Laparoscopic Inguinal Hernia Repair Periprocedural Care

Updated: Aug 09, 2016
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Patient Education and Consent

Special patient preparations are minimal for totally extraperitoneal (TEP) repair. Patients should not eat after midnight before the operation. Shaving the operative site before arrival at the hospital should be discouraged.

Informed consent should center on the alternatives to TEP and on potential complications, including recurrence. Patients should be aware that TEP requires general anesthesia, which carries its own attendant risks. An alternative is an anterior repair with local anesthesia.

There are several complications that are potentially severe in TEP but typically negligible in anterior repairs. Life-threatening hemorrhage due to major vascular injuries is possible. Entry into the peritoneum may occur during the procedure potentially resulting in visceral injury and adhesions.

Patients who are undergoing laparoscopic repairs should be educated regarding expected postoperative pain, possible temporary discoloration of the groin and scrotum, and seroma formation within the first few postoperative days. It is also important to discuss the possibility of nerve injury and chronic postoperative pain (defined as pain lasting longer than 6 months). Although this is an uncommon result, it can be highly frustrating to the patient and should therefore be addressed beforehand.

Patients undergoing a unilateral laparoscopic repair should be counseled on the possibility that bilateral hernia repair may be necessary if a contralateral hernia is encountered during surgery. Consent for this procedure should be obtained.

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Equipment

Instruments

All methods of laparoscopic hernia repair require the following standard laparoscopic equipment:

  • Blunt graspers
  • A 30° laparoscope
  • A tacking device or fibrin glue applicator system

A laparoscopic clip applier and suction irrigator should be available on standby.

It is common to place a Foley catheter so as to decompress the bladder and maximize the preperitoneal space. Patients who are undergoing unilateral hernia repair (a short procedure) and have no history of urinary retention can probably avoid placement of a Foley catheter if they void immediately prior to the operation.

In a TEP repair, most surgeons use specialized dissecting balloons for the initial dissection of the preperitoneal space. This saves time but does add some cost. Alternatively, the preperitoneal space can be created by means of simple blunt dissection with the laparoscope. Some surgeons prefer to use an integrated trocar−dissector balloon system to prevent evacuation of the carbon dioxide from the preperitoneal space. In addition, a 5-mm trocar and an 11-mm trocar are typically placed.

Standard laparoscopic trays usually have all the instruments needed for a transabdominal preperitoneal (TAPP) repair. The authors commonly place a pair of 5-mm trocars and one 11-mm trocar. A reusable suture passer may also be useful for closing the 11-mm fascial incision at the umbilicus.

Mesh

Choice of mesh

The mesh used for the repair must be a permanent material cut to a size large enough to produce a wide overlap beyond the defect’s edges. The choice of material depends on surgeon preference; both lightweight polypropylene and polyester are good choices. The size may range from 5 × 10 cm to 10 × 15 cm. The mesh can either be flat and rectangular or preformed to fit the myopectineal orifice. Although some surgeons prefer anatomic mesh configurations, a flat sheet works just as well and is more cost-effective.

In general, a standard uncoated mesh is used for laparoscopic repairs, because the mesh will be shielded from the intra-abdominal organs by the peritoneum. When the peritoneum is torn and cannot be repaired, coated polypropylene or polyester-based meshes or other meshes approved for intra-abdominal applications (eg, expanded polytetrafluoroethylene [ePTFE]) can be used.

Although further study remains necessary, it appears that lightweight meshes may have some advantages over standard heavyweight polypropylene meshes with regard to the development of postoperative pain and discomfort after inguinal hernia repair. [74, 75, 76, 77, 78]

Approach to mesh fixation

Whether to fix the mesh in place and which type of fixation device to use are matters of individual surgeon preference. The many options for mesh fixation currently available give the surgeon a range of choices.

In TEP repair, titanium spiral tacks are commonly used to affix the mesh to the Cooper ligament superomedially and superolaterally. Use of more than five tacks has been shown to correlate with higher rates of chronic postoperative pain. [79] Absorbable tacks may be a useful alternative; they are made of a specialized polymer that disintegrates after 4-10 weeks, allowing ample time for the collagen to grow into the interstices of the mesh to anchor it in place.

In TAPP repair, titanium tacks also have traditionally been used to fix the mesh and can also be used to close the peritoneal flap. However, a 2011 report showed that acute pain was increased when more than 10 tacks were placed. [80] A number of surgeons have now switched to using absorbable tacks to fix the mesh and close the peritoneum. Sutures or hernia stapling devices can also be employed.

