Hernia DOI 10.1007/s10029-017-1639-2
ORIGINAL ARTICLE
Laparoscopic inguinal hernioplasty after robot‑assisted laparoscopic radical prostatectomy M. Sakon1 · Y. Sekino1 · M. Okada1 · H. Seki1 · Y. Munakata1
Received: 9 September 2016 / Accepted: 6 August 2017 © Springer-Verlag France SAS 2017
Abstract Purpose To evaluate the efficacy and safety of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair in patients who have undergone robot-assisted laparoscopic radical prostatectomy (RALP). Methods From July 2014 to December 2016, TAPP inguinal hernia repair was conducted in 40 consecutive patients who had previously undergone RALP. Their data were retrospectively analyzed as an uncontrolled case series. Results The mean operation time in patients who had previously undergone RALP was 99.5 ± 38.0 min. The intraoperative blood loss volume was small, and the duration of hospitalization was 2.0 ± 0.5 days. No intraoperative complications or major postoperative complications occurred. During the average 11.2-month follow-up period, no patients who had previously undergone prostatectomy developed recurrence. Conclusions Laparoscopic TAPP inguinal hernia repair after RALP was safe and effective. TAPP inguinal hernia repair may be a valuable alternative to open hernioplasty.
hernia repair has become standard because it is associated with more rapid recovery, less pain, and a lower recurrence rate compared with open hernioplasty [1–3]. However, several aspects of laparoscopic inguinal hernia repair remain controversial. The laparoscopic approach was initially contraindicated in patients who had undergone previous abdominal surgery or radical prostatectomy; however, the effectiveness and safety of recent laparoscopic inguinal hernia repair techniques after radical prostatectomy or previous lower abdominal surgery has been reported in several articles [4–6]. A large number of prostatic cancer surgeries are now performed robotically, and the number of patients presenting with inguinal hernia after robot-assisted laparoscopic radical prostatectomy (RALP) is increasing. The feasibility of laparoscopic transabdominal preperitoneal (TAPP) repair of primary inguinal hernia has been well established. However, the surgical outcome of TAPP inguinal hernia repair after RALP is unclear. We retrospectively evaluated patients who had undergone TAPP inguinal hernia repair after RALP.
Keywords Laparoscopic · Inguinal hernioplasty · Robotassisted laparoscopic radical prostatectomy · TAPP
Materials and methods
Introduction Inguinal hernia is the most common condition encountered in general surgery. In recent years, laparoscopic inguinal * M. Sakon [email protected] 1
Department of Surgery, Nagano Municipal Hospital, 1333‑1 Tomitake, Nagano 381‑8551, Japan
Patients We retrospectively analyzed the data from patients who underwent laparoscopic TAPP inguinal hernia repair from July 2014 to December 2016. We included all patients who were diagnosed with unilateral or bilateral reducible inguinal hernias. We excluded patients with a history of a recurrent hernia or multiple lower abdominal surgeries. In total, 40 consecutive patients who had previously undergone RALP underwent TAPP inguinal hernia repair. Intraoperative and
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postoperative data from these patients were analyzed. The patients were followed up for at least 3 months. Operative technique Surgery was performed with the patient in the supine position. A 10-mm trocar was inserted through the umbilicus incision for a flexible laparoscope. Pneumoperitoneum was maintained at 10 mmHg using carbon dioxide insufflation. A 5-mm trocar was then placed at the lateral left and right midclavicular lines. We performed TAPP inguinal hernia repair using the standard technique through three ports [7]. After identifying anatomical landmarks and the hernia defect, a peritoneal incision was made from the lateral to internal ring and then to the medial umbilical fold. The lateral space of the spermatic cord was dissected until the psoas muscle was reached (Fig. 1a), and the hernial sac was then incised. The medial space was carefully dissected to expose the transverse abdominal muscle inside the inferior epigastric vessels. Because of the presence of hardened medial scar tissue from previous surgery in patients who had undergone RALP, the dissected area toward the pubic symphysis was smaller than that in patients who had not undergone RALP (Fig. 1b). A 13.4- × 7.9-cm lightweight mesh (3D Max Light; Bard, Murray Hill, NY, USA) was placed into this dissected preperitoneal space. During primary hernia surgery, we usually use a 13.4- × 7.9-cm lightweight mesh. Because Japanese patients are generally anthropometrically small, the preperitoneal space from the pubic symphysis to the anterior superior iliac spine can be covered with a 13.4- × 7.9-cm mesh. The mesh was laterally fixed with six to eight absorbable staples (two staples in the rectus muscle and Cooper’s ligament, and three to five staples in the transverse fascia), avoiding the area of the external iliac vessels and nerves. The peritoneum was closed using absorbable running suture. Statistical analysis Continuous variables are expressed as median with range.
