I have read the rather large response to the subject of a laparoscopic approach to hernia repair and find it quite interesting. I was trained a large community program where approximarely 85% of herniorraphies were tissue repairs, mostly Shouldice and McVay.
Two surgeons began to perform laparoscopic approaches near the end of my residency. One utilized the TAP approach and the other preperitoneal. Both had operative times in excess of 2 hours and you could cut the tension in the room with a knife.
I am presently a fellow of laparoscopic surgery. I entered my fellowship believing laparoscopic herniorraphy had no place in the operating room, but I was quickly converted. Nine surgeons presently perform the procedure at four different hospital. They have STANDARDIZED A SYSTEMATIC APPROACH and operative time rarely exceeds one hour. We only use the preperitoneal approach. Well over 500 procedures have been performed and there is fairly good patient follow-up. To date we have identified 5 recurrences, all in the early part of our experience. Complications have been mimimal, again mostly early on.
PATIENT ACCEPTANCE has been wonderful. PAIN has been minimal. Patients that have had previous “open” herniorraphies say that the pain is only a fraction of what the experienced with “open” techniques. This includes tissue and well as mesh repairs. Excluding workman’s compensation patients, a majority return to work in a few days. We have also operated on athletes, who only missed a few practices.
COST has been a problem and we are presently working to reduce this. We are using more reusable instruments including dissectors and trocars and have worked with our product representatives to supply herniorraphy packages at reduced costs.
GENERAL ANESTHESIA is also a concern. We have had some success with local anesthesia and IV sedation but have found or success to be mostly anesthesiologist dependent.
My experience leads me to believe that most of the COMPLICATIONS described by my collegues are a result of inexperience and an improper understanding of the anatomy of this area from the preperitoneal angle.
Nerve entrapement is usually a result of improper staple placement. No staples should be placed laterally on the mesh below the iliopubic track. This is were the ilioinguinal and genitofemoral nerves lie and you are just asking for trouble.
Recurrance is usually a result of either inadequate dissection or improper mesh placement. Identification and reduction of an indirect sac must be complete. The tip of the sac must be well below the lower edge of the mesh and not allowed to creep under the mesh where the pneumopreperitoneum is released. Additionally the proper placement of the mesh is very important. There is a tendency to place the mesh with equal amounts above and below coopers ligament. Since all hernias, indirect, direct and femoral occur (and reoccur) above coopers ligament the mesh below is useless. The mesh is better placed more anterior over hesselbach’s triangle for direct space coverage and recreating the internal ring for indirect coverage. We keyhole the mesh though I have no hard evidence that this is better than just an overlay patch. The mesh should also be large enough to cover medially at least to the pubic tuberacle. We do not hesitate to use a second piece of mesh medially to obtain adequate coverage.
Lastly a few tricks to help reduce oprative time.
1. Develop a systematic approach. Always completely define you anatomy well before you place the mesh. This includes the iliopubic tract laterally and coopers ligament medially. This takes less than five minutes and is well worth it.
2. When mobilizing the cord make sure the hole underneath it is large (One of our surgeons says you should be able to drive a MACK truck through it. This will help make mesh placement much easier.
3. We mark our mesh. Usually with a suture in one of the corners. There is nothing worse and more time consuming than losing orientation of the mesh. Also never let go of the mesh. Introduction into the preperitoneal space and placement around the cord is one motion. Where you let go and try to readjust problems usually occur.
4. Lastly we believe that three midline ports are the best and that this is a one surgeon operation. Good two hand technique utilizing traction/countertraction is essential.