Laparoscopic Inguinal Hernia Repair with Closure of Hernial Defect and Central Mesh Fixation Using Glubran 2

doi:10.4236/ss.2013.412107

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Surgical Science, 2013, 4, 554-557

Published Online December 2013 (http://www.scirp.org/journal/ss)

http://dx.doi.org/10.4236/ss.2013.412107

Open Access SS

Laparoscopic Inguinal Hernia Repair with Closure of

Hernial Defect and Central Mesh Fixation

Using Glubran 2

Ahmed E. Lasheen*, Adel M. Tolba, Hany Mohamed, Hatem Mohammed, Nadia A. Smaeil

General Surgery Department, Faculty of Medicine, Zagazig University,

Egypt and National Hospital, Riyadh, Saudi Arabia

Email: *[email protected]

Received November 2, 2013; revised December 2, 2013; accepted December 10, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Laparoscopic tension-free repair of inguinal hernia was presented in 1990s, promising less pain and short

recovery period, but carrying the risk mesh bulging and migration. Objective: We have presented our technique in

which central zone of mesh is fixed only after closure of hernial defect. Patients and Methods: This study included 27

males patients (14 indirect inguinal hernias, 9 direct inguinal hernias, 4 both direct and indirect inguinal hernias on the

same side). These cases are undergoing tension-free mesh repair after closure of hernial defect, and the mesh is fixed

only at its central zone using Gulbran 2, between April 2011 and March 2013. The follow-up period ranged from 6 to

30 months. The intra and postoperative complications were recorded. Results: Mean hospital stay was 1 day. The age

of this group of patients ranged from 23 to 63 years (mean, 47 years). The operative time ranged from 30 to 100 min-

utes (mean, 45 minutes). The intraoperative complications were in form of mild bleeding in 7 patients (25.9%) during

hernial sac dissection. Postoperativ e complications were mild inguinal pain in 4 patients (14.8%) for three weeks. Mild

hydrocele in 3 patients (11%) was recorded. No recurrence or bulging at hernia site was noticed during the period of

follow-up. Conclusion: Laparoscopic inguin al hernia repair with central mesh fixation after closure of hernial defect is

effective, easy and free of complications.

Keywords: Laparoscopic Hernia Repair; Defect Closure; Mesh Fixation Glubrane 2

1. Introduction

Herniorraphy is the second prevalent operation after ap-

pendectomy in general surgery [1]. The standard method

for inguinal hernia repair had been changed little over a

hundred years until the introduction of synthetic mesh.

This mesh can be placed as either an open or a minimally

invasive endoscopic technique. The most common endo-

scopic techniques are transabdominal preperitoneal (TAPP)

[2] and totally extraperitoneal (TEP) [3] approaches.

Classical mesh fixation using tacher may be etiology of

postoperative pain, bladder injury and major blood ves-

sels injury [4]. Some surgeons advocated placing the

mesh without fixation (tension-free mesh repair) in the

preperitoneal space to avoid these complications, but

carrying the risk of mesh bulging or migration [5,6]. In

this study, the central zone (about central one third) of

mesh corresponding iliop ubic tract is fixed only by using

Glubran 2, afte r closure of hernia l defect .

2. Patients and Methods

This study was included 27 males patients (14 indirect

inguinal hernias, 9 direct inguinal hernias, 4 both direct

and indirect inguinal hernias on same side). All informa-

tion about the technique was discussed with all patients,

and all patients gave writing consent for inclusion of

their data in this study. The age of the patients ranged

from 23 to 63 years (mean, 47 years).

Surgical technique: Under general anesthesia, the

laparoscopic transabdominal preperitoneal (TAPP) tech-

nique is used in this patients group. The patient asked to

urinate, while in the surgical preparation room, in order

to empty the bladder. The Veress needle is inserted su-

pra-umbilically to install the pneumoperitoneum of 14

mmHg has been achieved. A 0-degree, 10 mm laparo-

*Corresponding a uthor.

A. E. LASHEEN ET AL. 555

scope is used for the whole procedure. Two additional

trocars of 5 mm in diameters, one on the right side of the

patient, at the level of umbilicus, lateral to the rectus

sheath, and another one, on left side of the patient,

slightly below the umbilicus, lateral to the rectus sheath.

The patient is in supine, Trendelenburg position, with the

right arm along the body and venous access on the left

arm. The surgeon takes up a position on the right side of

the patient and assistant and scrub nurse on the left. As

usually, the peritoneum is incised superiorly, three to

four cm above the hernia defect. This incision extends

from the medial umbilical ligament to the anterior supe-

rior iliac spine laterally. After dissection of hernia sac

and complete exposure of the preperitoneal space, the

hernia defect was closed helping spinal needle (No. 22G)

percutaneously and using prolene No. 2/0, and the suture

is tied ext racorporeal or intracorporeal (Figures 1(a)-(e)).

