Canadian Association of General Surgeons Association canadienne de chirurgiens...

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192 JCC, Vol. 40, No 3, juin 1997

Canadian Association of General SurgeonsAssociation canadienne de chirurgiens généraux

SYMPOSIUM ON THE MANAGEMENT OF INGUINAL HERNIAS

3. LAPAROSCOPIC GROIN HERNIA SURGERY: THE TAPP PROCEDURE

Demetrius E.M. Litwin, MD;* Quynh N. Pham, MD;† Fredrick H. Oleniuk, MD;‡ Andreas M. Kluftinger, MD;‡ Ljubomir Rossi, MD‡

From the *Department of Surgery, Mount Sinai Hospital,†Department of Surgery, The Toronto Hospital, Toronto, Ont., and the ‡Department of Surgery, Saskatoon CityHospital, Saskatoon, Sask.

Symposium presented at the annual meeting of the Canadian Association of General Surgeons, Montreal, Que., Sept. 16, 1995

Accepted for publication Jan. 29, 1997

Correspondence to: Dr. Demetrius E.M. Litwin, Department of Surgery, Mount Sinai Hospital, 600 University Ave., Ste. 1225, Toronto ON M5G 1X5

© 1997 Canadian Medical Association (text and abstract/résumé)

OBJECTIVE: To describe the technique and results of laparoscopic transabdominal preperitoneal (TAPP)hernia repair.DESIGN: A case series, with a detailed description of the operative technique.SETTING: A university affiliated hospital.PATIENTS: A consecutive series of 554 patients (494 male, 60 female) who underwent laparoscopic herniarepair in a single institution. The mean follow-up was 14 months.INTERVENTIONS: Laparoscopic TAPP hernia repair was performed in almost all patients. Simple closure wasperformed in a patient with a strangulated hernia, and a mesh-based repair was used in a patient with bilat-eral obturator hernias.MAIN OUTCOME MEASURES: Complications and recurrence.RESULTS: The laparoscopic TAPP repair was successful in 550 of the 554 patients who underwent 632 her-nia repairs. Conversion was necessary in 4 patients. Complications were infrequent and there were no re-currences. Only 3.4% of patients were lost to follow-up. The most frequent complications were urinary re-tention (27) and hematoma and seroma (38) in the early postoperative period. Neuralgia (11) andhydrocele (10) also occurred. Mesh infection occurred in only 1 patient and port-site hernias in 3 patients.There was 1 death from an acute myocardial infarction.CONCLUSION: Laparoscopic TAPP hernia repair is associated with an exceedingly low recurrence rate andan acceptable complication rate.

OBJECTIF : Décrire la technique et les résultats de la réparation d’une hernie effectuée par voie transabdom-inale prépéritonéale (TAPP) et par laparoscopie.CONCEPTION : Série de cas et description détaillée de la technique opératoire.CONTEXTE : Hôpital affilié à une université.PATIENTS : Série consécutive de 554 patients (494 hommes et 60 femmes) qui ont subi une réparation dehernie par laparoscopie dans un même établissement. Le suivi médian a été de 14 mois.INTERVENTIONS : Réparation de hernie par voie transabdominale prépéritonéale et par laparoscopie chezpresque tous les patients. On a procédé à une fermeture simple chez un patient qui avait une hernie étran-glée et réparé au moyen d’un treillis de deux hernies obturatrices chez un patient.PRINCIPALES MESURES DES RÉSULTATS : Complications et répétition.RÉSULTATS : La réparation par voie TAPP et par laparoscopie a réussi chez 550 des 554 patients, chez

LAPAROSCOPIC GROIN HERNIA REPAIR

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CJS, Vol. 40, No. 3, June 1997 193

The benefits of laparoscopiccholecystectomy have encour-aged surgeons to develop

other therapeutic laparoscopic proce-dures. Groin hernia repair became, formany surgeons, the next elective oper-ation that they tackled. The early prac-titioners of the laparoscopic approachinitially oversimplified the procedureby adopting either simple peritonealclosurel or preperitoneal placement ofa mesh plug with a small patch.2 It be-came apparent early that the laparo-scopic approach would only be suc-cessful if already established principlesof the open preperitoneal approachwere adopted. Nyhus and Condon3

and Stoppa and colleagues4 had longpromoted preperitoneal placement ofa large sheet of mesh through an ab-dominal incision for difficult hernias.Laparoscopic surgeons progressed toplacement of increasingly larger sheetsof mesh to prevent early recurrence.5

