who had a laparoscopic hernioplasty (Tapp or Tep) between 1990 and 1996 at centers specializing in laparoscopic repairs (>500 repairs at each center).

This large multicenter study demonstrated that the incidence of recurrence after laparoscopic hernioplasty performed by experienced surgeons was extremely low and that some causes could be corrected by experience, whereas others will require changes in technique or equipment.

Reasons for early recurrence following laparoscopic hernioplasty.Phillips EH - Surg Endosc - 01-FEB-1995; 9(2): 140-4; discussion 144-5

• A multi-institutional study was performed among the pioneers in the field. The incidence figures were obtained by survey of surgeons who had significant experience (over 100 cases) and kept concurrent records.

• Fifty-four recurrences (1.7%) occurred after 3229 laparoscopic hernia repairs.

• Technical factors were responsible for nearly all recurrences.

Laparoscopic repair of recurrent inguinal hernias afterendoscopic herniorrhaphyM. T. T. Knook,1 W. F. Weidema,2 L. P. S. Stassen,3 C. J. van Steensel2

Surg Endosc (1999) 13: 1145–1147

• Identification of the causes of recurrence after endoscopic hernia repair is crucial for the future treatment of all inguinal hernias, whether primary or recurrent.

Mechanisms of Hernia Recurrence After Preperitoneal Mesh Repair: Traditional and Laparoscopic

Lowham, Anthony S. M.D.*; Filipi, Charles J. M.D.*; Fitzgibbons, Robert J. Jr. M.D.*; Stoppa, Rene M.D.†; Wantz, George E. M.D.‡; Felix, Edward L. M.D.§; Crafton, W. Boyd M.D.[//]

• The factors leading to recurrence in the traditional repair (i.e., tension on the suture line, decreasing collagen content with age) do not lead to recurrence in the preperitoneal repair.

Statistics

Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg

Rutkow IM, Robbins AW (1993) Clin North Am 73: 413–426

• Primary repair has been associated with recurrence rates as high as 10–15% .


Surg Endosc (1998) 12: 226–231

• Recurrence rates after laparoscopic repairs, however, have varied widely between different series.

• A few groups have reported short-term recurrence rates <1% , whereas others have reported rates that range from 2 to 10% .


Surg Endosc (1998) 12: 226–231

• Only in isolated centers specializing in hernia repair have reported recurrence rates approached an acceptable level of <1% .

• The incidence of recurrence for the centers ranged from 0.1% to 0.9% and was not correlated with the number of hernioplasties performed

Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphyM. T. T. Knook,1 W. F. Weidema,2 L. P. S. Stassen,3 C. J. van Steensel2

Surg Endosc (1999) 13: 1145–1147

• The recurrence rate for endoscopic herniorraphy is low (0–3%)

Groin Hernia Repair by Laparoscopic Techniques: Current Status and Controversies

Maurice E. Arregui1 and Susan B. Young1World Journal of Surgery Société Internationale de Chirurgie 2005

10.1007/s00268-005-7968-9

• Table 1. Review of recent studies: recurrence and complication rates.

• Study No. of patients Recurrence Complications• Minor Major• Schwab [16] 2002 (L) 1388 11 (0.6%) 83 (6.0%) 18 (1.3%)• Fazzio [11] 2002 (L) 408 1 (0.2%) 3 (0.74%) 0• Schmedt [18] 2002 (L) 5524 55 (1.8%) Total 202 (3.7%) • Ramshaw [10] 2003 (L) 337 1 (0.3%) 22 (6.5%) 0• Bell [19] 2003 (L) 186 1 (0.53%) 10 (5.4%) 0• Pawanindra [12] 2003 (L) 25 0 3 (12.0%) 0• Schneider [13] 2003 (L) 28 1 (3.6%) 5 (17.9%) 0• Winslow [15] 2004 (L) 147 3 (2.0%) 49 (33.3%) 0• Feliu [14] 2004 (L) 78 1 (1.3%) 12 (13.9%) 1 (1.3%)• Heikkinen [17] 2004 (L) 62 5 (8.0%) 0 1 (1.6%)

Causes of Recurrence

Causes of Recurrence in Traditional Anterior Repairs

• Tension • Missed or overlooked hernias • Intrinsic weakness in the collagen floor• Technical errors committed during the repair.

