Perioperative management - Inguinal hernia repair, bilateral transabdominal preperitoneal hernioplasty (TAPP)

The repair of the 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, patients with a positive family history are significantly more often affected.

Risk factors are:

• 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 discreetly 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 as well as the timing with the patient, taking into account the health status and social circumstances; if necessary, “watchful waiting” may be an option.

Approach for primary inguinal hernia

The data situation for recurrent hernia is not as clear, so one would also recommend surgery for asymptomatic, non-progressive hernia.

Approach for recurrent inguinal hernia

? = adequate expertise in laparoscopic hernia surgery assumed

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 treatment of their hernia should be made promptly in women.

EHS classification of inguinal hernias

The transabdominal preperitoneal patch plasty (TAPP) is the most commonly used surgical technique for inguinal hernia in German clinics.

In addition to TEP and open Lichtenstein operation, TAPP 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.

The laparoscopic/endoscopic procedures have a longer learning curve compared to open procedures.

Advantages of laparoendoscopic procedures in:

• 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 possible after posterior procedure with appropriate expertise.

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 incarcerated content with assessment of organ perfusion afterward. In about 90% of cases, organ perfusion recovers after repositioning.

The treatment of the inguinal hernia can occur depending on the local infection situation simultaneously or at a later time.

Absolute Contraindications

• Inability to undergo general anesthesia as a prerequisite for pneumoperitoneum
• Infections in the surgical area
• Patients who refuse foreign material or have known intolerances
• Status post pelvic irradiation
• Intestinal necrosis/perforation, Lichtenstein repair possible under certain circumstances

Relative Contraindications:

• Patients on permanent anticoagulation. Each case must be evaluated individually.
• Giant hernias and scrotal hernias are poorly suited for this method, as the hernia contents are hardly reducible in MIC technique and the repair of very large hernia defects remains uncertain in 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 dissection of the hernia sac is also demanding and often leads to rebleeding and large hematomas.
• Very obese patients can significantly complicate the surgery, up to making it technically impossible.
• Status post intra- and preperitoneal interventions in the lower abdomen
• Status post preperitoneal mesh implantation

For the diagnosis of inguinal hernia, a sole clinical examination is sufficient. It includes inspection, palpation of the groin in standing and lying patients, including digital exploration of the inguinal canal. A reducible bulge in the inguinal region is a clear indication of a hernia.

In cases of a so-called occult hernia or a recurrence, diagnostic certainty can be increased by ultrasound. In case of unclear ultrasound findings, the diagnostics should be extended to magnetic resonance or computed tomography.

The purely clinical confirmation of the 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 case of incarceration or anamnestic abnormalities (stool irregularities, micturition complaints), the diagnostic concept may need to be expanded: Colonoscopy, abdominal CT

• Marking the corresponding side in 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 special risks for wound and mesh infection (immunosuppression, corticosteroid therapy, diabetes mellitus etc.), a 2nd generation cephalosporin is given preoperatively, ½ h before the skin incision.
• Patients should absolutely empty their bladder immediately before the operation. A bladder 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 severance of the ductus deferens
• Injury to the testicular vessels resulting in functional impairment of the testicle up to its loss
• Nerve injury/chronic pain
• Seroma formation
• Infection of the implant with the consequence of having to remove it again.
• Recurrent hernia
• Conversion to open procedure intraoperatively
• Injury to the femoral vessels
• Injury to abdominal organs
• Follow-up interventions
• Lethality
• Trocar hernias
• Procedure for a previously undiagnosed contralateral inguinal hernia

Intubation anesthesia in pneumoperitoneum

• Supine position in Trendelenburg position of 20°-30° (bilateral shoulder supports prevent the patient from sliding down)
• both arms at the sides

• For 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-holding assistant stands/sits on the hernia side opposite to him.
• For bilateral surgery, start with the larger hernia. During the procedure, the surgeon and assistant switch sides. The monitor is placed at the foot end of the patient as shown.
• Instrumenting OR nurse to the right of the surgeon

• Laparoscopic Basic Set
• 30° Camera
• Meshes: Macroporous, lightweight meshes are mandatory. The size of the mesh should be at least 10 x 15 cm, monofilament with a pore size of not less than 1.0-1.5 mm (“lightweight”) and a tensile strength of 16 N/cm in all directions. For defects direct > 3-4 cm/indirect > 4-5 cm, a larger mesh (12 x17 cm) is recommended.
• Tissue Adhesive

Postoperative Analgesia

• Non-steroidal anti-inflammatory drugs are generally sufficient; if necessary, escalation with opioid-containing analgesics can occur.
• Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management).
  Follow the link here to the current guideline: Treatment of acute perioperative and posttraumatic pain.

Medical Follow-up Care

• As soon as the patient awakens from anesthesia, they may drink and consume light food. Mobilization occurs at the latest with the trip to the toilet.
• Removal of the Redon drainage on the 1st or 2nd postoperative day

Thrombosis Prophylaxis

• In the absence of contraindications, due to the moderate thromboembolism risk (surgical procedure > 30min duration), low-molecular-weight heparin should be administered in prophylactic, possibly weight- or disposition risk-adapted dosage, in addition to physical measures, until full mobilization is achieved.
• Note: Renal function, HIT II (history, platelet monitoring)
  Follow the link here to the current guideline Prophylaxis of venous thromboembolism.

Mobilization

• immediate
• gradual resumption of physical activity
• Full weight-bearing when symptom-free

Physiotherapy

• if necessary, breathing exercises for pneumonia prophylaxis

Diet Build-up

• immediate

Bowel Regulation

• if necessary, laxatives starting from the 2nd postoperative day

Inability to Work

• 1-2 weeks