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Laparoscopic TEP Using 3D Mesh to Treat Bilateral Inguinal Hernia
artificial mesh fixation and selection. 2,10–12 Gass et al. reviewed meshes from the Bard-Davol (France) (trade name 3DMax™ Mesh)
6,505 unilateral inguinal hernia patients and 3,048 bilateral with polypropylene structure, size 8.5 × 13.7 cm or 10.8 × 16 cm.
inguinal hernia patients treated with 3D TEP laparoscopic surgery
and showed no difference significantly in terms of postoperative Surgical Procedures
hospital stay and surgical referral rate, but reduced cost and The surgical procedures were performed as per the following steps:
number of treatment days compared to those with double First, all the patients underwent endotracheal anesthesia, lying on
surgeries. 2,12 Therefore, for bilateral inguinal hernia, TEP is a safe, their back in Trendelenburg position, with their hands closed along
viable treatment option that can be performed with results similar the torso. The first trocar with a 10 mm diameter was placed at the
to that of unilateral herniation surgery. 2,12,13 This study aimed to navel. We dissected through peritoneum with fingers and pumped
evaluate the effectiveness of 3D artificial mesh in TEP surgery CO . We then placed the remaining two trocars with 5 mm diameter
2
among Vietnamese adults with inguinal hernia. in three positions (Fig. 1).
Then, we performed dissection of the anterior peritoneal cavity,
treated the right herniated sac (Figs 2A and B), and dissected the
MAterIAls And Methods right anterior peritoneum, revealing the lateral umbilical folds, the
Study Design and Patients right inferior epigastric artery, and lateral abdominal wall to the
We performed a case series at Thanh Nhan Hospital, Hanoi, lower margin of the pelvic lumbar muscle. For a direct inguinal
Vietnam. Eligible patients were people aged 18 years old or above; hernia, we pushed the herniated sac into the abdominal cavity. For
were diagnosed as bilateral inguinal hernia based on clinical and indirect inguinal hernia, we performed constriction and cut at the
radiology examination (ultrasound, computed tomography); neck of the herniated sac. Subsequently, we dissected the anterior
and were treated with TEP surgery to place an artificial 3D mesh peritoneum and treated the same left side herniation sac similarly
outside the peritoneum. Other selection criteria included patients to the opposite side.
having complete medical records and patients who agreed and We used a 3D MAX™ polypropylene mesh from Bard-Davol
signed informed consent to participate in the study. Exclusion (France), with dimensions of 8.5 × 13.7 cm or 10.8 × 16 cm. After
criteria included: (1) unilateral inguinal hernia, choking hernia, the peritoneal cavity on the two sides was dissected large enough,
recurrence hernia; (2) patients with contraindications to TEP we inserted two artificial 3D meshes through the 10 mm trocar.
laparoscopic surgery for inguinal hernia; (3) patients with systemic We then placed the 3D Max mesh in the position that the outer
or bilateral inguinal infection; (4) patients with pre-anesthesia corner of the mesh was placed on the outer pelvic artery; the top
health classification score, American Society of Anesthesiology of the mesh was placed in the inguinal ligament; the directional
(ASA) >III; (5) patients with blood clotting disorder; (6) patients marker (blue) was placed on the pubic tubule helping to align the
who did not agree to participate in the study; and (7) patients grid in the correct position; the upper edge of the net was placed
with incomplete medical records. The study was approved by the in front which was far enough to cover the entire myopectineal
Institutional Review Board (IRB) of Thanh Nhan Hospital (Code: orifice (the distance from the edges of the mesh to myopectineal
01/BVTN-HDDD). orifice was at least 2.5–3 cm). We did not actively fix the mesh
(Fig. 3). We released CO under the direct camera observation and
2
Surgical Preparation closed the trocar holes.
All patients admitted to the hospital were clinically examined Variables
and performed paraclinical tests, such as abdominal ultrasound, In this study, we collected the following information from patients:
blood biochemistry, basic hematology, echocardiography (for
patients over 60 years old), electrocardiogram, or chest X-ray. Patient Characteristics
Then, we consulted specialists in cardiology, endocrinology, and Age, sex, history of abdominal surgery, body mass index (BMI),
anesthesia to assess the condition of the patient and treat any inguinal hernia classification by anatomical location (direct,
medical diseases (if any) before surgery. We explained to patients indirect), and herniation diameter.
and their families about surgical techniques, complications in
surgery, and possible postoperative complications. The patients
had completely fasted before surgery for at least 6 hours and
evacuated stool in enema twice before surgery by Fleet 133 mL.
We then cleaned and marked the operating area. We then let the
patients to urinate 30 minutes before surgery to ensure that the
bladder was collapsed. No urinary catheter was placed before
and during surgery. Cephalosporin generation II or III was used
for intravenous 30 minutes before surgery and repeated 6 hours
after surgery.
A laparoscopic surgery machine was prepared with full
equipment including monitors, image transceivers from cameras,
CO pumps, and cold light sources. We used one trocar 10 mm
2
and two trocars 5 mm, two optic endoscopies with 10 and 5 mm
with diameter 30° or 0° viewing angle, laparoscopic grasper 5 mm
(grasper), laparoscopic dissector 5 mm, electric hook (L-hook),
needle-bearing pliers, endoscope, straw, clip Hemlock 5 mm,
and other common open surgery tools. In this study, we used 3D Fig. 1: Creation of anterior peritoneum and trocar placement

196 World Journal of Laparoscopic Surgery, Volume 14 Issue 3 (September–December 2021)