Causes of recurrence after laparoscopic hernioplasty A multicenter study E. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7

Mechanisms of Recurrence for Traditional Preperitoneal Herniorrhaphy

• Most recurrences after prosthetic repair occur during the first postoperative year and result from technical mistakes associated with selection of an insufficiently sized prosthesis, improper placement, or as a result of complications such as infection or a hematoma.

• Wantz,Stoppa, and Rignault all note that hernia recurrences in their respective series occur within the first postoperative year and often within 6 months.

Mechanisms of Hernia Recurrence After Preperitoneal Mesh Repair: Traditional and LaparoscopicLowham, Anthony S. M.D.*; Filipi, Charles J. M.D.*; Fitzgibbons, Robert J. Jr. M.D.*; Stoppa, Rene M.D.†; Wantz, George E. M.D.‡; Felix, Edward L. M.D.§; Crafton, W. Boyd M.D.[//] Ann Surg. 1997 Apr;225(4):422-31.

A unified approach to recurrent laparoscopic hernia repairsE. L. Felix

Surg Endosc (2001) 15: 969–971

• Because laparoscopic hernioplasty eliminates missed hernias, tension, and intrinsic weakness of the floor, which are the most common causes of recurrence after open hernia repair, technical errors remain the most important cause of failure after a laparoscopic hernia repair.

Causes of Recurrence

• Evolution of technique• Inexperience (learning

curve)• Incomplete dissection

- missed lipoma - missed hernia - inadequate reduction of direct hernia sac - inadequate dissection of indirect hernia sac

Mesh related :• Mesh size • Mesh configuration• Mesh fixation• Mesh displacement

Laparoscopic repair for groin hernias Chad J. Davis, MD*, Maurice E. Arregui, MD Surg Clin N Am 83 (2003) 1141–1161

Causes of recurrence after laparoscopic hernioplastyA multicenter study

E. Felix,1 S. Scott,2 B. Crafton,3 P. Geis,4 T. Duncan,5 R. Sewell,6 B. McKernan7


Surg Endosc (1999) 13: 1145–1147

TableMissed Hernia

Retained Lipoma

Keyhole Inadequate fixation

Small mesh

Inadequate dissection

Inadequate mesh overlap

Felix 2001 11%

4/35

9%

3/35

15%

5/35

65%

22/35

Knook 38% 13/34

26%9/34

Philipis 20% 32%

19/54

60%

36/54

Lowham 7%

1/13

0% 14%

2/13

46%

6/13

30%

4/13

Chowbery 25% (1/4)

75% (3/4)

Evolution of technique

Evolution of the Technique

• Advancement from simple suture or staple closure of isolated defects to the use of a prosthesis, first to cover a single defect and finally to cover and overlap all hernia sites, correlates well with the decreasing recurrence rate.

Mechanisms of Hernia Recurrence After Preperitoneal Mesh Repair: Traditional and LaparoscopicLowham, Anthony S. M.D.*; Filipi, Charles J. M.D.*; Fitzgibbons, Robert J. Jr. M.D.*; Stoppa, Rene M.D.†; Wantz, George E. M.D.‡; Felix, Edward L. M.D.§; Crafton, W. Boyd M.D.[//]



Ann Surg. 1997 Apr;225(4):422-31.

• Shultz et al reported a decrease in the rate of hernia recurrence from 26% to 0% when switching from the plug-and-patch repair to the preperitoneal placement of a large prosthesis

secured with staple fixation.

Transabdominal preperitoneal laparoscopic inguinal herniorrhaphy: lessons learned and modifications. Schultz LS, Graber JN, Hickok DF. In: Arregui ME, Nagan RF, eds. Inguinal Hernia: Advances or Controversies? Oxford, England: Radcliffe Medical Press; 1994:301-306. Ann Surg. 1997 Apr;225(4):422-31.

