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

Intubation anesthesia in pneumoperitoneum

• Supine position
• Arms adducted

• In the case of a unilateral hernia, the surgeon stands on the contralateral side of the hernia, so that the surgeon, groin, and the patient's big toe form an axis with the monitor.
• The camera assistant stands/sits on the hernia side opposite him.
• In bilateral surgery, the procedure begins with the larger hernia. During the procedure, the surgeon and assistant switch sides. The monitor is positioned at the foot of the patient as shown.
• Instrument nurse to the right of the surgeon

Basic Equipment MIC:

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

Instruments:

• a 10mm optic
• one 10mm and two 5mm trocars, preferably with threads to maintain trocar position
• two slender Langenbeck retractors
• a 5mm dissector, a fine 5mm grasping forceps, a 5mm scissors, a 5mm coagulation forceps
• 5mm irrigation and suction optional
• Meshes: Large-pore, lightweight meshes are mandatory. The size of the mesh should be at least 10 x 15 cm, monofilament with a pore size of no less than 1.0-1.5 mm ("lightweight") and a tensile strength of 16 N/cm in all directions. For defects directly > 3-4 cm, indirectly > 4-5 cm, a larger mesh (12 x 17 cm) is recommended.
• long Pean clamp with a preparation swab
• a sharp clamp
• optional Redon or silicone drainage, which fits through a 5mm trocar

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

Medical Aftercare:
If the course is normal, the patient is discharged a few hours after the operation. Check-ups are usually on the first and seventh postoperative day.

Thrombosis Prophylaxis:
For this procedure with a low risk of thrombosis, prophylaxis with low molecular weight heparin for a total of 3 – 4 days is usually sufficient. In the presence of relevant pre-existing conditions and medication, an individual plan must be made. Follow the link here to the current guideline: Prophylaxis of venous thromboembolism (VTE).

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

Physical Therapy:
Not required

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

Bowel Regulation:
Not required

Incapacity for Work:
1-2 weeks, full physical capacity after 2 – 3 weeks.