Published online Dec 27, 2017. doi: 10.4240/wjgs.v9.i12.264
Peer-review started: August 7, 2017
First decision: September 6, 2017
Revised: November 6, 2017
Accepted: November 19, 2017
Article in press: November 19, 2017
Published online: December 27, 2017
Surgery is the standard treatment for inguinal hernia. The surgical techniques used for inguinal hernia consist of the traditional anterior technique and laparoscopic surgery. One type of laparoscopic surgery has totally extraperitoneal hernia repair (TEP). The outcome of TEP is superior to the conventional anterior approach; less postoperative pain, fewer postoperative complications, lower recurrence rates, early discharge, and faster return to daily life and superior cosmetic outcome. The authors cannot observe intraperitoneal cavity on TEP, so the opposite side hernia might be overlooked if the hernia is present. And it is difficult to perform the procedure for patients with intestinal incarceration in the hernia sac.
It is difficult to repair hernia by TEP for patients with large indirect inguinal hernia, intestinal incarceration and postoperative prostatectomy. The authors must compensate for these drawbacks of TEP.
By using intraperitoneal inspection (iSTEP), it is possible to view the inguinal region without overlooking coexisting lesions if the hernia present on the opposite side. And when an intestinal incarceration in the hernia sac was found, we can return the intestine and confirm the presence of intestinal damage. iSTEP is a very useful technique because diagnosis and reinforcement can be performed reliably.
Seventy-five patients who underwent iSTEP at the Prefectural Hiroshima Hospital were enrolled. Small skin incision was made in the umbilicus, extending to the intraperitoneal cavity. First of all, insert the laparoscope into the abdominal cavity to observe the intraperitoneal cavity. The type of hernia was diagnosed and whether there was the presence of intestinal incarceration was confirmed. Once the peritoneum was closed, STEP was performed, and finally, intraperitoneal observation was performed to reconfirm the repair. And data on patient demographics, clinical data, intraoperative findings, and postoperative course is prospectively collected.
The authors performed iSTEP for 75 hernias, 58 were on one side, 17 were on both sides, and 10 were recurrences. The respective median operation times were 100 min (range, 66 to 168), 136 min (range, 114 to 165), and 125 min (range, 108 to 156), with median bleeding amounts of 5 g (range, 1 to 26), 3 g (range, 1 to 52), and 5 g (range, 1 to 26), respectively. Intraperitoneal observation showed hernia on the opposite side in 2 cases, intestinal incarceration in 3 cases, omental adhesion into the hernia sac in 2 cases, severe postoperative intraperitoneal adhesions in 2 cases, and bladder protrusion in 1 case. There was only 1 case of recurrence. Compared with previous reports which repaired by conventional method and TEP, the operation time is longer, but the bleeding volume is equivalent, and the outcome is excellent with respect to postoperative complications. Cost is equal because special equipment is not required.
Single-incision totally extraperitoneal inguinal hernia repair with intraperitoneal inspection is very useful technique and makes hernia repairs safer and reducing postoperative complications.
This study suggests that iSTEP is a very useful technique for inguinal hernia repair without history of prostate surgery, giant inguinal hernia, young patients with small indirect inguinal hernia, strangulated hernia, and patients who could not tolerate general anesthesia. The study described a modification of conventional TEP approach with the addition of intraperitoneal observation. We suggested advantage of inspecting the contralateral side for hernia and the possibility to examine incarcerated bowel. It also allowed easy conversion between TEP and TAPP when necessary. The authors will compare with iSTEP and conventional SILS-TEP and so we report that results.