Page 45 - World Journal of Laparoscopic Surgery

Laparoscopic versus Open Repair of Inguinal Hernia

F. Pregnancy POSTOPERATIVE PAIN AND AMOUNT OF
G. Unfit for GA NARCOTICS USED
The open tension-free mesh repair is found to cause less
Inguinal Hernia Repair in Pediatric Patients
postoperative pain than open non-mesh repairs. However most
Small children gain little benefit from laparoscopic hernia repair randomized trials assessing postoperative pain between open
as inguinal skin crease incision used in the herniotomy is one tension-free repairs and laparoscopic repairs report less pain in
of best incisions as far as cosmesis is concerned. It is hardly the laparoscopic groups. In many cases this also results in less
visible after a few months. Also, it is covered in the underwear. analgesia being consumed by the patient. 8-11
Compared to this three stab incisions, however small, are in the
visible area. 3
COMPLICATION RATES
Inguinal Hernia Repair in Obese Patients Complications in endoscopic inguinal hernia surgery are more
dangerous and more frequent than those of open surgery,
Operations in patients with BMI above 27 may be difficult for especially in inexperienced hands and hence are best avoided.
less experienced surgeons, particularly when trying to encircle It is possible to avoid most of these complications if one follows
an indirect sac. Patients with BMI of above 30 should be a set of well-defined steps and principles of endoscopic inguinal
encouraged to loose weight or should even be turned down for hernia surgery. 4,12
the laparoscopic approach. They are incidentally more likely to Complications of laparoscopic repair of inguinal hernia can
develop recurrence after an open hernia repair. It is also easy be divided into:
for the laparoscopic surgeon to become disoriented when the • Intraoperative
patient is very obese.
• Postoperative
Inguinal Hernia Repair in Recurrence
Intraoperative Complications and Precaution to
Generally, the short-term recurrence rate of laparoscopic inguinal Avoid these Complications
hernia repair is reported to be less than 5%. In both the open During Creation of Preperitoneal Space
and laparoscopic repair procedures, the aim is to cover the
whole inguino-femoral area by a preperitoneal prosthetic mesh, This is the most important step for beginners.
and recurrences should not occur. When they do occur, • A wide linea alba may result in breaching the peritoneum; in
recurrences must be regarded as technical failures. Recurrences such a situation, it is best to close the rectus and incise the
after laparoscopic repair most often result from using too small sheath more laterally
a mesh, or not using staples to fix the mesh. Most recurrences • Improper placement of balloon trocar causing dissection of
after laparoscopic hernia repair occurred medially, and the muscle fibers
technique was adjusted. The mesh is now placed at least until • Entry into peritoneum causing pneumoperitoneum
the midline, and occasionally hernia staples are used when an • Rupture of balloon in preperitoneal space
adequate overlap (2 cm) cannot be achieved medially. The totally • The Hassan’s trocar must snugly fit into the incision to
extraperitoneal technique is now used more often, allowing for avoid CO leak
2
better visual control in the medial part of the operating field. To avoid these, one must ensure that the balloon is made
properly and the correct space is entered by retracting the rectus
OPERATING TIME muscle laterally to visualize the posterior rectus sheath. Also
the balloon trocar is inserted gently, parallel to the abdominal
Operating times of surgical techniques varies between surgeons wall, to avoid puncturing the peritoneum. The balloon must be
and also vary considerably between centers. It reduces with inflated slowly with saline to ensure smooth and even distension
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experience and comparison between laparoscopic and open and prevent its rupture.
surgery is subject to bias due to pre-existing familiarity with
open techniques. It is less important to the patient than a Precautions during Port Placement
successful operation; the time taken to perform the surgery can
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have cost implications. The operative time to perform unilateral The trocars should be short and threaded in proportion to less
primary inguinal repair has frequently been reported as longer workspace and to ensure a snug fit respectively. The skin
for laparoscopic compared to open repair, however the mean incisions should be just adequate to grip the trocar and prevent
7
difference in 36 of 37 randomized trials is 14.81 minutes. These its slipping. The patient should empty their bladder before
differences disappear in bilateral and recurrent hernia repairs. surgery as the suprapubic trocar could injure a filled bladder.

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