The recurrence rate varied drastically with the technique:

Technique

Recurrence

Plug and patch Ring closure IPOM TAPP TEP

Tetik 22% 3% 2.2% 0.7% 0.4%

Philipis 9% 2.6% 2% 1% 0%

Reasons for early recurrence following laparoscopic hernioplasty. Phillips EH - Surg Endosc - 01-FEB-1995; 9(2): 140-4; discussion 144-5

Complications and recurrences associated with laparoscopic repair of groin hernias. A multi-institutional retrospective analysis. Tetik C - Surg Endosc - 01-NOV-1994; 8(11): 1316-22; discussion 1322-3

Totally extraperitoneal repair of recurrent inguinal hernia Results from 179 consecutive ptsH. Scheuerlein, A. Schiller, C. Schneider, H. Scheidbach, C. Tamme, F. Ko¨ ckerling

Surg Endosc (2003) 17: 1072–1076

• In the beginning of our experience with TEP in 1994, the recurrence rate for the first 200 patients was 3%

• Presumably due to the lower level of operative experience and the use of a smaller mesh size (8 · 12 cm).

Totally Extraperitoneal (TEP) Approach for Inguinal Hernia: The Favorable LearningCurve for Trainees

Jaime Haidenberg, MD, Michael L. Kendrick, MD, Tobias Meile, MD, and David R. Farley, MDCURRENT SURGERY • Volume 60/Number 1 • January/February 2003

• Our overall recurrence rate is relatively low (2%),

• It is important to note that of the 8 overall recurrences, 6 occurred in the first 40 cases when our technique involved placement of a 2.54-inch piece of permanent mesh and did not emphasize holding down the lower, lateral corner of the mesh upon evacuation of the CO2 gas.



• A major factor in recurrence included inadequate fixation due to the unavailability of staplers early in the development of laparoscopic herniorrhaphy or clips pulling through tissue.

Learning curve

Totally extraperitoneal endoscopic inguinal hernia repair (TEP) Results of 5,203 hernia repairsC. Tamme, H. Scheidbach, C. Hampe, C. Schneider, F. Ko¨ ckerling

Surg Endosc (2003) 17: 190–195

• 29 recurrent hernias (0.6%) were observed

• More than 50% of which occurred during the first 2 years after the technique was introduced (1.8%).

• During subsequent years, the recurrence rate settled to approximately 0.3%.


Surg Endosc (1999) 13: 1145–1147

• The prevailing opinion is that recurrences are due to technical errors.

• It is obvious that many technical errors could be avoided if we knew how to prevent them.

• Most recurrences occur during the surgeon’s early experiences with endoscopic hernia repair .


Surg Endosc (1998) 12: 226–231

As surgeons gained experience, the incidence of recurrence due to missed hernias or too small a mesh decreased.


Surg Endosc (2001) 15: 969–971

• Experience has eliminated technical errors such as missed hernias, too small a mesh, and inadequate dissection.

• The incidence of technical errors is decreased by experience .

Open Mesh versus Laparoscopic Mesh Repair of Inguinal HerniaLeigh Neumayer, M.D., Anita Giobbie-Hurder, M.S., Olga Jonasson, M.D., Robert Fitzgibbons, Jr., M.D.,

Dorothy Dunlop, Ph.D., James Gibbs, Ph.D., Domenic Reda, Ph.D., and William Henderson, Ph.D.,for the Veterans Affairs Cooperative Studies Program 456 Investigators*

n engl j med 350;18 29, 2004

• The recurrence rate associated with laparoscopic repair was greater than 10 percent for the 58 surgeons who reported having performed 250 or fewer laparoscopic repairs in any category,

• whereas the recurrence rate was less than 5 percent for the 20 surgeons who reported having performed more than 250 laparoscopic repairs

Incomplete Dissection

Laparoscopic repair for groin herniasChad J. Davis, MD*, Maurice E. Arregui, MD

Surg Clin N Am 83 (2003) 1141–1161

• The two most common causes of recurrence are incomplete dissection of the myopectineal orifice and inadequate size of the mesh.

Laparoscopic repair for groin herniasChad J. Davis, MD*, Maurice E. Arregui, MD

Surg Clin N Am 83 (2003) 1141–1161

• Lowham et al reviewed 13 videotapes of hernias that had recurred in the multicenter trial by Fitzgibbons et al and found that incomplete dissection of the myopectineal orifice was the primary cause of recurrence.



Ann Surg. 1997 Apr;225(4):422-31.

Incomplete dissection

Missed hernia



• Missed hernias were responsible for failure in four cases; all of these procedures were done early in the surgeon’s experience, and all used the TAPP approach.

Recurrent hernia following endoscopic total extraperitoneal repair.Chowbey PK - J Laparoendosc Adv Surg Tech A - 01-FEB-2003; 13(1): 21-5

• One of the four patients (25%) was found to have a missed indirect hernia sac.