Results Patient characteristics From July 2014 to December 2016, TAPP inguinal hernia repair after RALP was performed in 40 patients with a mean age of 69.7 years (range 60–77 years). Thirty-five patients had a unilateral hernia, and 5 patients had bilateral hernias (45 inguinal hernia repairs). All patients were male because of the inclusion criterion of previous prostate surgery. According to the Nyhus hernia classification,
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Fig. 1 a Laparoscopic view of a Nyhus type 3B hernia on the right side. Because of the presence of hard scar tissue, the dissection area on the medial side in the cases of hernia after robot-assisted laparoscopic radical prostatectomy is smaller than that in the cases of primary hernia. b Laparoscopic view of the lateral side. The dissection area on the lateral side in the cases of hernia after robot-assisted laparoscopic radical prostatectomy is similar to that in the cases of primary hernia
44 hernias were type 3B (indirect hernia) and 1 was type 3A (direct hernia) (Table 1). Operative results All procedures were performed by surgeons with a minimum experience of 50 laparoscopic hernia repairs per surgeon. The mean operative time was 99.5 ± 38.0 min (Table 2). No conversion to open surgery occurred. All patients who had undergone RALP were discharged on the second or third postoperative day without exceptions. The operative and postoperative data are summarized in Table 2.
Hernia Table 1 Patient demographics and hernia sites and classifications Variable
TAPP after RALP (n = 40)
Number of patients Age (years) Sex Male Female Site of hernia Right inguinal Left inguinal Bilateral inguinal Nyhus type 2 3a (direct hernia) 3b (indirect hernia) 3c
40 71 ± 4.8 40 0 22 13 5 0 1 44 0
TAPP transabdominal preperitoneal, RALP robot-assisted laparoscopic prostatectomy
Table 2 Comparison of operative and postoperative data Variable
TAPP after RALP (n = 40)
Operative time (min) Blood loss (ml) Intraoperative complication Conversion Hospital stay (days) Complication Seroma Wound infection Bleeding/hematoma Recurrence
99.5 ± 38 2 ± 1.9 0 0 2 ± 0.5 3 2 1 0 0
TAPP transabdominal preperitoneal, RALP robot-assisted laparoscopic prostatectomy
Complications No intraoperative complications occurred. No major postoperative complications occurred; only two patients developed a seroma, and one patient developed a wound infection at the umbilicus. After an average follow-up of 11.2 months (range 3–29 months), no recurrence had developed in any of the 45 hernia repairs conducted in patients who had undergone RALP (Table 2).
