Conversion to Stoppa Procedure in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair.

2012·0.06 MB·English

by  Ates, Mustafa

S P
CIENTIFIC APER
Conversion to Stoppa Procedure in Laparoscopic
Totally Extraperitoneal Inguinal Hernia Repair
Mustafa Ates, MD, Abuzer Dirican, MD, Dincer Ozgor, MD, Fatih Gonultas, MD, Burak Isik
ABSTRACT INTRODUCTION
Background and Objectives: Conversion to open sur- Many surgical procedures have been developed and per-
geryisanimportantproblem,especiallyduringthelearn- formedforinguinalherniarepair.Laparoscopy,especially
ing curve of laparoscopic totally extraperitoneal (TEP) the laparoscopic totally extraperitoneal (TEP) approach,
inguinal hernia repair. has gained popularity for inguinal hernia repair.1,2 Ran-
domized controlled studies and metaanalyses comparing
Methods: Here, we discuss conversion to the Stoppa
TEPherniarepairwithotherlaparoscopicproceduresand
procedureduringlaparoscopicTEPinguinalherniarepair.
conventionalopensurgeryhaveshownbetterresultswith
Outcomes of patients who underwent conversion to an
TEP in terms of less postoperative pain, earlier ambula-
open approach during laparoscopic TEP inguinal hernia
tion, earlier return to work, better cosmetic results, and
repairbetweenSeptember2004andMay2010wereeval-
improved cost-effectiveness compared with other hernia
uated.
repairprocedures.2–10However,surgeonsperformingTEP
Results:Intotal,259consecutivepatientswith281ingui- hernia repair should be thoroughly familiar with the pos-
nal hernias underwent laparoscopic TEP inguinal hernia terior anatomical view of the laparoscopic approach and
repair.Thirty-oneherniarepairs(11%)wereconvertedto must have enough advanced laparoscopic experience to
open conventional surgical procedures. Twenty-eight of preventcomplications,conversions,andtocorrectionde-
31 laparoscopic TEP hernia repairs were converted to fects.4,10,11
modified Stoppa procedures, because of technical diffi-
Mostthedatapublishedonlaparoscopyinherniasurgery
culties. Three of these patients underwent Lichtenstein
have focused on patient outcomes and surgical data. Al-
herniarepairs,becausetheyhadundergoneprevioussur-
thoughtheseendpointsareimportant,mostofthosestud-
geries.
ies,itseems,haveignoredconversionasanintraoperative
Conclusion: Stoppa is an easy and successful procedure complication, which may occur in up to 10.6% of cases.
used to solve problems during TEP hernia repair. The Although selected conversion types included transabdomi-
Lichtenstein procedure may be a suitable option in pa- nal preperitoneal (TAPP), Lichtenstein, Shouldice, anterior
tientswhohaveundergonepreviousoperations,suchasa preperitoneal, Kugel, and Stoppa repair in these studies,
radical prostatectomy. authorsofferednoguidanceontheoptimalconversiontype
duringlaparoscopicTEPherniarepairandnoexplanationas
Key Words: Totally extraperitoneal hernia repair, Con-
to why they prefer one of those technique specifically.2–19
version, Stoppa.
Thus, we undertook this study to evaluate conversion to
the modified Stoppa procedure during laparoscopic TEP
inguinal hernia repair through an analysis of our data.
METHODS
Outcomes of patients who underwent conversions to
DepartmentofGeneralSurgery,InonuUniversityMedicalFaculty,Malatya,Turkey
open surgery during laparoscopic TEP inguinal hernia
(allauthors).
repair between September 2006 and May 2010 at Malatya
Presentedasanoralpresentationatthe32ndInternationalCongressoftheEuro-
StateHospitalandTurgutOzalMedicalCenterwereeval-
peanHerniaSociety,October6–9,2010,Istanbul,Turkey.
uated retrospectively with regard to conversion type.