• The hernia was never repaired in three cases (20%).


Missed lipoma

Lipomas of the cord and round ligament.Lilly MC - Ann Surg - 01-APR-2002; 235(4): 586-90

• A lipoma of the cord is herniated fat that appears to originate from the retroperitoneal fat outside and posterior to the internal spermatic fascia and protrudes through the internal ring lateral to the cord. They are generally not visible by transperitoneal inspection unless manually reduced.

• Lipomas of the cord and round ligament occur with a significant incidence 22.5%.

• They can cause hernia-type symptoms in the absence of a true hernia (associated with a peritoneal defect). They should be considered in the patient with groin pain and normal examination results.

• They can be easily overlooked at the time of laparoscopic hernia repair, and this can lead to an unsatisfactory result.



• A retained or missed lipoma of the cord was the cause in four patients 9%



• A retained or missed lipoma was responsible for one-third of the TEP repairs that failed.

• When performing a totally extraperitoneal dissection, the surgeon may overlook a lipoma if there is no indirect hernia or the indirect hernia is quite small.



10.1007/s00268-005-7968-9

• A missed lipoma of the cord or subsequent herniation of preperitoneal fat may mimic recurrence.

• This usually occurs through the internal ring but can occur at the site of a previous direct hernia.

• This is difficult to prevent even with well placed mesh, as the fat can work its way between the mesh and the abdominal wall.

Missed lipoma of the spermatic cord. A pitfall of transabdominal preperitoneal laparoscopic hernia repair.

Gersin KS - Surg Endosc - 01-JUN-1999; 13(6): 585-7

• Missed lipoma of the spermatic cord is a pitfall unique to the transabdominal preperitoneal (TAPP) laparoscopic hernia repair.

• This problem occurs when a palpable inguinal mass is noted preoperatively, but no identifiable hernia defect is found at time of laparoscopy and the procedure is terminated.


Surg Endosc (2001) 15: 969–971

• Retained lipomas and migration of the mesh remain the most common causes of recurrence in the hands of experienced surgeons .

• Retained lipomas are the result of the surgeon failing to identify and remove the lipoma from the canal or breaking part of it off and leaving it behind.


Inadequate reduction of direct hernia sac


Inadequate dissection of proximal indirect sac from cord


Surg Endosc (1999) 13: 1145–1147

• During a TAPP, it is sometimes difficult to create enough room to position the prosthesis correctly, which probably led to medial recurrence due to insufficient overlap on this side.



• In the TEP repair, there may be a tendency not to dissect the peritoneum far enough off the cord structures to allow the mesh to lay under the peritoneum.



Ann Surg. 1997 Apr;225(4):422-31.

• The predominant primary factor resulting in hernia recurrence

was found to be insufficient dissection.



Ann Surg. 1997 Apr;225(4):422-31.

• Inadequate dissection results in poor overall assessment of the groin floor, missed hernias, and insufficient delineation of fascial structures.

• Incomplete dissection leads to a number of secondary mechanisms of recurrence, including insufficient prosthetic size and overlap, incomplete fixation, and lipomatous hernia

"recurrence."

Mesh Related

Mesh Size and Configuration

• Insufficient size of the mesh (too small)• Insufficient overlap over the defect• Slit or keyhole

Mesh related

Size / Insufficient Overlap


Surg Endosc (1999) 13: 1145–1147

• Often cited as a mechanism for recurrence is the inadequate size of the prosthesis, so that not all of the defect is covered and the overlap is insufficient .



Ann Surg. 1997 Apr;225(4):422-31.

• Inadequate prosthetic overlap and prosthetic size were related predominant primary and secondary factors.



• The size of the mesh was rarely a cause of failure in TEP repairs.


• The most common reason for recurrence was that the mesh

was too small (36/54) (60%).



• A prosthesis placed over an isolated defect ignores the possible weakness of the entire inguinal region, and the result is a future recurrence at another site (i.e., direct repair with indirect recurrence).

• This can be labeled inadequate coverage of potential hernia defects because future development of a hernia at another site would have been prevented with a prosthesis covering the entire myopectineal orifice.



Ann Surg. 1997 Apr;225(4):422-31.

• Inadequate overlap as a mechanism in recurrence is related directly to inadequate dissection and an insufficiently sized prosthesis.