Discussion The present study is the first to show the safety and feasibility of TAPP inguinal hernia repair after RALP. No intraoperative complications occurred. Although postoperative complications developed in three patients, these were only minor. No hernia recurrence developed in the patients who had undergone RALP. The TAPP approach is useful in complicated cases such as those involving inguinal hernia after RALP, similar to the cases involving primary hernias. TAPP allows the surgeon to confirm the intra-abdominal anatomical situation. Although the operative time was longer in patients who had undergone RALP than in patients with primary hernias, this difference may be clinically unimportant. Several published reports have described laparoscopic inguinal hernia repair after radical prostatectomy. A recent prospective clinical trial revealed no major postoperative complications and no recurrence in 20 cases of laparoscopic TAPP inguinal hernia repair after radical prostatectomy [4]. Wauschkuhn et al. [5] reported low morbidity and low recurrence in 264 cases of TAPP inguinal hernia repair after radical prostatectomy; they showed that TAPP repair after radical prostatectomy can be performed effectively and safely by skilled laparoscopic surgeons. Dulucq et al. [6] reported a mean operative time of 36 min for the totally extraperitoneal approach for hernia repair after radical prostatectomy in 10 patients; this is shorter than the time reported in other series of TAPP inguinal hernia repair [4, 5], although there were two conversions to TAPP [6]. Dulucq et al. [6] experienced no major intraoperative complications and no postoperative complications. However, there are no reports on TAPP inguinal hernia repair after RALP, and the advantage of the laparoscopic approach for inguinal hernia repair is unclear. We have been using the TAPP approach for inguinal hernia repair after radical prostatectomy since 1996 and the TAPP procedure for inguinal hernia after RALP since 2014. The risk of inguinal hernia may be lower in RALP than open surgery. In one study, the cumulative risk of inguinal hernia development 48 months after prostatectomy was 12.2% among patients who underwent retropubic radical prostatectomy and 5.8% among those who underwent RALP [8]. Several prostatic cancer surgeries are now being performed robotically, and the number of cases of inguinal hernia development after RALP is increasing. Therefore, it is necessary to establish a surgical approach for inguinal hernia repair after RALP. Our study indicates that the TAPP approach for inguinal hernia after RALP can be a valuable alternative. Almost all hernias in the prostatectomy group were Nyhus type 3B, probably because of traumatization of the transverse fascia during the RALP procedure. Urologists should thus minimize trauma to the transverse fascia to reduce the development of inguinal hernias after RALP.
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Hernia
There were some limitations to the present study. First, our study was based on retrospective data, and the sample size was small. Our data lack the power to detect rare but severe adverse events. A prospective study is necessary to further evaluate TAPP inguinal hernia repair after RALP. Second, the dissection area on the medial side of the epigastric vessels toward the pubic symphysis was smaller in patients who had undergone RALP than in patients with primary hernias; this was because of the hard scar tissue from the previous surgery on the medial side. However, all but one of the patients in our study who had previously undergone RALP had an indirect hernia; after laparoscopic diagnosis of the indirect hernia, we performed hernia repair mainly by dissecting the lateral space around the internal ring. In the one patient with a direct hernia, we attempted to dissect the medial side of the hernia defect, but dissection toward the pubic symphysis was impossible because of the hard scar tissue; therefore, we had no alternative but to repair the hernia using the intraperitoneal onlay mesh technique [9]. If a direct hernia is confirmed on laparoscopy, we recommend open repair because of the risk of injury to the urinary bladder when laparoscopically dissecting the scar tissue on the medial side. A direct hernia after RALP is very difficult to repair with the TAPP procedure. Such a hernia should not be repaired using the intraperitoneal onlay mesh technique if the operator is unfamiliar with this procedure. Because we used the TAPP approach for indirect hernias (with the exception of a direct hernia in only one case), the operation procedure was standardized. Moreover, the operation time was shortened as the learning curve progressed. The difficulty of dissection was reduced by minimizing the dissection of hard scar tissue on the medial side.
Conclusions In the present study, laparoscopic TAPP inguinal hernia repair after RALP is feasible. TAPP repair for indirect hernias may be a valuable alternative to open hernioplasty. However, the follow-up period was too short to assess the prevention of recurrence. Another problem is that the mesh size is smaller and a direct hernia is very difficult to repair with the TAPP procedure. Further prospective studies are necessary to validate the feasibility and safety of TAPP inguinal hernia repair after RALP. Compliance with ethical standards Conflict of interest Masahiro Sakon, Yasushi Sekino, Masao Okada, Hitoshi Seki, and Yasuhiro Munakata have no conflicts of interest or financial ties to disclose.
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Funding No specific funding was received for this study. Ethical approval This study was approved by the Human Ethics Review Committee of the Nagano Municipal Hospital. Human and animal rights Our procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national). Informed consent Informed consent was obtained from all patients included in the study.
