Page 19 - World Journal of Laparoscopic Surgery

Study of Selection of Method of Laparoscopic Inguinal Hernia Repair
Table 15: Duration of surgery Table 17: Postoperative complications
Mean Udwadia Complication % TEP (%) TAPP (%)
Type of surgery N (time in minutes) Tehemton MRC trial Hematoma 0 0 0
Laparoscopic 30 90 67.5 58.4 Seroma 4 3 1
hernia repair
Wound infection 2 0 2
Scrotal edema 2 0 2
Table 16: Intraoperative complications Urinary retention 0 0 0
Complication Present study (%) MRC trial (%) Shoulder pain 4 0 4
Bladder injury 0 2
Common iliac artery injury 0 1 Other unique complications of laparoscopic surgeries are port
Lateral femoral cut; nerve injury 0 1 site hernias, hemorrhage due to injury to epigastric and gonadal
vessels, hypotension, hypercapnia, and subcutaneous emphysema.
Minor intraoperative complications such as subcutaneous
This may be due to the difficult initial learning curve in emphysema were encountered in 24% of cases of TEP, and it
laparoscopic hernia repair. The time taken to perform laparoscopic was never found in TAPP repair. Surgical emphysema was noted
repair also depends on the type of hernia (direct/indirect) and in 48% patients of bilateral TEP repair and 56% patients of
size of the defect. Encircling the cord in laparoscopic indirect pneumoperitoneum due to peritoneal breach encountered in a
inguinal hernia repair is challenging as compared to direct inguinal study by Philips et al. Pneumoperitoneum was easily managed by
hernia repair, therefore requiring more time in indirect hernias. In insertion of Veres needle at Palmer’s point or repair of the peritoneal
laparoscopic TEP repair, there is the possibility of an accidental tear rent. No active management is required for subcutaneous
in the peritoneum. It can cause seepage of carbon dioxide into the emphysema. It usually resolves with time.
abdominal cavity. This decreases the working preperitoneal space.
Also, repair of the peritoneal tear has to be done. This can increase Postoperative Complications
the operative time for TEP repair in such cases. In our study, the postoperative complications such as hematoma,
In our study, there were 12 cases of bilateral direct inguinal seroma, wound infection, scrotal edema, urinary retention, and
hernia repair done laparoscopically. For bilateral inguinal hernias shoulder pain were reported in 0, 4, 2, 2, 0, and 4% cases in the
repair, TEP is simple because there is the creation of common laparoscopic hernia repair group (Table 17).
preperitoneal space for repair on both sides by balloon. Whereas In the study done by Tehemton et al. wound infection rates
in TAPP, different peritoneal flaps have to be made. This is proven were significantly lower after laparoscopic techniques (1%). Also, a
by our study, as the average time taken for bilateral TEP was 100 surgical site infection (SSI) of 0.6–1.5% was observed by McCormack
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minutes, and for TAPP was 140 minutes. et al. and Schmedt et al. in the laparoscopic method. Our study
has comparable results with the above study regarding wound
Intraoperative Complications infection. Wound infection at the port site is managed with regular
Laparoscopic hernia repair can be faced with serious intraoperative cleaning and dressing. One of the advantages of laparoscopic hernia
complications (Table 16). When laparoscopic hernia was newly repair is decreased incidence of SSI. A single shot of preoperative
developed these complications were encountered more often, antibiotic can drastically lower the chances of postoperative SSI.
but it was due to the lack of the number of surgeries performed Probable causes of SSI were high volume centers, not maintaining
with this method and hence experience was minimal. Few studies proper aseptic and antiseptic protocols, local site skin infections,
and trials showed common injuries during laparoscopic surgeries; lack of hygiene, and lack of usage of postoperative antibiotics. in our
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according to the MRC trial, three complications were common study, 2% of cases operated by TAPP developed port site infection
during TAPP surgeries, which were bladder injury, lateral femoral most probably due to missed intraperitoneal infection. It is less
cutaneous nerve injury, and common iliac artery injury. About in TEP as we remain outside the peritoneum while performing
15 visceral and vascular injuries were reported in TAPP repair by surgery and the peritoneum act as a barrier for infection to reach
the laparoscopic group of the European Union Hernia Trialists the port side.
Collaboration. Two bladder injuries were reported while performing In our study, no incidence of hematoma was recorded. In the

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TAPP during the clinical study (SCUR). Vascular injuries of 0.42% study done by Tehemton et al.,the incidence of inguinal hematoma
and visceral injuries of 0.11% were reported in the study of Brittner was found to be significantly lower after the laparoscopic repairs

et al. 2011. As mentioned previously, due to lack of exposure to (13.1%). McCormack et al. encountered 8.7% hematoma; Schmedt
such surgeries, herniation of small bowel loops through incomplete et al. found hematoma in 13.1%. Contrary to this, Phillips et al.
sheath closure at the port site causing obstruction that occurred had 0% hematoma in their patients. The incidence of hematoma
more often, but they were gradually recognized and with sheath formation in laparoscopic repair is comparatively low.
closure compulsorily performed their incidence has decreased. In our study, 4% of laparoscopic hernia repair patients develop
In our study, there were no major complications such as major seroma. In a study done by Tehemton et al., seroma formation was
vascular injury, or visceral injury in laparoscopic inguinal hernia observed in (10%) by laparoscopic techniques. This shows that there
repair. These major complications are not usually witnessed in open is an increased incidence of seroma in laparoscopic repair, making
inguinal hernia repair surgeries as there is no dissection in deeper it a disadvantage. The reason is, increase dissection is required in
planes in open inguinal hernia repair surgeries. laparoscopic repair either to make preperitoneal space or to make

18 World Journal of Laparoscopic Surgery, Volume 16 Issue 1 (January–April 2023)