Surg Endosc (1999) 13: 1145–1147

• In 20% (7/34), an indirect recurrent hernia was found.

• In these patients, either the primary hernial sac was not fully dissected or the mesh was too small, since the recurrent hernia was found to protrude under the original mesh prosthesis.

Mesh related

configuration


Surg Endosc (1999) 13: 1145–1147

• In the TEP procedure, incorrect positioning is the most

probably cause of medial recurrence.



• The keyhole was responsible for 15% of all recurrences and one-third of the TEP failures.

• An additional mesh over the keyhole placed in some of the repairs may have prevented this number from being even higher.



• Mesh slitting has been noted to be a mechanism of recurrence in some studies. The prosthesis wraps around the vessels and is drawn into the inguinal canal leading to an indirect recurrence .

• If the slit edges are not reapproximated adequately, an opening is present for recurrence.



• Felix thinks a slit to accommodate the vas and spermatic vessels is needed because they tend to elevate the mesh off the inguinal floor.



• Crafton favors an inferior mesh slit lying below the iliopubic tract with reapproximation by staples.


Surg Endosc (2001) 15: 969–971

• Keyholing the mesh reduces lateral failures, but it increases the chance of recurrence through the mesh and may increase pain along the cord .

Mesh related

fixation

Mesh Fixation

• Mesh poorly fixed laterally• Mesh poorly fixed medially• Mesh never fixed• Clips pulled through


• The mesh was never stapled in 19 instances (32%),

• The clips pulled through the tissue in six cases (8%)



• Inadequate lateral fixation of mesh was one of the major causes of failure in both approaches : 36% of TAPP and 22% of TEP repairs.

• Because of the location of major nerves, fixation cannot be done below the iliopubic tract. The mesh is therefore vulnerable to being elevated off the lateral wall, which results in an indirect recurrence.


Surg Endosc (1999) 13: 1145–1147

• The advantages of stapling include a lower risk of mesh migration; the disadvantages include nerve entrapment, vessel laceration, and pain in the abdominal wall .

• Since we prefer not to use staples for mesh fixation, we advocate the use of a larger mesh prosthesis .



• Proper staple fixation also acts to prevent early displacement, folding or invagination of the prosthesis into the defect in the early postoperative period, before cellular infiltration and collagen depostion.



• A study by Powell et al also showed that a linear relation existed between the number of staples used (one to three) and the maximum load tolerated.

Randomized Clinical Trial of Fixation vs Nonfixation of Mesh in TotalExtraperitoneal Inguinal Hernioplasty

Alfredo Moreno-Egea, MD; José Antonio Torralba Martínez, MD;Germán Morales Cuenca, MD; José Luis Aguayo Albasini, MD

Arch Surg. 2004;139:1376-1379

• Stapling the mesh in total extraperitoneal inguinal hernioplasty offers no advantages and increases the cost of the process.

• Our results suggest the possibility of limiting the use of mesh fixation in total extraperitoneal inguinal hernioplasty to cases of direct bilateral hernias.

Mesh related

Displacement

Mesh Displacement

• Mesh lifting secondary to Hematoma ,Seroma• Migration• Rolling ,folding or twisting of the mesh• Shrinkage


• Medial recurrences developed in three of the four patients because of medial displacement of the mesh.


Surg Endosc (1999) 13: 1145–1147

• In 65% (22/34), a medial recurrent hernia was found.

• In these cases, the original mesh probably did not cover the defect sufficiently on the medial side, since the hernia passed the mesh medially.

• Another possibility is that the mesh moved laterally during or after desufflation.



Ann Surg. 1997 Apr;225(4):422-31.

• If the preperitoneal space is not developed adequately and a prosthesis is inserted with insufficient room for placement, folding may result.


Surg Endosc (1999) 13: 1145–1147

• After desufflation, when a hematoma or a seroma forms, floating of the mesh can lead to mesh movement.

• Elevation of the intraabdominal pressure might lead to protrusion of the mesh into the hernial defect.

Groin Hernia Repair: Open TechniquesParviz K. Amid1, 2

World Journal of Surgery June 2005

• shrinkage of the mesh in vivo, is approximately 20%.



• A small prosthesis placed over an isolated defect may lead to recurrence because of subsequent enlargement of the defect or shrinkage of the prosthesis.