Today, laparoscopic groin hernia re-pair is an important operation for thegeneral surgeon because it offers anopportunity to enhance laparoscopicexperience and skills by increasing thevolume of laparoscopic cases of greatertechnical difficulty than laparoscopiccholecystectomy. The purpose of thispaper is to report our technique andthe results of the laparoscopic transab-dominal preperitoneal (TAPP) herniarepair.

PATIENTS AND METHODS

Between July 1991 and December1994, 554 consecutive patients (494male, 60 female) underwent laparo-scopic hernia repair in a single institu-tion. All hernia types (unilateral, bilat-eral, incarcerated, primary, recurrent,femoral, obturator or a combinationof these) were included (Tables I andII). The TAPP repair was not per-formed for the bilateral obturator her-nias although a mesh-based repair wasused. One patient with a strangulatedfemoral hernia underwent simple clo-sure laparoscopically with laparoscopicsmall-bowel resection. The mean ageof the patients was 53.2 years (range

from 9 to 91 years). There were 632hernia repairs (78 were bilateral).Twenty cases were emergency opera-tions for incarceration and strangula-tion. Recurrent hernias accounted for82 of the cases (13%). Follow-up was6 weeks, 3 and 6 months, 1 year andannually thereafter. This group of pa-tients was followed up for an averageof 14 months. Nineteen (3.4%) pa-tients were lost to follow-up, but theremainder adhered to the follow-upprotocol. We analysed the results forcomplications and recurrence.

OPERATIVE PROCEDURE

Indications

The laparoscopic approach is ac-ceptable for most patients. Relativecontraindications to the TAPP proce-dure included the following: unsuit-ability for general anesthesia; age un-der 18 years; multiple previous low erabdominal operations; an intra-abdominal inflammatory process, suchas active Crohn’s disease; previous intra-abdominal preperitoneal surgery,such as retropubic prostatectomy; andstrangulated hernia with necrotic gut.

lesquels on a réparé 632 hernies. Il a fallu procéder à une conversion chez quatre patients. Les complica-tions ont été peu fréquentes et il n’y a pas eu de répétition. Seulement 3,4 % des patients ont été perdus ausuivi. Les complications les plus fréquentes ont été la rétention urinaire (27) et l’hématome et le sérome(38) au début de la période postopératoire. Il y a eu aussi des cas de névralgie (11) et d’hydrocèle (10). Il ya eu infection du treillis chez un patient seulement et du site de l’orifice chez trois patients. On a enregistréun décès causé par un infarctus aigu du myocarde.CONCLUSION : On établit un lien entre la réparation des hernies par voie transabdominale prépéritonéale etpar laparoscopie et un taux de répétition extrêmement faible et un taux de complications acceptable.

Table II

Other Hernia Types

Type

Simple

Incarcerated

Strangulated

Bilateral 0

1

5

10

Primary femoral hernia

0

0

0

1

Prevascularhernia

1

0

0

0

Obturatorhernia

Table I

Direct 0 0

Indirect 19 2

Both 3

Types of Inguinal Hernia

0

Type

Direct

Indirect

Both

Incarcerated

Direct 3

29

339

118

Primary

3

10

29

34

Recurrent

Indirect 19 3

Both 1 1

Sliding

The procedure can be carried outfor indirect, direct, femoral or com-bined hernias, both primary and re-current. Incarcerated hernias can usu-ally be reduced and repair performedin standard fashion. Strangulated her-nias can also be repaired provided thecontents are reducible and sterile. Theoperative approach was similar for allhernias.

