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Laparoscopic (keyhole) hernia repair

What about Laparoscopic (keyhole) repair?

Depending on the type of your hernia, a laparoscopic repair might well be the best option for you. With Laparoscopy there is possibly less pain than with the conventional repair. It allows for shorter hospitalisation and you will able to resume normal activities at an earlier stage, than with traditional repairs. The disadvantages are that the procedure requires a general anaesthetic and that there are more equipment expenses namely; the laparoscopic ports, the mesh and the hernia tacker, which is used to fix the mesh in place. There are 2 methods of laparoscopic repair using either the Transabdominal preperitoneal (TAPP) approach or the total extraperitoneal (TEP) approach. The TAPP approach involves placing laparoscopic trocars in the abdominal cavity and approaching the inguinal region from the inside. This allows the mesh to be placed and then covered with peritoneum. While the TAPP approach is a straightforward laparoscopic procedure, it requires entrance into the peritoneal cavity for dissection. Consequently, the bowel or vascular structures may be injured during the procedure. In the TEP approach, the extraperitoneal space of the inguinal region is developed, sometimes with the use of an inflatable balloon. For most surgeons, the TEP approach to hernia repair is more technically demanding than the TAPP approach.

In both the TAPP and TEP approaches, the hernial sac is reduced, and a large piece of mesh is placed to cover the indirect, direct and femoral areas of the inguinal region. The mesh is held in place by metal staples.

Most of the inguinal herniae especially recurrent ones are suitable for laparoscopic repairs. However, previous Pelvic or lower abdominal surgery, such as radical prostatectomy or aorto-femoral grafts, would prevent the peritoneum separating from the muscle and render the laparoscopic procedure unsuitable.

The outcome is more or less the same for both the open and laparoscopic repair. You can discuss this with your surgeon.

How is it done?

The operation is performed through three very small incisions under a general anaesthetic, and involves the insertion of a mesh to completely reinforce the groin or the defect in case of the abdominal wall hernia. It might be performed as a day case, depending on the type and size of the hernia. It usually leads to a rapid return to normal activity and shorter hospital stay. The technique is appropriate for new hernias, and is also the best way to treat recurrent and bilateral hernias.

Laparoscopic Inguinal Hernia Mesh Repair

This description refers to the extra-peritoneal laparoscopic (TEP) repair for an inguinal or femoral hernia.

image059.jpgUnder a general anaesthetic, three small incisions are made in the abdominal wall. The largest of these is 1.5-2cm just below the umbilicus. An incision in the superficial sheath of the rectus abdominis muscle, the space between the abdominal muscles and the lining of the abdomen (the peritoneum) is developed, sometimes with a balloon device which is then withdrawn after deflation and the space is maintained by the continuous inflation of CO2. The abdominal cavity is not entered during this procedure, therefore greatly reducing the likelihood of damage to the abdominal organs or production of adhesions. A telescope inserted into the space.Two further 0.5 cm incisions are made and 2 fine 0.5 cm diameter ports will be inserted to accommodate operating instruments. The peritoneum is then gently pushed away from the muscle layer until a sizeable space is created and the muscle defect is revealed. The sac of the hernia is pulled back into this space. A piece of flexible polypropylene mesh measuring 12 X 15cm in diameter is then rolled like a cigar through the large port and fixed so as to cover the defect in the muscle and also all other potential weak areas where hernias can occur. The mesh is held in place with approximately 3-4 tiny spiral tacking devices. The space is deflated after withdrawal of the ports and removal of the CO2.

The positive pressure in the abdominal cavity pushes the peritoneum onto the mesh. Any increase in the abdominal pressure, as in straining, simply pushes the mesh firmly against the abdominal wall. Straining therefore, does not have the effect of pulling apart the repair as it does in sutured repairs. This contributes enormously to the strength and durability of the repair. Skin wounds are closed with dissolvable stitches.

What is the best way to repair an inguinal hernia?

Randomised controlled trials have shown that laparoscopic inguinal repair has significant benefits compared with open repair which involves a large cut under general or local anaesthetic, with less pain and a quicker recovery, and yet has as good better long-term results. The National Institute of Health and Clinical Excellence (NICE), the NHS advisory body, has endorsed the laparoscopic repair of both primary and recurrent unilateral and bilateral hernias.

How long am I in hospital?

Day surgery is possible although I usually advise an overnight stay.

How long is the convalescence?

Sedentary workers may resume duties in a few days. Manual labourers can resume duties in 4-6 weeks. I advise no strenuous exercise such as tennis or golf for 4 weeks.

What are the side effects?

The Local discomfort and stiffness at the site of the operation usually diminishes over 2 weeks. Twinges of pain after the procedure can occur on exertion, and sometimes, albeit rarely for up to four months. This is not severe and tends to ease steadily. Bruising can appear in the genital area. This is not painful and disappears over 1-2 weeks. Swelling in the groin, at the site of the hernia, may occur due to serum collecting in the cavity left by reducing the hernial sac. This can alarm patients who think that the hernia is still present but it rapidly absorbs or may be aspirated if it is large. In men, there can be some swelling and tenderness in the scrotum and involving the testes. This also resolves over a few weeks.

What are the potential complications of Hernia Repair?

This is by no means a complete list all of the complications that can occur in this, and indeed in any other operation. It is merely an attempt to cover the most serious, specific complications that could potentially occur in this procedure. Again I would like to emphasise that the incidence of complications to date, is very low indeed. I have no hesitation in recommending the procedure in appropriate cases.

  1. Anaesthetic problems, these can vary from anaphylactic shock, cardiac irregularities or cardiac arrest, causing death.
  2. Damage to major vessels or to the intestine.
  3. Recurrence of the hernia.
  4. Infection of the mesh. This would require removal of the mesh and is the reason antibiotics are given at the time of surgery.
  5. Nerve injury. Some of the nerves supplying the skin of the upper thigh. Temporary pain radiating down the outer part of the thigh can be a potential complication albeit rare.
  6. Haematoma formation. Scrotal haematomas can occur with very large hernias extending into the scrotum especially when these are long standing.
  7. Bowel obstruction rarely occurs if the small bowel became trapped in an accidental tear in the deep muscle under the uppermost incision when performing a laparoscopic repair.
  8. Pneumonia and other lung complications.
  9. Thrombosis and lung embolism. With the use calf compressors during surgery and advising early mobilization, these are rare complications.
  10. Bowel Trauma if it was trapped in the sac of a hernia, especially if it is a recurrent hernia.

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