Visceral Injury
The transabdominal preperitoneal repair has the potential of injuring bowel and vascular structures during initial trocar placement as well as during hernia repair. It is imperative that appropriate patient selection be used when choosing a laparoscopic repair. Patients with multiple prior laparotomies or previous pelvic surgery may be better served through open repair. During totally extraperitoneal repair, there is also the potential for bladder injury with initial balloon dissection. A bowel obstruction can occur if the peritoneum is opened during a totally extraperitoneal repair and not recognized, and the bowel herniates into the preperitoneal space during desufflation.
TABLE2 ■ Postoperative Complications
|
Nonrepair related: |
Urinary retention |
|
MI, UTI, DVT, etc. | |
|
Repairs related: |
Seroma |
|
Hematoma | |
|
Neuralgias: |
Nerve entrapment |
|
Nerve injury | |
|
Groin pain: |
Early (transient) |
|
Late (chronic) | |
|
Testicular symptoms: |
Pain |
|
Ischemia | |
|
Trocar site problems: | |
|
Bleeding, Hernia, | |
|
Infection | |
|
Wound infection | |
|
Mesh complications: |
Infection |
|
Late rejection | |
|
Abbreviations: MI, myocardial Infection; | |
|
UTI, urinary tract infection; DVT, deep | |
|
venous thrombosis. | |
If the bowel is injured during laparoscopic hernia repair, the bowel should be repaired and mesh placed using an open approach to prevent mesh infection.
Bladder injury may be avoided carefully directing the balloon above the pubic tubercle with an empty bladder.
Patients with previous retropubic surgery should not be offered a totally extraperitoneal repair. Bowel herniates into the preperitoneal space during desufflation is prevented by closing all peritoneal openings with an endoloop and desufflating under careful visualization.
During transabdominal preperitoneal repair, it is also important to completely close the peritoneum to prevent exposure of the mesh to bowel. Polyprolene mesh exposed to bowel can lead to erosion of the biomaterial into bowel. If the peritoneum does not cover the mesh in its entirety, then an alternative biomaterial must be used to decrease the risk of adhesion and fistula formation.
Although both transabdominal preperitoneal and totally extraperitoneal repairs offer excellent results in regard to hernia repairs, there appears to be a trend toward more surgeons performing the totally extraperitoneal repair. This may be related to the decreased risk of bowel and vascular injury seen during totally extraperitoneal surgery (11). However, the incidence of complications is directly related to the surgeon's experience with the type of laparoscopic repair and therefore should the surgery.
|
Nerve |
Function |
Preventing injury |
|
Ileohypogastric |
Sensation along inguinal crease |
Avoid deep tack placement, important to provide bimanual palpation |
|
Ileoinguinal |
Sensation over the base of the penis |
As for ileohypogastric |
|
Lateral femoral cutaneous |
Sensation for entire lateral thigh |
Avoid tacks below the ileopubic tract lateral to iliac vessels (triangle of "pain") |
|
Genitofemoral |
Genital branch is sensation of scrotum and adjacent thigh; Femoral branch innervates proximal anterior thigh |
As for lateral femoral cutaneous |
|
Femoral |
Muscular innervation of leg |
Avoid dissecting deep to the femoral vessels (triangle of "doom") |
The most common causes of hernia recurrence are incomplete dissection and inadequate size of the mesh coverage.
Numerous studies have demonstrated that at least 2 to 3 cm of defect overlap is required, as well as the size of prosthesis being greater than 10 X 14 cm to prevent this type of failure.
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