Perioperative management - Inguinal hernia repair using TEP technique

The repair of inguinal hernia represents the most common operation in visceral and general surgery. The lifetime risk for men is 27% (women 3%).

The incidence increases with age, and patients with a positive family history are significantly more affected.

Risk factors include:

• COPD
• Nicotine abuse
• Reduced BMI
• Collagen diseases

Indirect inguinal hernias occur twice as often as direct ones. Femoral hernias account for only 5% of inguinal hernias. Right-sided hernias are more common than left-sided ones.

There is no general recommendation for surgical therapy in discretely symptomatic or asymptomatic, non-progressive inguinal hernia in men. Since most patients develop symptoms over time, it is recommended to discuss the indication for surgery and the timing with the patient, considering health status and social circumstances; "watchful waiting" may be an option.

Approach to Primary Inguinal Hernia

The data on recurrent hernia is not as clear, so even with asymptomatic, non-progressive hernia, surgery would be advised.

Approach to Recurrent Inguinal Hernia

? = provided adequate expertise in laparoscopic hernia surgery

In women, femoral hernias occur more frequently than in men. Since no diagnostic procedure can reliably distinguish between inguinal and femoral hernias, and femoral hernias incarcerate significantly more often than inguinal hernias, the indication for surgical repair of their hernia should be made promptly in women.

EHS Classification of Inguinal Hernias

In addition to TAPP and open Lichtenstein operation, TEP is recommended in all guidelines as the preferred elective treatment for inguinal hernia.

The minimally invasive procedures are based on a posterior approach and are always mesh-based.

Laparoscopic/endoscopic procedures have a longer learning curve compared to open procedures.

Advantages of laparoscopic/endoscopic procedures include:

• primary unilateral inguinal hernia in men (lower incidence of postoperative pain)
• inguinal hernia in women (high recurrence rates after Lichtenstein repair in women)
• bilateral inguinal hernias
• recurrent inguinal hernia after anterior approach, but also after posterior procedure with appropriate expertise possible.

In incarcerated inguinal hernias, which can be distinguished from irreducible hernias by pronounced pain, acute onset, and signs of bowel obstruction, the diagnostic superiority of laparoscopy should be utilized.

Its advantage is the possibility of repositioning the incarceration with assessment of organ perfusion thereafter. In about 90% of cases, organ perfusion recovers after repositioning.

Inspection of an incarcerated bowel loop is limited in the extraperitoneal approach.

The treatment of inguinal hernia can be performed immediately or at a later time depending on the local infection situation.

absolute contraindications

• Impossibility of general anesthesia as a prerequisite for a pneumoperitoneum
• More extensive previous open surgeries in the lower abdomen, e.g., open prostatectomy, cesarean section, etc. In these cases, the prevesical and preperitoneal space can no longer be adequately dissected. A normal open appendectomy generally does not cause significant problems.
• Infections in the surgical area
• Patients who refuse foreign material or have known intolerances.
• Post-radiation of the pelvis

Relative contraindications:

• Patients on permanent anticoagulation. Each case must be individually assessed.
• Giant hernias and scrotal hernias are poorly suited for this method, as the hernia contents are hardly reducible using MIC technique, and the repair of very large hernia gaps remains uncertain with this technique. Another challenge is the complete dissection of the hernia sac from the scrotum. If this is not successful, a very persistent seroma must be expected. Endoscopic hemostasis during the dissection of the hernia sac is also demanding and often leads to rebleeding and large hematomas.
• Very obese patients can significantly complicate the surgery, making it technically impossible.
• Condition after preperitoneal mesh implantation

For the diagnosis of inguinal hernia, a clinical examination alone is sufficient. It includes inspection, palpation of the groin while the patient is standing and lying down, including digital exploration of the inguinal canal. A reducible bulge in the groin area is a clear indication of a hernia.

In cases of so-called occult hernia or recurrence, diagnostic certainty can be increased by ultrasound. If the ultrasound findings are unclear, diagnostics should be expanded to include magnetic resonance imaging or computed tomography.

The clinical confirmation of recurrent hernia is often complicated by scar tissue.

Non-reducible tissue structures must be subjected to further diagnostics even in the absence of symptoms.

In cases of incarceration or anamnesis abnormalities (irregular bowel movements, urinary complaints), the diagnostic concept may need to be expanded: colonoscopy, abdominal CT.

• Mark the corresponding side on the patient examined while standing.
• Whenever possible, anticoagulants and platelet aggregation inhibitors should be discontinued before surgery.
• A general antibiotic prophylaxis cannot be recommended. If there are particular risks for wound and mesh infection (immunosuppression, corticosteroid therapy, diabetes mellitus, etc.), a second-generation cephalosporin is administered preoperatively, ½ hour before the skin incision.
• Patients should definitely empty their bladder immediately before surgery. A urinary catheter is only placed if a long operation time is expected or there is an increased risk of bladder injury.

General:

• Deep vein/pelvic vein thrombosis
• Pneumonia
• Bleeding, hematoma
• Wound infection/wound healing disorder
• Excessive scar formation

Specific:

• Injury to the spermatic cord with transection of the vas deferens
• Injury to the testicular vessels resulting in testicular dysfunction up to the loss of the testis
• Nerve injury/chronic pain
• Seroma formation
• Infection of the implant with the consequence of having to remove it
• Recurrent hernia
• Conversion to open procedure intraoperatively
• Injury to the femoral vessels
• Injury to abdominal organs
• Subsequent interventions
• Lethality
• Trocar hernias