Page 64 - World Journal of Laparoscopic Surgery

CLINICAL TECHNIQUE
A Novel Technique Using Mesh to Repair a Recurrent Large

Indirect Inguinoscrotal Hernia

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Ho L Chong , Adnan Taib , Andrew N Wilson , Muhammad A Khan , Alexandrina Braniste , Ateeq Jamil , Ali Warsi 7
AbstrAct
Background: The positioning of a slit mesh around cord structures during laparoscopic transabdominal preperitoneal (TAPP) hernia repair
rests the mesh better without kinks, thereby minimizing recurrences. However, studies also suggest that insufficient closure of the mesh slit
may lead to recurrences.
Aim: This report describes a novel technique using AbsorbaTacks (Covidien) to close the mesh slit and refashion an artificial ‘deep ring’ to
minimize recurrence.
Technique: We report the case of a fit 82-year-old Caucasian male presenting with a recurrent large right indirect inguinoscrotal hernia (8 x
8 × 7 cm with 4 × 4 cm deep inguinal ring). The patient underwent a TAPP repair with a background of unsuccessful open repair by another
surgeon previously. Following mesh deployment, the mesh was lifted up by the cord structures, which was under tension due to a large defect.
A slit was made in the inferomedial aspect of the mesh. This allowed it to be wrapped around the cord structures. The overlapped trouser flaps
were then stapled together encircling the cord, by AbsorbaTacks to create a secure artificial ‘deep ring’. Edges of the mesh were also standardly
affixed by AbsorbaTacks to the pectineal ligament and posterior abdominal wall. This creates a secure four-point fixation of the mesh scaffold
to prevent ‘windsock’ effect, which happens when the mesh is pushed into the widened deep inguinal ring, leading to early recurrences. The
peritoneal incision was also closed with AbsorbaTacks.
Conclusion: No complications were registered during the early postoperative period. The patient had an uneventful recovery and was discharged
within 20 hours with simple analgesia. No recurrence was reported during the 6 months follow-up period.
Clinical significance: The anchoring of a slit mesh with tackers around the cord structures can be used to repair large recurrent inguinal hernias
laparoscopically following an open repair. This technique potentially minimizes further recurrences.
Keywords: Case report, Inguinoscrotal hernia, Laparoscopy, Mesh fixation, Mesh migration, Recurrent, Slit mesh, Transabdominal preperitoneal
(TAPP).
Abbreviations: TAPP: Transabdominal preperitoneal; TEP: Totally extraperitoneal
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1429

bAckground
1–7 Department of General Surgery, University Hospitals of Morecambe
Inguinal hernia repairs are one of the most commonly performed Bay NHS Foundation Trust, Furness General Hospital, Cumbria,
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general surgical procedures worldwide. Annually, more than England, United Kingdom
75,000 hernia repairs with mesh are performed within the National Corresponding Author: Ho L Chong, Department of General Surgery,
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Health Service in England alone. Primary and recurrent inguinal University Hospitals of Morecambe Bay NHS Foundation Trust, Furness
hernia repairs can be carried out openly or laparoscopically. A General Hospital, Cumbria, England, United Kingdom, Phone: +44
laparoscopic mesh repair, an evolving technique, is well known for 7475252656, e-mail: h.l.chong@lancaster.ac.uk
its minimally invasive advantages, such as less postoperative pain, How to cite this article: Chong HL, Taib A, Wilson AN, et al.
earlier recovery, and shorter hospital stay, as compared to an open A Novel Technique Using Mesh to Repair a Recurrent Large Indirect
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repair. Depending on the approach, a laparoscopic transabdominal Inguinoscrotal Hernia. World J Lap Surg 2021;14(1):65–67.
preperitoneal (TAPP) hernia repair or totally extraperitoneal (TEP) Source of support: Nil

hernia repair can be performed. 4 Conflict of interest: None
Available evidence suggests that a considerable proportion
(15%) of all inguinal herniorrhaphies are performed due to
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recurrences, which may be due to structural weakness of However, studies also suggest that insufficient closure of the
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the abdominal wall and distorted anatomy. The European mesh slit may lead to further recurrences. This report describes
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Hernia Society guidelines have recommended that a posterior a novel technique using AbsorbaTacks (Covidien) to close the
preperitoneal approach should be the procedure of choice for the mesh slit and refashion a deep artificial ring in a large recurrent
management of all recurrent inguinal hernias after previous open inguinoscrotal hernia to achieve a successful repair.
repair unless otherwise indicated. 7
However, there is controversy arising around the optimal
technique for mesh placement within the preperitoneal technique
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space during a TAPP repair. Some surgeons presume that the We report the case of a fit 82-year-old Caucasian male, presenting
positioning of a slit mesh around the cord structures rests the with a recurrent large right indirect inguinoscrotal hernia
mesh better without kinks, thereby minimizing recurrences. (8 × 8 × 7 cm with 4 × 4 cm deep ring). This patient underwent a

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