The procedure

The operation is performed undergeneral anesthesia. As a routine, pre-operative intravenous antibiotics (ce-fazolin sodium) are administered, andin many the mesh is soaked in a cefa-zolin sodium and saline solution. In-sufflation is carried out with the Ver-ess needle placed in a subumbilicalposition. For all hernias, a 12-mmport is placed in the subumbilical po-sition. If the hernia is unilateral, a 10-mm port is placed on the side of thehernia and a 5-mm port on the con-tralateral side (Fig. 1). The surgeonoperates from the patient’s left withthe telescope translocated to the lat-

eral 10-mm port position. For bilat-eral hernias 2 10-mm ports are placedlaterally, slightly below the level ofthe umbilicus. If possible, the tele-scope is again translocated to the sideof the hernia to allow the surgeon tooperate comfortably from the oppo-site side of the hernia. Occasionally,the telescope will be too near the op-erative site and will need to bebrought back to the umbilical port.Both lateral ports must then be usedto operate, but this position is not ascomfortable for the surgeon. The lat-eral ports are always placed at the lat-eral edge of the rectus sheath.Once the trocars are positioned,

the presence and the type of hernia isidentified (Fig. 2). If present, incar-cerated contents are reduced. If stran-gulated bowel is present, the proce-dure is converted to an open ante -rior approach. A curvilinear incision ismade in the peritoneum (Fig. 3),starting laterally and carried supero-medially to the level of the obliteratedumbilical vessel (lateral umbilical liga-ment). A flap of peritoneum is createdmedially by blunt dissection inferiorly

to expose Cooper’s ligament (Fig. 4).Laterally, the loose areolar tissue be-tween the muscular layer and the peri-toneum is stripped away, beginninglaterally and progressing medially un-til the cord structures are identified sothat they can be dissected free of theperitoneal flap. At this stage, an indi-rect sac is usually reduced by bluntdissection, but if the sac is large it can be transected with electrocautery.Once an adequate preperitoneal pocketis made within which to place a 10 ×14-cm piece of Marlex mesh, it isplaced in the abdomen and unfurled(Fig. 5). It is placed as flat as possibleagainst the abdominal wall, and theindirect, direct and femoral spaces arecovered broadly (Fig. 6). The mesh isstapled to Cooper’s ligament and tothe superomedial and superolateralcorners (Fig. 7). Only 6 to 8 staplesare generally required. Reperitoneal-ization is carried out by stapling theperitoneal edges together. The opera-tor must be certain that the peri-toneum is tightly opposed so that her-niation will not occur in any gaps inthe peritoneum.

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194 JCC, Vol. 40, No 3, juin 1997

FIG. 1. Trocar positions are depicted. Whenever possible, the telescope is positioned on the side of the hernia and the surgeon operates from the opposite side.

RESULTS

Laparoscopic herniorrhaphy wassuccessful in 550 patients. Conversionto a conventional anterior approach tothe groin was necessary in 4 patientsbecause of morbid obesity (1 patient),massive scrotal hernia (1 patient) and

technical problems with insufflation (1patient) early in our experience. In thefourth patient, the bladder was enteredwhile reducing a sliding hernia. Theinjury was repaired laparoscopicallyand a Foley catheter was placed for 1week. Fear of placing mesh in a po -tentially contaminated environment

prompted us to convert to an anteriorgroin hernia repair without mesh. Theremainder of this patient’s hospitalcourse was uncomplicated. One 78-year-old man who had a history of car-diac disease died of a myocardial in-farction on postoperative day 4. Mostcomplications related to the hernia re-



CJS, Vol. 40, No. 3, June 1997 195

FIG. 3. A curvilinear incision is made in the peritoneum, and a flap is cre-ated. Laterally, all attachments to the peritoneum are stripped off towardthe abdominal wall. The superior margin (inset) is also stripped off the ab-dominal wall to create a large enough pocket for the mesh.

FIG. 4. Medial dissection is carried out on the rectus abdominis. All fibro-fatty tissue in this layer is pulled back with the peritoneum. The direct her-nial sac is easily reduced with traction and blunt dissection. A reverse“pseudosac” of attenuated transversalis fascia is usually identified andpulled off the true hernial sac.

FIG. 5. Adequate dissection of a preperitoneal pocket must be carried outto admit a 10 × 14-cm piece of mesh.

FIG. 2. The posterior inguinal anatomy, showing a direct hernia. Familiar-ization with the anatomy from this position is of paramount importance tothe laparoscopic surgeon.