References 1. Peitsch WK (2014) A modified laparoscopic hernioplasty (TAPP) is the standard procedure for inguinal and femoral hernias: a retrospective 17-year analysis with 1123 hernia repairs. Surg Endosc 28:671–682 2. Bansal VK, Misra MC, Babu D, Victor J, Kumar S, Sagar R, Rajeshwari S, Krishna A, Rewari V (2013) A prospective randomized comparison of long-term outcomes: chronic groin pain and quality of life following totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repar. Surg Endosc 27:2373–2382 3. Wang WJ, Chen JZ, Fang Q, Li JF, Jin PF, Li ZT (2013) Comparison of the effects of laparoscopic hernia repair and Lichtenstein tension-free hernia repair. J Laparoendosc Adv Surf Tech A 23:301–305 4. Claus CMP, Coelho JCU, Campos ACL, Cury Filho AM, Loureiro MP, Dimbarre D, Bonin EA (2014) Laparoscopic inguinal hernioplasty after radical prostatectomy: is it safe? Prospective clinical trial. Hernia 18:255–259 5. Wauschkuhn CA, Schwarz J, Bittner R (2009) Laparoscopic transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: is it safe? Results of prospectively collected data of more than 200 cases. Surg Endosc 23:973–977 6. Dulucq J-L, Wintringer P, Mahajna A (2006) Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or previous lower abdominal surgery. Surg Endoscopy 20:473–476 7. Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ (2002) Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg 89:1062–1066 8. Stranne J, Johansson E, Nilsson A, Bill-Axelson A, Carlsson S, Holmberg L, Johansson J, Nyberg T, Ruutu M, Wiklund N, Steinech G (2010) Inguinal hernia after radical prostatectomy for prostate cancer: results from a randomized setting and a nonrandomized setting. Eur Urol 58(5):719–726 9. Czudek S, Mec V, Riha D, Matloch J, Branny J (2001) Methods of intraperitoneal placement of mesh in laparoscopic surgery of inguinal hernias (IPOM—Intraperitoneal Onlay Mesh). Rozhl Chir 80:30–34
ORIGINAL ARTICLE
Laparoscopic inguinal hernioplasty after robot‑assisted laparoscopic radical prostatectomy M. Sakon1 · Y. Sekino1 · M. Okada1 · H. Seki1 · Y. Munakata1
Received: 9 September 2016 / Accepted: 6 August 2017 © Springer-Verlag France SAS 2017
Abstract Purpose To evaluate the efficacy and safety of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair in patients who have undergone robot-assisted laparoscopic radical prostatectomy (RALP). Methods From July 2014 to December 2016, TAPP inguinal hernia repair was conducted in 40 consecutive patients who had previously undergone RALP. Their data were retrospectively analyzed as an uncontrolled case series. Results The mean operation time in patients who had previously undergone RALP was 99.5 ± 38.0 min. The intraoperative blood loss volume was small, and the duration of hospitalization was 2.0 ± 0.5 days. No intraoperative complications or major postoperative complications occurred. During the average 11.2-month follow-up period, no patients who had previously undergone prostatectomy developed recurrence. Conclusions Laparoscopic TAPP inguinal hernia repair after RALP was safe and effective. TAPP inguinal hernia repair may be a valuable alternative to open hernioplasty.
hernia repair has become standard because it is associated with more rapid recovery, less pain, and a lower recurrence rate compared with open hernioplasty [1–3]. However, several aspects of laparoscopic inguinal hernia repair remain controversial. The laparoscopic approach was initially contraindicated in patients who had undergone previous abdominal surgery or radical prostatectomy; however, the effectiveness and safety of recent laparoscopic inguinal hernia repair techniques after radical prostatectomy or previous lower abdominal surgery has been reported in several articles [4–6]. A large number of prostatic cancer surgeries are now performed robotically, and the number of patients presenting with inguinal hernia after robot-assisted laparoscopic radical prostatectomy (RALP) is increasing. The feasibility of laparoscopic transabdominal preperitoneal (TAPP) repair of primary inguinal hernia has been well established. However, the surgical outcome of TAPP inguinal hernia repair after RALP is unclear. We retrospectively evaluated patients who had undergone TAPP inguinal hernia repair after RALP.
