Page 18 - Journal of WALS

Galal MM Abou El-Nagah

Table 2: Relation between method of preperitoneal insufflations operative duration, controversial benefits and the need for
and operative time in the first group general anesthesia due to the perceived risk of adverse
Instrument Mean operative p effects of pneumoperitoneum, which is thought not to be
used time
well-tolerated by a patient who is awake during the
Veress needle 88 (65%) 39.4 0.79 procedure. While the traditional open mesh repair requires
Trochar 5 mm 49 (35%) 36.2
average surgical skills and the delivery of local or regional
Total 137 (100%) 30.2
anesthetics in most of the cases.
It is now accepted widely that bilateral inguinal hernia
The repair of inguinal hernias no longer involves just repair and recurrences are indications for TAPP repair, with
the sewing together of a defect in the musculature. Several clear benefits for the patient in terms of less postoperative
approaches, which hernia surgeons must be familiar with, pain and shorter work absence. 10
have been used for repair of groin hernias and have included Laparoscopic techniques for the repair of inguinal
tissue repairs (later termed ‘tension’ repairs), as well as mesh hernias have become an increasingly popular alternative to
11
or tension-free repairs and laparoscopy. Although each of open techniques. There is good evidence that laparoscopic
these repairs boasts its successes, there are advantages and repair of a groin hernia is associated with excellent results
disadvantages to each approach. when performed by expert surgeons. No clear consensus
Tension-free repairs are considered as a milestone in has emerged as to the best laparoscopic technique. 11
the evolution of the hernia repair surgeries. The use of mesh When faced with an unforeseen anomaly during TEP in
in hernia repairs, however, was not widely accepted for use which improved abdominal visualization is necessary, a
3
until Lichtenstein coined the term ‘tension-free’ repair. This surgeon may convert from a TEP to a TAPP approach. 11
repair uses nonabsorbable sutures and a prosthetic flat mesh With better equipment and techniques for creation of
screen to reinforce the canal floor. Since its introduction, pneumoperitoneum serious complications are now
this repair has been the most widely performed groin hernia infrequent. 12
repair and is used as the standard to which newer techniques In our novel techniques, the formation of ‘pneumo-
are compared. In an attempt to improve on the Lichtenstein peritoneum–like’ state facilitates the dissection of the
4
repair, Gilbert used the internal ring as direct access to the peritoneum and fascia transversalis off anterior abdominal
preperitoneal space through an open anterior approach. This wall under vision so as to reduce complications from
innovation of accessing the preperitoneal space from an unpredictable anomalies and in the same time reducing the
anterior approach led to the development of the Prolene operative time. Intraoperative and postoperative
Hernia System mesh. Finally, advancements in laparoscopy complications are minimal as well as recurrence rate.
led to the development of laparoscopic inguinal hernia Patients’ satisfaction is good. The ability of repair recurrent
repair. Currently, there are multiple tension-free techniques, hernia and bilateral hernias in less time is another advantage.
which include the open anterior approach (on-lay The new technique requires more prospective studies to
Lichtenstein patch, plug and patch), open posterior approach assess the postoperative complications, training curve of
(Stoppa-Rives, Kugel), and the closed posterior approach the surgeons and its statistical significance.
(laparoscopic) either TAPP or TEP. 5
The laparoscopic approach for inguinal hernia repair was CONCLUSION
introduced in the 1990s and has since been modified and Our novel use of a laparoscopic combined TEP approach
refined. The early descriptions of laparoscopic inguinal and TAPP approach to repair inguinal hernia is feasible,
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8
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herniorrhaphy were by Ger, Shultz et al, Corbitt, and save and seems to be easier and time saving than original
9
Filipi et al. Laparoscopic techniques are being used methods separately.
increasingly in the repair of ventral hernias and offer the REFERENCES
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excellent results of conventional open hernia repair. The 3. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The
tension-free hernioplasty. Am J Surg 1989;157:188-93.
uptake into practice of this procedure by general surgeons 4. Gilbert Al. An anatomic and functional classification for the
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