Ilioinguinal nerve

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196 JCC, Vol. 40, No 3, juin 1997

pair (Table III) were minor. They in-cluded urinary retention (27 patients),hematoma (26 patients), seroma andhydrocele. More potentially seriouscomplications included hernia at a port

site (3 patients) and mesh infection (1patient). Over a mean period of 14months, there were no recurrences.

DISCUSSION

Inguinal herna repair is one of themost common operations performed bygeneral surgeons, and yet there is stillno agreement as to which repair is thebest. All hernia repairs employ eithernative tissue or prosthetic mesh tostrengthen the posterior wall of the in-guinal canal. Traditional open hernior-rhaphies such as Bassini, Shouldice andMcVay repairs all share a common dis-advantage: suture-line tension. Despitereported low recurrence rates (fre-quently less than 1%) by surgeons withlarge experience and dedicated inter-est,3,6,7 these repairs can be associatedwith a recurrence rate of 10% for pri-mary hernia repair and 20% for recur-rent hernias.8–10 The Lichtenstein tension-free mesh repair corrects thepotential collagen defect11 that occursin hernia patients and eliminates suture-

line tension by reinforcing the inguinalcanal floor with a sheet of Marlex mesh.The results of this repair have been ex-cellent with minimal risk of mesh infec-tion (0.03%) and very low recurrencerates (0.02%).12 Therefore, the routineuse of mesh and the concept of tension-free repair should be considered estab-lished, and current laparoscopic repairsadhere to these concepts.Laparoscopic groin hernia repair as

an alternative to conventional ap-proaches has been embraced whole-heartedly by only a small cadre of ab-dominal surgeons. There are manyreasons for this, but the most likely isthe degree of technical difficulty. Cur-rent laparoscopic repairs require a largesheet of mesh placed in a preperitonealposition in the groin that widely over-laps the indirect, direct and femoralspaces. This can be accomplished byeither the TAPP5 or the totally ex-traperitoneal13 approach, both ofwhich create a “new” transversalis fas-cia. This has theoretic appeal becausesuch a prosthesis should not fail and is

FIG. 6. A standard piece of mesh is placed. It is imperative that the mesh isflat and that there is enough overlay beyond the defect.

FIG. 7. The mesh is positioned under the peritoneal flaps. It must extend tothe midline and must drape over Cooper’s ligament. Only a few staples areplaced to fix the mesh in position. Retroperitonealization is carried out withthe stapler. No defects (shower curtain effect) can be present.

Table III

Umbilical hematoma 2

Umbilical infection 1

Mesh infection 1

Other* 13

Postoperative Complications

*Nonspecific groin pain 3, testicular pain 1, osteitis pubis1, fixed testicle 1, massive subcutaneous emphysema 1,pneumonia 2, cardiac arrhythmia 2, sinus tachycardia 1,death secondary to acute myocardial infarction 1

Complication

Urinary retention

Hematoma

Seroma

Neuralgia

Hydrocele 10

11

12

26

27

No.

Ileus 3

Epididymitis 3

Port-site hernia 3

unlikely to move once it has scarred inposition. This is the same strategy thatNyhus and Condon3 and Stoppa andcolleagues4 used when they developedthe preperitoneal approach for recur-rent or complex hernias. Indeed, to-day’s laparoscopic surgeon is likely touse a larger sheet of mesh than thatrecommended by Nyhus and Condon.One might expect, then, that the re-currence rate for this type of repair willbe exceedingly low, and this wasdemonstrated in our series, supportingthe belief that this is a strong repair.Traditionally, recurrence alone has

been considered the most importantoutcome of groin hernia surgery. In athought-provoking article, however,Rutkow14 challenged this concept andinsisted that other outcomes are of sim-ilar importance. These include: techni-cal difficulty in performing the repair;complication rate and seriousness ofcomplications; postoperative pain andreturn to daily activities and work; so-cioeconomic factors, including hospitalcosts and time off work; and, of course,recurrence rate. Certainly, the relativemerits of any of these may vary amongpatients, but large randomized pros -pective trials are required to truly quan-