Addresscorrespondenceto:MustafaAtes,MD,TurgutOzalMah.1.Sokak,Almira
SitesiABlokNo:29,44080,Malatya,Turkey.Telephone:(cid:1)904223773000,Fax:
(cid:1)904223410036,Gsm:(cid:1)905447439294,E-mail:[email protected] Data of patients who underwent conversion were ana-
lyzed, including age, sex, type of hernia, operative time,
DOI:10.4293/108680812X13427982376347
perioperativecomplications,conversiontypeandreason,
©2012byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. use of drains, postoperative morbidity, length of hospital
250 JSLS(2012)16:250–254
stay (days), mean follow-up period (months), and recur- theexternaliliacvesselsandtheiliopsoaswereidentified.
rencerate.Allsurgicalprocedureswereperformedbythe After dissecting free and retracting the hernial sac, a 14-
first author in the 2 hospitals. He is experienced in both cm(cid:2)10-cmpolypropyleneheavyweightmeshequipped
theStoppaprocedureandlaparoscopicherniarepair.The with a horizontal slit was inserted into the preperitoneal
studyprotocolwasapprovedbytheethicscommitteeand space, covering all potential hernias of the inguinal floor
institutionalreviewboardoftheMedicalFacultyofInonu and the spermatic cord, and fixed to the groin using a
University with a reference number 2010/84. hernia stapler. A closed-suction drain was then placed
betweenthemeshandtheabdominalwall,andumbilico-
Surgical Technique prevesical fascia was closed using 2-0 polypropylene su-
tures. The skin was closed separately using 3-0 polypro-
General anesthesia was administered to all patients. Pa-
pylene sutures.
tients were positioned on the operation table in a neutral
supine position. All patients received cefazolin 1g IV in- The technique for conversion to the Lichtenstein proce-
traoperatively.Thesurgicalsitewasshavedjustbeforethe dure was as follows: a standard groin incision was made
operation,andtheskinwaspreparedwith10%povidine- into the external oblique aponeurosis, and the spermatic
iodinesolution.A2-cmverticalinfraumbilicalincisionwas cord was elevated from the posterior wall of the inguinal
made, and the ipsilateral anterior rectus sheath was canal.Theherniasacwasopened,inspected,andligated.
opened.Therectusmusclewasretractedlaterally,andthe A sheet of polypropylene mesh measuring 14cm (cid:2) 7cm
space between the rectus muscle and posterior rectus wasplacedintothegroinandsecuredtothelateralborder
sheath was enlarged by blunt digital dissection to allow oftherectussheath,theaponeurotictissueoverthepubic
insertionofa10-mmtrocarwithaballoondissectorinthe tubercle (overlapping the pubic tubercle), and the ingui-
preperitonealspacetothepubicbone.Afterreplacingthe nalligamentusingarunning2-0Prolenesuture.Themesh
balloon with a Hasson trocar, CO was insufflated up to was split to re-create the internal ring. The 2 tails of the
2
14mm Hg, and a 30° laparoscope was introduced via a meshwerecrossed,suturedtogether,andattachedtothe
10-mm trocar. After 2 trocars had been introduced at the inguinalligament,lateraltothecord.Thesuperiorportion
midlinebetweentheumbilicusandpubisintothepreperi- ofthemeshwassecuredtotherectussheathandinternal
toneal space, anatomical landmarks including the os pu- oblique muscle using 3 interrupted sutures. After meticu-
bis, the retropubic space of Retzius, Cooper’s ligament, lous hemostasis, a closed suction drain was placed be-
and the space of Bogros were identified by laparoscopy. neath the external oblique aponeurosis. All fascias and
After dissecting free and retracting the hernial sac, a 14- skin were then closed. The drain was removed after 24
cm(cid:2)10-cmpolypropyleneheavyweightmeshequipped hoursandthepatientsweredischarged.Theyreturnedfor
with a horizontal slit was inserted into the preperitoneal follow-up after 10 days for suture removal, and a further
space,coveringtheinguinalfloorandthespermaticcord, 3-month follow-up at the outpatient clinic was advised.
andfixedbytitaniumhelicaltacker(meshfixationstaples)
to the groin margins through the 5-mm port. CO2 was Statistical Analyses
desufflated,andtheanteriorrectussheathwasclosedwith
Continued variables are reported as means(cid:3)standard de-
2-0 polyglactin. When there was a need for conversion,
viations,andcategoricalvariablesarereportedasnumber
because of, for example, peritoneal breach/laceration or
and percent in this study.
vessel injury, the laparoscopic TEP procedure was con-
verted to Stoppa or Lichtenstein hernia repair.