• Displacement of the prosthesis with uncovering of a hernia defect may lead to recurrence and most often results from improper fixation.

• Minimal migration or shrinkage of the prosthesis or both from fibroblast ingrowth may result in uncovering of the hernia defect if inadequate overlap is used.



• Fiennes and Taylor think that desufflation after laparoscopic herniorrhaphy tends to elevate the lower edge of the prosthesis and predisposes to migration of the inferomedial aspect from the space of Retzius in the presence of a direct defect.

• They noted that four of five recurrences in their experience resulted from herniation inferomedially with the prosthesis and emphasized secure fixation to Cooper's ligament.



• Hematoma mesh lifting also has been noted by Wantz and Stoppa (personal communication, 1996) to produce hernia recurrence.


Surg Endosc (2001) 15: 969–971

• Migration of the mesh, or lifting of the mesh, in either the medial or lateral position, is due to inadequate fixation medially or the inability to fix the mesh laterally because of the position of the nerves.

• There are techniques that limit the elevation of the lateral mesh, but none of them are entirely effective.

Techniques

To Avoid Recurrence



• Stoppa advocates minimal suture placement, relying on intra-abdominal pressure to hold the

prosthesis in place. Of 11 recurrences, 7 are described inferior to the mesh and were repaired by additional mesh placement or further fixation to Cooper's ligament. Three recurrences were noted lateral to the mesh.

• Wantz advocates use of a diamond-shaped Mersilene prosthesis (Ethicon, Inc., Somerville, NJ) measuring approximately 12 cm × 15 cm for unilateral GPRVS. He thinks the diamond shape conforms to the myopectineal orifice better than a rectangular mesh and ensures a circumferential and adequate overlap.

• If the mesh is not to be fixed, Wantz recommends Mersilene, because it is soft, conforms to the complex curves of the pelvis, and stays in place. Other meshes, all the polypropylene meshes and Gore-Tex (W. L. Gore and associates, Phoenix AZ), must be fixed along the periphery.

• Wantz also recommends drainage in all patients with incomplete hemostasis or a large retained sac in which blood accumulates and may result in formation of a presumed recurrent hernia.

• It is emphasized that thorough dissection and identification of all fascial defects will prevent herniation external to the abdominal wall, the so-called "lipomatous hernia."

The cause, prevention, and treatment of recurrent groin hernia. Lichtenstein IL, Shulman AG, Amid PK (1993) Surg Clin North Am 73: 529– 544

• To prevent recurrent hernias, the following five cardinal principles need to be followed

• Do not depend on fascial structures to close or reinforce the defect.

• Reinforce the entire inguinal floor irrespective of the type of hernia.

• Avoid all tension on suture lines.• Avoid the use of scarred or devascularized tissue in the repair

of recurrent hernias.• Use a large prosthetic material to reinforce the entire inguinal

floor permanently.

Technical Guidelines

• Detailed knowledge of the inguinal anatomy is required.• Systematic complete dissection with identification of all potential hernia sites

and landmarks of fixation is the mainstay of successful preperitoneal hernia repair.

• The fascial edges of direct hernia defects must be defined fully.• The proximal hernia sac should be dissected free of the cord and reduced

into the peritoneal cavity for indirect hernias.• The prosthesis must cover and overlap the entire myopectineal orifice

without folding or twisting.• If a slit is placed for the vas deferens and gonadal vessels, it should be

closed carefully with staples and a double buttress considered.• All smaller prostheses (<12 cm × 12 cm) require fixation to Cooper's

ligament, the transversus abdominis aponeurosis, and anterior lateral abdominal wall with a stapling device developed for this purpose.

• Care must be taken to place the inferior edge of the prosthesis flatly against the pelvic floor.

Mechanisms of Hernia Recurrence After Preperitoneal Mesh Repair: Traditional and LaparoscopicLowham, Anthony S. M.D.*; Filipi, Charles J. M.D.*; Fitzgibbons, Robert J. Jr. M.D.*; Stoppa, Rene M.D.†; Wantz, George E. M.D.‡; Felix, Edward L. M.D.§; Crafton, W. Boyd M.D.[//]



• Full exposure of Cooper's ligament,

• Removal of excess preperitoneal fat and cord lipomas,

• Complete assessment of all potential hernia sites,

• Full reduction of the direct sac,

• Complete dissection of the proximal indirect sac from the cord (complete dissection of the distal sac can result in testicular atrophy), and identification of the vas deferens and gonadal vessels are required.