tify any differences that exist betweenlaparoscopic and open groin hernia re-pair. Nonetheless, the data in trials todate that have either been either com-pleted or are under way suggest thatthe laparoscopic repair has a benefit interms of pain reduction, disability asmeasured by performance tests and re-turn to regular activity. These stud-ies15–20 (Table IV) suggest that laparo-scopic herniorrhaphy does not requiremore operative time (71 v. 59 min-utes), does not have a significantlyhigher recurrence rate (1.6% v. 0.7%)and has a shorter convalescence timeprior to return to normal work (12 v.29 days). Although laparosopic herniarepair costs more, the complication rateassociated with the procedure (11.9%v. 21.8% [Table IV15–19]) is not greater.Preliminary results of a randomizedtrial by Barkun and associates21 showedthe benefits of the laparoscopic ap-proach in terms of postoperative painand possibly quality of life, but the costis substantially more in the context of aCanadian health care system.The incidence of complications as-

sociated with the laparoscopic ap-proach in our series was acceptable(Table III). Hematomas are quite

common (4.1%) but are painless, donot limit activity and resolve sponta-neously without treatment. Aspirationor drainage should not be carried out.The relatively high incidence ofhematoma in our experience is proba-bly because we excise the hernial sacin most instances. Once the mesh isplaced in the preperitoneal space, it isnot surprising that blood products ac-cumulate in the space behind themesh that was once occupied by thehernia. Infections are rare either at theport sites or in the mesh. The singlecase of mesh infection that we en-countered pointed in the groin whereit was drained. Drainage and intra-venously administered antibioticswere all that was required. Three pa-tients had an ileus despite the laparo-scopic approach, but it resolved spon-taneously in all instances, and in ourexperience this can happen after la-paroscopic cholecystectomy also.Four patients had bowel obstruc-

tion, some time after the hernia repair,that may or may not have been relatedto the laparoscopic approach. In 2cases of partial obstruction, the pa-tients were treated conservatively 6weeks and 2 months after hernia re-



CJS, Vol. 40, No. 3, June 1997 197

Table IV

40

56

35

67

96

Open

Prospective Series Comparing Open and Laparoscopic Transabdominal Preperitoneal (TAPP) Repairs

ORT, min

45

68

50

Series

79

114

Tension-free meshrepair

TAPP

Brooks, 199415

Millikan et al, 199416

Stoker et al, 199417

21

17

28

48

21

Open

RTW, d

10

9

14

9

10

TAPP

19.5

18

21.3

48.9

1.7

Open

Complication rate, %

16.4

12

7

15–19

NS

Follow-up, mo

8

9.3

13.9

0.0

3.9

0.0

Open

Recurrence, %

TAPP

0.0

2.7

7.0

TAPP

Leibl et al, 199520 13–21 0.0 0.0 NS NS 38 21 — —

Average 0.7 1.6 59 71 29 12 21.8 11.9

ORT = operating room time, RTW = return to work

Payne et al, 199418 7–18 0.0 0.0

Wilson et al, 199519 NS 0.0 0.0

Shouldice repair

pair. Symptoms resolved in both pa-tients, and neither has had a recurrenceof the symptoms. One of these pa-tients had not had previous abdominalsurgery. Of the remaining 2 patients,1 presented 16 months after laparo-scopic groin hernia repair with a small-bowel obstruction and underwent laparoscopic lysis of adhesions. A con-stricting band remote from the groinhernia site was responsible. This pa-tient had had previous open surgery.The remaining case was a dementedpatient, difficult to assess, who wethought might have a component ofobstruction. Laparoscopy 3 weeks af-ter the initial laparoscopic hernia repairrevealed adhesions to the groin site butno signs of obstruction. In retrospect,the patient likely had an ileus.Early in our experience we felt that

neuralgias would not occur from thelaparoscopic approach, but occasion-ally they do. We encountered 11 casesmost frequently involving the ilioin-guinal nerve. There was only 1 case ofneuralgia involving the lateral femoralcutaneous nerve of the thigh. This canbe avoided by not fixing the mesh be-low the level of the iliopubic tract lat-eral to the internal inguinal ring. Neu-ralgia involving the ilioinguinal nerveis more difficult to explain, but in ouropinion the nerve may be involvedwith a staple or suture superior andlateral to the internal ring where ittravels just beneath transversus abdo-minis muscle. Although neuralgias areuncommon, they can be unpleasantfor the patient. For this reason, we tryto minimize the number of fixationpoints for the mesh in a high lateralposition, although less fixation maylead to a higher recurrence rate. Port-site hernias occurred in 3 patients.This is troubling since in essence weare substituting one type of hernia foranother. The complication under-scores the need for good fascial clo-sure of 10- and 12-mm ports.