Some authors have advocated the use of fibrin glue to fixate the mesh. [81, 82, 65] A specialized laparoscopic device can be deployed to direct the application of the fibrin glue. More widely used in Europe, glue fixation appears to be a promising means of decreasing chronic pain. [83]

Still other authors use no fixation at all but instead rely on peritoneal pressure to maintain the mesh in proper position. [84, 85, 62] Short-term study results have been generally favorable, though most surgeons still prefer to employ some method of fixation. An alternative to no fixation might be the use of self-fixating mesh. This product is new to the market, and its efficacy remains to be determined.

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Patient Preparation

Anesthesia

Although a TEP repair can be performed with epidural anesthesia, general anesthesia is preferred as a rule.

Elective inguinal hernia repair is considered a clean procedure (<2% rate of surgical site infection). Although the data currently available are not conclusive, one meta-analysis supports the use of antibiotic prophylaxis when performing a mesh-based repair. [86] Typically, a single dose of a cephalosporin (eg, cefazolin) is administered by the anesthesiologist before the skin incision. [87] A definitive answer to the antibiotic question awaits the performance of a properly powered, well-constructed, prospective, randomized study.

General anesthesia is usually required for a TAPP repair, though there are reports of spinal anesthesia being used. [50, 51] If a patient cannot tolerate or prefers not to undergo general anesthesia, open repair should be considered.

Positioning

The correct surgical site is confirmed and marked preoperatively in the holding area. The patient is placed in the supine position on the operating table. For large defects, slight Trendelenburg positioning may facilitate exposure by reducing the visceral contents into the abdomen.

The upper extremities are comfortably padded and tucked at the sides. (Some surgeons leave the arms out on armboards.) Even when a unilateral repair is scheduled, it is important to secure both arms, so that if an occult hernia is found on the contralateral side, it can be fixed during the same procedure.

The surgical site is shaved with electric clippers, then prepared and draped in standard surgical fashion so as to expose an extending area from above the umbilicus to below the pubis. The prepared area should be wide enough to permit conversion to an open technique if this should become necessary.

The operating surgeon stands on the side opposite the hernia, and the assistant stands on the side of the hernia. A single monitor or a pair of monitors may be placed at the foot of the bed. It is most convenient to have the light source, the carbon dioxide insufflator, and the video processor situated at the foot of the bed, though alternative locations will also work.

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Monitoring and Follow-up

Most patients who have undergone a TEP procedure can be discharged on the day of the operation. Because urinary retention occasionally develops, all patients should be able to void before discharge. Patients should also be told to expect some ecchymosis at the base of the penis and some temporary edema of the testes. Narcotic pain medicine is usually required for 2-3 days after the operation.

While the postoperative course is generally uncomplicated, patients must be routinely instructed to recognize certain signs and symptoms that can alert them to the potential complications as discussed above. [88, 89]

Large-scale studies examining the convalescence period after elective inguinal herniorrhaphy determined that the median length of absence from work was 7 days when patients were advised by their surgeons to limit the recuperation period and to resume normal activities within 1 day after the procedure. Moreover, these studies confirmed that early resumption of activities (including exercise) did not increase the risk of recurrence. Thus, with adequate analgesia, patients can safely return to their daily duties. [88, 89]

After a TEP repair, patients should be seen in the office for a follow-up visit within 1 month (ideally, within 1 week). Patients who had large hernias often have seromas, which can be easily differentiated from recurrent hernias on examination, in that a seroma is a distinct fluid collection that is not reducible. If the diagnosis is in doubt, ultrasonography may be useful. Most seromas resolve within 6 weeks of the operation. After the initial visit, follow-up may be scheduled on an as-needed basis.

Long-term monitoring for a TAPP repair is much the same as that for other hernia repair techniques. Routine follow-up in 1-2 weeks is warranted for checking the wound and assessing the patient’s overall condition. Longer-term follow-up is scheduled on an as-needed basis. Because hernia recurrences typically do not manifest until 6-12 months after the repair, long-term follow-up will be necessary in some cases. Patients should be counseled about the signs and symptoms of hernia recurrences and followed as needed.

Typically, postoperative pain resolves or greatly decreases by the first postoperative visit. Patients with ongoing pain issues after surgery require frequent office visits and complex multidisciplinary treatment that includes pain specialists and physical therapists; in some instances, surgical treatment will subsequently be required.

Because patients often do not return to their primary surgeon for long-term follow-up, surgeons who perform TAPP procedures should consider keeping a database of their patients or becoming involved in national registries to assess long-term outcomes.

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