RESULTS
The technique for conversion to the modified Stoppa
procedurewithsomeminormodificationswasasfollows: A total of 259 consecutive patients with 281 inguinal
a midline incision extending infraumbilically between herniaswhounderwentlaparoscopicTEPinguinalhernia
5-mm trocars was made, and the umbilico-prevesical fas- repairandwereprospectivelyfollowed-upwererecruited
cia was cut along its entire length. The preperitoneal to the study. In all, 31 of 281 laparoscopic TEP hernia
space was entered with blunt dissection due to TEP op- repairs (11%) were converted to open conventional sur-
erations. The dissection included the retropubic space of gical procedures, because of dense adhesion, vascular
Retziusandextendedlaterallybehindtheiliopubicramus injury,ortechnicaldifficultiesthatpreventedfurtherlapa-
inthespaceofBogros.Thedissectionproceededlaterally roscopicdissection.Ofthese,25patientsweremen,1was
undertherectusabdominalisandposteriortotheinferior awoman,andthemedianageofthepatientswas46(cid:3)8.9
epigastric vessels on the side opposite the surgeon until years.Five(19.23%)patientshadbilateralhernias;among
JSLS(2012)16:250–254 251
ConversiontoStoppaProcedureinLaparoscopicTotallyExtraperitonealInguinalHerniaRepair,AtesMetal.
unilateral inguinal hernias, 15 (57.69%) were on the right repair with conversion was 74.45(cid:3)6.54 minutes, that for
side, and 6 (23.08%) were on the left side. Two (7.69%) bilateral was 95.22(cid:3)4.34 minutes, and the mean hospital
patients had had a recurrent inguinal hernia, and 5 staywas2.2(cid:3)1.1days.Themeanfollow-upofthepatients
(19.23%) had previous lower abdominal surgery (1 right was 18(cid:3)1.8 months without recurrence.
pararectal incision, 1 caesarian delivery, 2 radical prosta-
tectomy, 1 midline incision).
DISCUSSION
Twenty-eight of 31 laparoscopic TEP hernia repairs were
The Stoppa procedure led to improvement in the laparo-
converted to modified Stoppa procedures, 5 of which
scopicTEPapproachtopreperitonealplacementtension-
werebilateralhernias.Twoofthe28herniarepairpatients
free mesh hernia repair in the early 1990s, because the
had undergone previous abdominal operations (1 right
procedure itself could now be exactly mimicked by lapa-
pararectal incision, 1 caesarian delivery), and 2 patients
roscopicmeans,andthemeshcouldbeinsertedinexactly
had a recurrent hernia. One case of bilateral pneumotho-
the same plane for reinforcing the inguinal region, as
raxwithhemodynamicinstabilityoccurredduringlaparo-
scopic TEP hernia repair, which was converted to the described by Stoppa.20 The laparoscopic TEP approach
combines the benefit of the Stoppa procedure and mini-
Stoppa procedure. The pneumothorax was successfully
mally invasive surgery without injury to the peritoneal
treatedbybilateralchesttubeinsertion.Thelast3patients
withpreviouslowerabdominaloperations(2radicalpros- cavity.11 In this context, the most important development
in hernia repair surgery may be the laparoscopic TEP
tatectomy, 1 midline incision) were converted to a Lich-
hernia procedure, which has lower recurrence and com-
tenstein hernia repair, because the previous operation
plication rates, a shorter hospital stay, a rapid return to
scars were dense, which could interfere with the midline
normal activities, and more postoperative comfort than
incision in the Stoppa procedure. Perioperative data and
reasons for conversion of these patients are presented in does open-repair and other laparoscopic techniques.2–10
Table 1.