The laparoscopic approach to groinhernias is an acceptable one with fewsignificant complications and low re-currence rates. Ongoing evaluationwill further define its role.

References

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2. Schultz L, Graber J, Pietrafitta J,Hickok D. Laser laparoscopic hernior-rhaphy: a clinical trial. Preliminary re-sults. J Laparoendosc Surg 1990; 1(1):41-5.

3. Nyhus LM, Condon RE, editors.Hernia. Philadelphia: J.B. Lippin-cott; 1989.

4. Stoppa RE, Rives JL, WarlaumontCR, Palot JP, Verhaeghe PJ, DelattreJF. The use of Dacron in the repair ofhernias of the groin. Surg Clin NorthAm 1984;64(2):269-85.

5. Arregui ME, Chad DJ, Osman Y, Na-gan RF. Laparoscopic mesh repair ofinguinal hernia using a preperitonealapproach: a preliminary report. La-parosc Endosc 1991;2(1):53-8.

6. Watz GE. The Canadian repair: per-sonal observations. World J Surg1989; 13:516-1.

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8. Clinical guidelines on the manage-ment of groin hernias in adults. Lon-don: Royal College of Surgeons ofEngland; 1993.

9. Asmussen T, Jensen FU. A follow-upstudy on recurrence after inguinalhernia repair. Surg Gynecol Obstet1983;156(2):198-200.

10. Ingimarsson O, Spak I. Inguinal andfemoral hernias. Long-term results ina community hospital. Acta ChirScand 1983;149(3):291-7.

11. Read RC. The role of protease-antiprotease in the pathogenesis ofherniation and abominal aorticaneurysm in certain smokers. Post-grad Gen Surg 1992;14:161.

12. Shulman AG, Amid PK, LichtensteinIL. The safety of mesh repair for pri-mary inguinal hernia: results of 3,019operations from five diverse surgicalsources [review]. Am Surg 1992;58(4):255-7.

13. McKernan JB, Laws HL. Laparoscopicrepair of inguinal hernia using a to-tally extraperitoneal prosthetic ap-proach. Surg Endosc 1993;7:26-8.

14. Rutkow IM. The recurrence rate inhernia surgery. How important is it?[see comment]. Arch Surg 1995;130(6):575-7. Comment in: Arch Surg1996; 131(1):107-8.

15. Brooks DC. A prospective compari-son of laparoscopic and tension-freeopen herniorrhaphy. Arch Surg 1994:129 (4):361-6.

16. Millikan KW, Kosik ML, Doolas A. Aprospective comparison of transab-dominal preperitoneal laparoscopichernia repair versus traditional openhernia repair in a university setting.Surg Laparosc Endosc 1994;4:247-53.

17. Stoker DL, Spiegelhalter DJ, Singh R,Wellwood JM. Laparoscopic versusopen inguinal hernia repair: ran-domised prospective trial [see com-ments]. Lancet 1994;343(8908):1243-5. Comments in: Lancet 1994;344(8914): 54-6.

18. Payne JH Jr, Grininger LM, IzawaMT, Podoll EF, Lindahl PJ, BalfourJ. Laparoscopic or open inguinalherniorrhaphy? A randomized prospec -tive trial [see comment]. Arch Surg1994;129:973-81. Comment in: ArchSurg 1995;130(4):448.

19. Wilson MS, Deans GT, Brough WA.Prospective trial comparing Lichten-stein with laparoscopic tension-freemesh repair of inguinal hernia. Br J Surg 1995;82:274-7.

20. Leibl B, Daubler P, Schwarz J, UlrichM, Bittner R. [Standardized laparo-scopic hernioplasty vs Shouldice re-pair. Results of a randomized com-parative study.] Chirurg 1995;66(9):895-8.

21. Barkun JS, Wexler MJ, Hinchey EJ,Thibeault D, Meakins JL. Laparo-scopic versus open ingunal hernior-rhaphy: preliminary results of a ran-domized controlled trial. Surgery1995;118(4):703-10.

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