Usefulness of repair using Hem-o-lok™ for peritoneal tear as a complication of totally extraperitoneal repair: Case series

Prevention and management of intraoperative complication during single incision laparoscopic totally extraperitoneal repair

Serious complications related to hernia surgeries have rarely been reported. One meta-analysis comparing laparoscopic and open mesh repair reported that 0.4% of potentially serious operative complications were reported. Previous studies have reported that uncommon serious intraoperative complications more frequently occur during laparoscopic inguinal hernia repairs. One study has shown that patients with history of lower abdominal surgery are at an increased risk of visceral injury during laparoscopic hernia repair. Vascular injuries at dissection and mesh fixation or suturing in the preperitoneal space typically involve the epigastric or aberrant obturator vessels crossing the Cooper’s ligament. However, complications can occur at every step of the operation, although only few are reported. Therefore, we report our experiences of intraoperative complications during single-incision laparoscopic totally extraperitoneal hernia repair and how to prevent and manage intraoperative complications.

TITANIUM CLIPS FOR CLOSURE OF THE PERITONEAL FLAP DURING LAPAROSCOPIC INGUINAL HERNIA REPAIR

BACKGROUND:

The laparoscopic approach for inguinal hernia repair has been widely used since its introduction in the 1990s. As a step in the procedure, the surgeon must access the preperitoneal space through an incision in the peritoneum, creating an adequate dissection for mesh placement. At the end of the procedure, the peritoneal flap must be closed to avoid adhesions. There are several methods to close the peritoneum.

AIMS:

The aim of this study was to propose a simple method for closing the peritoneal flap, using titanium clips, exposing its advantages and disadvantages.

METHODS:

Description of the peritoneum flap closure technique, using titanium clips, in the last 15 years.

RESULTS:

The pneumoperitoneum was reduced to a pressure of 7 mmHg; then, the two edges of the peritoneal flap were approximated together and, with the aid of a Maryland grasper, were kept together; titanium clips were used to close the flap. The process is repeated along the entire peritoneal incision until it is completely closed.

CONCLUSIONS:

The use of titanium clips proved to be a fast, inexpensive, and effective method for closing the peritoneal flap in videolaparoscopic inguinal hernioplasties, with no major or recurrent complications reported. Therefore, it is an effective and safe method for the closure of the peritoneal defect.

Causes of peritoneal injury during laparoscopic totally extraperitoneal inguinal hernia repair and methods of repair

INTRODUCTION

Peritoneal injury during laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is an intraoperative complication that affects accomplishment. We retrospectively examined the causes of peritoneal injury and methods of TEP repair.

METHODS

This study examined 58 patients with inguinal hernia (43 unilateral, 15 bilateral) who had undergone TEP repair; all procedures were performed by the same surgeon. The incidence of peritoneal injury, clinical characteristics that could have influenced peritoneal injury, and management of the injury were analyzed.

RESULTS

Peritoneal injury was noted in 16 inguinal hernias (21.9%, 16 /73). Injury occurred more frequently in right-sided hernias than in left-sided hernias (31.6% vs 11.4%, P = .049). No other factors were related to injury. Peritoneal injury occurred due to anatomical misrecognition in five hernias (31.3%, 5/16) and unintentional dissection in six hernias (37.5%, 6/16). All injuries due to unintentional dissection occurred in right-sided hernias. The procedures used for peritoneal injury repair were endoscopic suturing for 4 hernias, pre-tied loop ligation for 1 hernia, and ligation clips in 11 hernias. Additional techniques were required in three hernias repaired by endoscopic suturing (75% 3/4). After introduction of the ligation clips, endoscopic suturing was discontinued, and no additional techniques were needed.

CONCLUSION

Peritoneal injury more frequently occurred in right-sided inguinal hernia than in left-sided inguinal hernia during TEP repair. The common reasons for peritoneal injury were anatomical misrecognition and unintentional dissection. Repair using ligation clips is the best option for peritoneal injuries that occur during TEP repair.

Closing peritoneal tear during laparoscopic inguinal hernia repair: simple and effective technique

PURPOSE

Peritoneal tears occurring during TAPP and TEP are common, and can cause difficulty in continuing surgery, or, if left open can cause postoperative complications. A number of techniques to close the tear in the peritoneum have been described. These techniques are difficult and add to the operating time, and may not be successful in closing the opening in the peritoneum. We describe a simple, effective, fast technique of repairing these tears using the bipolar diathermy.

METHOD

We have used bipolar diathermy to seal inadvertent peritoneal tears occurring during TAPP/TEP repairs. This method of sealing the peritoneum has been used by us since 2015. We decided to review our results of sealing the tears in the peritoneum at TAPP/TEP from 01 Jan 2017 to 31 Dec 2019.

RESULTS

A total of 152 laparoscopic inguinal hernia repair (TAPP/TEP) procedures were done by the authors from 01 January 2017 to 31 December 2019, and of these, 101 cases had some degree of peritoneal tear. All peritoneal tears were very simply sealed using bipolar diathermy.

CONCLUSIONS

Peritoneal tears occurring inadvertently during Laparoscopic TAPP/TEP procedure for repair inguinal hernia can be effectively sealed with simple bipolar diathermy.