Keywords Laparoscopic · Inguinal hernioplasty · Robotassisted laparoscopic radical prostatectomy · TAPP
Materials and methods
Introduction Inguinal hernia is the most common condition encountered in general surgery. In recent years, laparoscopic inguinal * M. Sakon [email protected] 1
Department of Surgery, Nagano Municipal Hospital, 1333‑1 Tomitake, Nagano 381‑8551, Japan
Patients We retrospectively analyzed the data from patients who underwent laparoscopic TAPP inguinal hernia repair from July 2014 to December 2016. We included all patients who were diagnosed with unilateral or bilateral reducible inguinal hernias. We excluded patients with a history of a recurrent hernia or multiple lower abdominal surgeries. In total, 40 consecutive patients who had previously undergone RALP underwent TAPP inguinal hernia repair. Intraoperative and
13
Vol.:(0123456789)
Hernia
postoperative data from these patients were analyzed. The patients were followed up for at least 3 months. Operative technique Surgery was performed with the patient in the supine position. A 10-mm trocar was inserted through the umbilicus incision for a flexible laparoscope. Pneumoperitoneum was maintained at 10 mmHg using carbon dioxide insufflation. A 5-mm trocar was then placed at the lateral left and right midclavicular lines. We performed TAPP inguinal hernia repair using the standard technique through three ports [7]. After identifying anatomical landmarks and the hernia defect, a peritoneal incision was made from the lateral to internal ring and then to the medial umbilical fold. The lateral space of the spermatic cord was dissected until the psoas muscle was reached (Fig. 1a), and the hernial sac was then incised. The medial space was carefully dissected to expose the transverse abdominal muscle inside the inferior epigastric vessels. Because of the presence of hardened medial scar tissue from previous surgery in patients who had undergone RALP, the dissected area toward the pubic symphysis was smaller than that in patients who had not undergone RALP (Fig. 1b). A 13.4- × 7.9-cm lightweight mesh (3D Max Light; Bard, Murray Hill, NY, USA) was placed into this dissected preperitoneal space. During primary hernia surgery, we usually use a 13.4- × 7.9-cm lightweight mesh. Because Japanese patients are generally anthropometrically small, the preperitoneal space from the pubic symphysis to the anterior superior iliac spine can be covered with a 13.4- × 7.9-cm mesh. The mesh was laterally fixed with six to eight absorbable staples (two staples in the rectus muscle and Cooper’s ligament, and three to five staples in the transverse fascia), avoiding the area of the external iliac vessels and nerves. The peritoneum was closed using absorbable running suture. Statistical analysis Continuous variables are expressed as median with range.
Results Patient characteristics From July 2014 to December 2016, TAPP inguinal hernia repair after RALP was performed in 40 patients with a mean age of 69.7 years (range 60–77 years). Thirty-five patients had a unilateral hernia, and 5 patients had bilateral hernias (45 inguinal hernia repairs). All patients were male because of the inclusion criterion of previous prostate surgery. According to the Nyhus hernia classification,
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Fig. 1 a Laparoscopic view of a Nyhus type 3B hernia on the right side. Because of the presence of hard scar tissue, the dissection area on the medial side in the cases of hernia after robot-assisted laparoscopic radical prostatectomy is smaller than that in the cases of primary hernia. b Laparoscopic view of the lateral side. The dissection area on the lateral side in the cases of hernia after robot-assisted laparoscopic radical prostatectomy is similar to that in the cases of primary hernia
44 hernias were type 3B (indirect hernia) and 1 was type 3A (direct hernia) (Table 1). Operative results All procedures were performed by surgeons with a minimum experience of 50 laparoscopic hernia repairs per surgeon. The mean operative time was 99.5 ± 38.0 min (Table 2). No conversion to open surgery occurred. All patients who had undergone RALP were discharged on the second or third postoperative day without exceptions. The operative and postoperative data are summarized in Table 2.