Suitable mesh is fixed at central zone (about one third)

only corresponding from anterior superior iliac spine to

the symphy sis pubis using Glubran 2 (Gem srl, Viare g gio ,

Italy) Figures 2(a)-(c). The peritoneum is closed with

using Vicryl No. 2/0, and the mesh remains in a com-

pletely extraperitoneal position. The pneumoperitoneum

is emptied under direct viewing with the laparoscope and

external pressure is applied to the inguinal region. The

trocar sites are closed and an elastic support for scrotal

compression is placed. The follow up period ranged from

6 to 30 months (mean, 22 months). The intra and postop-

(a) (b)

(e)

Figure 1. (a) a—Anterior abdominal wall. b—Trocar port 5 mm. c—Hernia defect. d—Spinal needle No. 20G. e—Prolene No.

2/0 inside spinal needle. f—Peritoneal cavity. g—Posterior abdominal wall. The spinal needle and prolene No. 2/0 inside it

passed under the lower edge of hernia defect to peritoneal cavity. The prolene end was holed from peritoneal cavity by

grasper. (b) The spinal needle was partial withdraw and redirected to pass to peritoneal cavity above the upper edge of her-

nia defect with prolene thread. (c ) The spinal needle and prolene inside it passed to peritoneal cavity above the upper hernia

edge. Then, the other prolene end was holed by grasper. (d) The spinal needle was removed through prolene holding by

grasper. One suture is formed to pass under the lower edge of hernia defect, floor of defect, and above the upper edge of her-

nia defect. (e) The suture was tied extracorporeal or intracorporeal to close the hernia defect.

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A. E. LASHEEN ET AL.

556

(a) (b)

(c)

Figure 2. (a) One patient suffered from both (direct and indirect) types of inguinal hernia on right side and the dissection of

sacs started. (b) The hernia defects were closed by two sutures using prolene No. 2/0. (c) The central zone (about central one

third) of mesh corresponding to iliopubic tract was fixed to underlining tissue using Glubran 2.

erative complications were recorded.

3. Results

The mean surgical time was 45 minutes (ranged from 30

to 100 minutes). Twenty two patients (81.5%) of the

cases returned to their usual activities in one week and

five patients (18.5%) required up two weeks. Hydroceles

developed in three cases (11%), after correction of indi-

rect inguinal hernias, which were solved with a single

aspiration. Four patients (14.8%) experienced mild in-

guinal pain for three weeks. Mild bleeding occurred dur-

ing dissection of hernia sac from cord in 7 patients

(25.9%) which, controlled with cauterization. No recur-

rence or bulging of the mesh were recorded during the

period of follow up .

4. Discussion

The increased acceptance of inguinal hernia repair by a

laparoscopic approach has led to many reports confused

reports on technique, results, and complications related to

this procedure. Many of these complications are directly

related to lack of thorough knowledge of surgical anat-

omy or improper technique [7,8]. The complication rates

after laparoscopic hernioplasty vary from 5% to 13%, but

the definition of complications differs widely among

studies [9,10]. Severe bleeding usually due to vascular

injury of iliac vessels and generally occurs because the

using of staples during mesh fixation [11]. Patients who

undergo laparoscopic herniorraphy have 1.6% incidence

of neuralgias due to nerve entrapment during mesh fixa-

tion with staples [12]. Some surgeons advocated placing

the mesh without fixation in preperitoneal space to avoid

nerve injury [13]. In our technique, the central zone of

the mesh only fixed by using Glubrane 2 substance cor-

responding to iliopubic tract, preventing any injury to

nerves and vessels. Mesh bulging was considered a fail-

ure of the correct surgical techn ique to tightly stretch the

mesh over the hernia opening. Two factors are predis-

posed for mesh protrusion a loosely stretched mesh and

present of hernia defect [5]. The mesh in our technique is

fixed at central zone after closure of hernia defect to al-

low the mesh expanded peripherally when the pneumop-

eritoneum is released. The recorded recurrence rate is

0.1% following TAPP. The main cause of recurrence is

mesh not adequately fixed and presence of hernia defect

allowing the mesh to migrate through it [11]. The recur-

rence rate in our study is zero, this due to closure of her-

nia defect behind the mesh, which fixed adequately over

the closed hernial defect.

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A. E. LASHEEN ET AL. 557

5. Conclusion

Our technique for laparoscopic inguinal hernia repair is

easy, associated with good results and free of complica-

tions.

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