Laparoscopic hernia repair

Last week I had a case of a 54-year-old obese woman who went to the Emergency Room with right lower quadrant/groin pain. She is a medical biller who used to work in my office. She thought she might have appendicitis, but was told that she had a right femoral hernia. She has previously undergone 3 right inguinal hernia repairs. On my examination, she had some pain in the right femoral area, but I could not demonstrate a hernia. She also said she had a left inguinal hernia, though I was not able to feel one there either.

Treatment

I did a laparoscopy, and found that the tip of her appendix was adherent to a piece of marlex which must have been used as a plug in the “direct space.” I divided the adhesion, then dissected out the rest of the area. I found a wad of mesh in the femoral canal, and was unable to demonstrate what I would consider to be a hernia.

I put an 8×12 cm piece of Gore-Tex dual-mesh in to cover the entire inguinal floor. Next I explored the left side. After dissecting out the inguinal floor, I was unable to demonstrate a hernia there either. My practice in such cases has always been to proceed with the “repair” and put in a piece of PTFE… which I did in this case. I left the appendix alone, since I didn’t want to convert a clean case into a contaminated one.

What do those of you who do lap hernia repairs do when you can’t find a hernia? Do you just back out, or do a “repair”? My feeling has been that as long as I have done the dissection, there is little additional risk to putting in the PTFE (although many of you might disagree). Besides, I suppose I might weaken the floor by doing the dissection. In addition, there would be other problems such as what to tell the family, what to do if a hernia develops in the future, what to tell the lawyer who says I did unnecessary surgery… etc. It’s just easier to say there was a very very small hernia and I fixed it. I am interested in hearing how others deal with this issue.

29 Comments
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