Randomizedtrialsundoubtedlysupportbothsurgeonsandpa-
Seroma developed in 3 patients who underwent Stoppa tientsinmakingclinicaldecisionsinfavorofthelaparoscopic
procedures,urinaryretentionin5,andtesticularpainand TEPinguinalherniarepairprocedure.2,7,8,10,14LaparoscopicTEP
swelling in 2; all resolved completely with conservative inguinal hernia repair is, however, a challenge for surgeons,
treatment. The mean operative time for unilateral hernia especiallyatthebeginningofthelearningcurve,becauseofthe
unfamiliarposterioranatomicalviewoftheinguinalwallanat-
omy and orientational technical difficulties of laparoscopy.
Table1. Thesechallengesmaycauseconversionandseriouscompli-
PerioperativeDataandReasonsforConversionof
cations, such as major vascular injury, and bladder and
ThesePatients
bowelperforation.2,3,21AproblemuniquetotheTEPpro-
Parameters NumberandPercentage cedure is that technical difficulties can happen any time
duringdissectionandreductionoftheherniasac,possibly
Numberofpatients 26
resultinginconversiontoopensurgery.Theconversion,a
Numberofhernias 31
switchfromtheTEPrepairoperationtoothertechniques,
Meanage(years) 46(cid:3)8.9
can be defined as an intraoperative complication and
Sex(woman/man) 1/25 leads to the need for longer administration of analgesics
Siteofhernia and postoperative hospital stay. This can be attributed
-Rightinguinal 15(57.69%) largely to the technical difficulties of a narrow preperito-
neal space and serious adhesions due to previous sur-
-Leftinguinal 6(23.08%)
gery.9,11–18 We believe that conversion is a difficult and
-Bilateralinguinal 5(19.23%)
serious situation for both surgeon and patient, because
Numberofrecurrenthernias 2(7.69%)
patients have great expectations for maximal cosmetic
Previouslowerabdominalsurgery 5(19.23%) results with minimally invasive surgery, and the surgeon
-Rightpararectalincision 1 may be concerned that conversion to conventional open
-Caesariandelivery 1 surgerymayresultinadisasterforpatients,becauseofthe
needforanewincision.Undertheseconditions,choosing
-Radicalprostatectomy 2
the best conversion approach and explaining the reason
-Midlineincision 1
to patients is therefore a difficult problem for surgeons
252 JSLS(2012)16:250–254
during laparoscopic operations. Moreover, Inukai et al14 studywasdifficulttocarryout,andnoreportedstudyhas
experienced these difficulties and reported that perform- compared conversion types during laparoscopic hernia
ing any conversion procedure can be extremely difficult repair yet.
during laparoscopic TEP hernia repair. For this reason,
they suggested that excluding patients with a history of
CONCLUSION
previous surgery would be a better way to prevent con-
version,althoughsomereviewshavesuggestedthatmore Use of the modified Stoppa procedure can be consid-
than30casesareneededtoachievetechnicalproficiency eredsafeandeffectivewhenconversionisrequireddue
and to reduce the complication rate, in the experienced to technical difficulties during laparoscopic TEP hernia
hand. Unfortunately, the conversion rate may reach repair, and it provides the advantage of an open pre-
10.6%.9,11–19 Additionally, several studies and guideline peritoneal reinforcing inguinal region, especially in bi-
reports,includingaCochranereviewdescribingthetech- lateral hernia cases that require conversion. Entering
nique of the TEP approach, reported their conversion the peritoneal cavity can also be avoided by the Stoppa
rates; however, they had no clear data regarding the procedure, minimizing the risk of intraabdominal mesh
selected conversion types and did not offer an optimal adhesionformation.ConversiontotheLichtensteinpro-
method of conversion during laparoscopic TEP inguinal cedure should be the first choice in cases of dense
hernia repair.2,3,13,19,21,22 Most of them used TAPP and adhesions in the preperitoneal space, such as after
Lichtenstein for conversion procedures in their study and previous lower abdominal operations and radical pros-
did not argue the reason for their choice.9,14–19,23–25 Lal et tatectomy.
al11onlysuggestedthatconvertingtotheunilateralStoppa
procedure during the TEP repair operation has improved
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