Perioperative management - Inguinal hernia repair using TEP technique with ENDOLAP 3D

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
• Tobacco 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 their health status and social circumstances; "watchful waiting" may be an option.

Approach for Primary Inguinal Hernia

The data on recurrent hernia is not as clear, so surgery would also be recommended for asymptomatic, non-progressive hernia.

Approach for 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 differentiate between inguinal and femoral hernias, and femoral hernias are significantly more likely to incarcerate 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 repair, 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 are 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 afterward. In about 90% of cases, organ perfusion recovers after repositioning.

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

The management 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 pneumoperitoneum
• 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. Normal open appendectomy usually does not cause significant problems.
• Infections in the surgical area
• Patients who refuse foreign materials or have known intolerances.
• Post pelvic irradiation

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 with 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 in both standing and lying positions, including digital exploration of the inguinal canal. A reducible protrusion 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

• Marking the corresponding side on the patient examined while standing.
• Whenever possible, anticoagulants and platelet aggregation inhibitors should be discontinued before the operation.
• 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 the operation. 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 thrombosis of the leg/pelvis
• 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 testicle
• Nerve injury/chronic pain
• Seroma formation
• Infection of the implant with the consequence of needing to remove it
• Recurrent hernia
• Conversion to open procedure intraoperatively
• Injury to the femoral vessels
• Injury to abdominal organs
• Subsequent interventions
• Lethality
• Trocar hernias

Due to the necessity of CO₂ insufflation of the preperitoneal space with corresponding pressure increase also intraperitoneally, this procedure can only be performed under

• general anesthesia.

• Supine position
• The arm on the hernia side can be positioned outward.

• The surgeon stands on the side of the patient, opposite the groin region to be operated on.
• The assistant initially faces him; once all trocars are placed, on the surgeon's side behind him.
• The scrub nurse is on the surgeon's side towards the foot end.
• MIC tower at the hernia-side foot end of the patient.

Basic Equipment MIC:

• CO₂ insufflator, camera, monitor, light source, high-frequency coagulation

Instruments:

• Dissection balloon
• 10mm 0° optics
• one 10mm and two 5mm trocars or additional 10mm trocar; preferably isolated and threaded suprapubically
• two slender Langenbeck retractors
• atraumatic 5mm grasping forceps, 5mm Overholt clamp
• 5mm irrigation and suction optional

Mesh Implant:

DynaMesh®-ENDOLAP 3D is a three-dimensionally shaped mesh implant for the repair of inguinal and femoral hernias using TEP/TAPP technique. DynaMesh®-ENDOLAP 3D assumes the anatomically optimal shape after deflation of the pneumoperitoneum and exhibits excellent stabilizing function and defect overlap. The mesh is identical for both sides (right & left).
Special requirements are placed on the "bend zone" on the inguinal ligament with these three-dimensional mesh implants. This area of postoperative maximum deformation must not cause complications during the ingrowth process, so it must remain wrinkle-free and maintain high effective porosity. With the CURVATOR® specifically developed for curvature areas in meshes and integrated into the DynaMesh®-ENDOLAP 3D, the implant adapts excellently to the new anatomical conditions even in the "bend zone." Its seamless, multi-elastic design not only allows for wrinkle-free positioning but also wrinkle-free, anatomically appropriate reshaping of the implant during and after desufflation. The high effective porosity of the CURVATOR® is maintained even in "bend zones" with increased material density, minimizing local scar tissue formation and thus the risk of pain.

Postoperative Analgesia:
Non-steroidal anti-inflammatory drugs are generally sufficient.
Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management).
Follow this link to the current guidelines: Treatment of acute perioperative and post-traumatic pain.

Medical Follow-up:
If the course is normal, the patient can be discharged a few hours after the operation.

Thrombosis Prophylaxis:
In the absence of contraindications, due to the low to moderate risk of thromboembolism (surgical procedure > 30 minutes duration), low molecular weight heparin should be administered prophylactically, possibly in a weight- or disposition-risk-adapted dosage until full mobilization is achieved.
Note: Renal function, HIT II (history, platelet control)
Follow this link to the current guideline: Prophylaxis of venous thromboembolism (VTE).

Mobilization:
The patient can be fully mobilized immediately postoperatively. Load up to the subjective pain threshold.

Physical Therapy:
Not required

Dietary Progression:
The patient receives a regular diet as soon as he is sufficiently awake.

Bowel Regulation:
Not required

Incapacity for Work:
Approximately one week, full physical capacity after 2 – 3 weeks.