Surg Endosc (1999) 13: 1145–1147

• Not enough is known about how much overlap is essential to prohibit hernia recurrence.

• The basic requirement is a prosthesis large enough to cover and adequately overlap all potential hernia sites in the myopectineal orifice.

• It is thought that all defects should be overlapped by 2 cm if the mesh is stapled and 3 cm if it is left unstapled.

• A 15 × 15 cm prosthesis should therefore be adequate to prevent recurrent hernias, assuming that the mesh is positioned properly and complete dissection has been done .



• It appears a 10- to 15-cm × 10- to 15-cm prosthesis is necessary to form an adequate coverage of the inguinal floor.



• All of the surgeons recommended dissecting the entire floor of the groin to avoid missing any element of the hernia;

• They further recommended repairing all three potential hernia sites to prevent the development of new hernias in the future.

• The mesh was fixed to Cooper’s ligament, the transversalis fascia, and laterally above the iliopubic tract by all surgeons, but the specific choice of fixation device did not seem to influence the outcome of the repair.



• Care must be taken to clear the iliopubic tract in order to ensure the removal of an extraperitoneal fat that may be draping over the internal ring into the canal.



• To prevent lateral recurrences, several surgeons in our study utilized a keyhole in the mesh that placed it under the testicular vessels and vas deferens.



• Stable fixation of an adequately sized prosthesis to Cooper's ligament and the transversus abdominis aponeurosis and arch is recommended.

• Fixation just above the iliopubic tract will provide additional adherence inferolaterally, but care must be taken to place staples superior to the iliopubic to avoid injury to the lateral femoral cutaneous nerve.



• Placement of at least three staples in the easily identified and firm Cooper's ligament and several staples horizontally oriented in the muscular aponeurosis and just anterior to the iliopubic tract is recommended for small prostheses (10 cm × 12 cm).

Missed lipoma of the spermatic cord. A pitfall of transabdominal preperitoneal laparoscopic hernia repair.

Gersin KS - Surg Endosc - 01-JUN-1999; 13(6): 585-7

• When patients present with a groin mass, exploration of the preperitoneal space and cord structures is indicated during TAPP repair, even in the presence of a normal-appearing abdominal floor.

• Abandoning a transabdominal approach without exploration of the preperitoneal structures may lead to a failure to identify symptomatic and/or palpable cord lipomas.


• In addition to medial fixation of the mesh to the Cooper ligament, complete proximal dissection of the peritoneum from the spermatic cord and additional fixation of the mesh to the anterior abdominal wall, with careful avoidance of possible injury to the adjacent nerves, may prevent recurrences.



• A majority of recurrences after laparoscopic hernia repair could have been prevented with adequate dissection, full prosthetic coverage of all potential hernia sites, and adequate fixation.



• To prevent possible recurrence at the slit, he uses a double buttress technique and places a second 15-cm × 15-cm patch centered over the slit of the original 6-cm × 10-cm mesh.

discussion


• There was more than one reason in 35% of patients.(19/54 )



• Stoppa found the slit in the mesh to be a cause for concern in his open posterior repair and no longer recommends slitting the mesh in order to prevent herniation through it .

Abdominal wall anatomy: the key to a successful inguinal hernia repairShawn P. Fagan, M.D.*, Samir S. Awad, M.D.

The American Journal of Surgery 188 (Suppl to December 2004) 3S–8S

• The purpose of this article is not to present a comprehensive review of the anatomic structures within the groin, but to investigate the concept of a hernia being a pathologic hole arising from an anatomic hole or the myopectineal orifice.

• We believe an effective inguinal herniorrhaphy not only repairs the pathologic hole but covers future sites of herniation within the myopectineal orifice.


Surg Endosc (2001) 15: 969–971

• The errors committed by inexperienced surgeons using each of these approaches appear to be approach-related .

• In the TAPP approach, the surgeon may not develop enough space to place a large enough mesh; and in doing a TEP approach, mesh is more prone to be lifted laterally.



10.1007/s00268-005-7968-9

• A seroma or hematoma, can cause discomfort or be mistaken for a recurrence.

Conclusion

Avoiding Recurrence

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