Page 47 - World Journal of Laparoscopic Surgery

Laparoscopic versus Open Repair of Inguinal Hernia

0.9 to 1.5%. Most are transient. Orchitis was found in a small Mesh Size
number of patients but did not lead to testicular atrophy.
The mesh size should be adequate to cover the entire
myopectineal orifice. The established size in 2006 is 15 cm x 10
Mesh Infection and Wound Infection
cm per unilateral hernia, with minor deviations.
Wound infection rates are very low. Mesh infection is a very
serious complication and care must be taken to maintain strict Mesh Material
aseptic precautions during the entire procedure. Any The mechanical strength of available meshes exceeds the intra-
endogenous infection must be treated with an adequate course abdominal peak pressures and by far even the lightweight
of antibiotics prior to surgery.
meshes are strong enough for inguinal repair. Aachen group
made an important contribution for understanding the interaction
Recurrence
of the living tissue with the implanted mesh material. The
It is the most important endpoint of any hernia surgery. It negative impact of pronounced shrinkage of the traditional
requires a proper and thorough knowledge of anatomy and a heavyweight meshes was recognized as an important factor
thorough technique of repair to help keep the recurrence in promoting recurrence. Schumpelick and coauthors have
endoscopic repair to a minimum. introduced the logical trend of the use of lightweight meshes.
The new macroporous compound meshes present both the
Postoperative Recovery successful reduction of the overall foreign body amount and
the preservation of mesh elasticity after the scar tissue
Marked variations are seen in postoperative recovery due to ingrowths, due to very limited shrinkage and reduced bridging
patient motivation, postoperative advice, and definition of effect.
“normal activity”, existing co-morbidity and local “culture”.
Nevertheless all trials reporting this as an endpoint of study Fixation of the Mesh
show a significant improvement in the laparoscopic group, with
no real difference between the TAPP and TEP groups. This is In the early years of laparoscopic hernia repairs, a strong fixation
estimated to equate to an absolute difference of about 7 days in seemed to be the most important factor in prevention of
terms of time off work. 13 recurrence. With growing size of the mesh and true macro
porous materials being used, the belief in strength reduced and
RECURRENCE gave way to the concern of acute/chronic pain possibly caused
by fixation. The controversy of fixing or nonfixing the mesh is
Recurrence rates are low with the use of mesh and not currently under scrutiny.
significantly different between open or laparoscopic techniques.

Technical Experience
Causes of Recurrence in
Laparoscopic Inguinal Hernia Repair The long learning curve of endoscopic repairs contains the
potential risk of technical errors leading to unacceptable rise of
What then can cause mesh dislocation or failure? The factors recurrence rate. This fact highlights the need for structured
involved are insufficient size, wrong/defective material, incorrect well-mentored teaching, a high level of standardization of the
placement, immediate or very early displacement by folding, procedure and rigorous adherence to the principles of
lifting by a hematoma or urinary retention, missed cord lipomas laparoscopic hernia repair. The impact of experience on the
and herniation through the keyhole (mesh slit) late displacement recurrence rate was in both extremes well documented.
by insufficient scar tissue ingrowth, mesh protrusion, collagen
disease or pronounced shrinkage. Despite the correct and stable Collagen Status
mesh position, there is still a limited risk of a late sliding of the
retroperitoneal fat under/ in front of the mesh into the enlarged Inborn or acquired abnormalities in collagen synthesis are
inner ring. 14 associated with higher incidence of hernia formation and
Leibl et al in 2000 advised to avoid slitting of the mesh and recurrences.
increase its size to reduce the recurrence rate. Generous
dissection of preperitoneal space is required to eliminate Other Factors
potential herniation through the slit or strangulation of the cord The negative effect on healing in hernia repair is often related
structures completely and reduces the risk of genitofemoral with malnutrition, obesity, steroids, type II diabetes, chronic
neuropathy. lung disease, jaundice, radiotherapy, chemotherapy oral

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