Hernia Table 1 Patient demographics and hernia sites and classifications Variable
TAPP after RALP (n = 40)
Number of patients Age (years) Sex Male Female Site of hernia Right inguinal Left inguinal Bilateral inguinal Nyhus type 2 3a (direct hernia) 3b (indirect hernia) 3c
40 71 ± 4.8 40 0 22 13 5 0 1 44 0
TAPP transabdominal preperitoneal, RALP robot-assisted laparoscopic prostatectomy
Table 2 Comparison of operative and postoperative data Variable
TAPP after RALP (n = 40)
Operative time (min) Blood loss (ml) Intraoperative complication Conversion Hospital stay (days) Complication Seroma Wound infection Bleeding/hematoma Recurrence
99.5 ± 38 2 ± 1.9 0 0 2 ± 0.5 3 2 1 0 0
TAPP transabdominal preperitoneal, RALP robot-assisted laparoscopic prostatectomy
Complications No intraoperative complications occurred. No major postoperative complications occurred; only two patients developed a seroma, and one patient developed a wound infection at the umbilicus. After an average follow-up of 11.2 months (range 3–29 months), no recurrence had developed in any of the 45 hernia repairs conducted in patients who had undergone RALP (Table 2).
Discussion The present study is the first to show the safety and feasibility of TAPP inguinal hernia repair after RALP. No intraoperative complications occurred. Although postoperative complications developed in three patients, these were only minor. No hernia recurrence developed in the patients who had undergone RALP. The TAPP approach is useful in complicated cases such as those involving inguinal hernia after RALP, similar to the cases involving primary hernias. TAPP allows the surgeon to confirm the intra-abdominal anatomical situation. Although the operative time was longer in patients who had undergone RALP than in patients with primary hernias, this difference may be clinically unimportant. Several published reports have described laparoscopic inguinal hernia repair after radical prostatectomy. A recent prospective clinical trial revealed no major postoperative complications and no recurrence in 20 cases of laparoscopic TAPP inguinal hernia repair after radical prostatectomy [4]. Wauschkuhn et al. [5] reported low morbidity and low recurrence in 264 cases of TAPP inguinal hernia repair after radical prostatectomy; they showed that TAPP repair after radical prostatectomy can be performed effectively and safely by skilled laparoscopic surgeons. Dulucq et al. [6] reported a mean operative time of 36 min for the totally extraperitoneal approach for hernia repair after radical prostatectomy in 10 patients; this is shorter than the time reported in other series of TAPP inguinal hernia repair [4, 5], although there were two conversions to TAPP [6]. Dulucq et al. [6] experienced no major intraoperative complications and no postoperative complications. However, there are no reports on TAPP inguinal hernia repair after RALP, and the advantage of the laparoscopic approach for inguinal hernia repair is unclear. We have been using the TAPP approach for inguinal hernia repair after radical prostatectomy since 1996 and the TAPP procedure for inguinal hernia after RALP since 2014. The risk of inguinal hernia may be lower in RALP than open surgery. In one study, the cumulative risk of inguinal hernia development 48 months after prostatectomy was 12.2% among patients who underwent retropubic radical prostatectomy and 5.8% among those who underwent RALP [8]. Several prostatic cancer surgeries are now being performed robotically, and the number of cases of inguinal hernia development after RALP is increasing. Therefore, it is necessary to establish a surgical approach for inguinal hernia repair after RALP. Our study indicates that the TAPP approach for inguinal hernia after RALP can be a valuable alternative. Almost all hernias in the prostatectomy group were Nyhus type 3B, probably because of traumatization of the transverse fascia during the RALP procedure. Urologists should thus minimize trauma to the transverse fascia to reduce the development of inguinal hernias after RALP.
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Hernia
There were some limitations to the present study. First, our study was based on retrospective data, and the sample size was small. Our data lack the power to detect rare but severe adverse events. A prospective study is necessary to further evaluate TAPP inguinal hernia repair after RALP. Second, the dissection area on the medial side of the epigastric vessels toward the pubic symphysis was smaller in patients who had undergone RALP than in patients with primary hernias; this was because of the hard scar tissue from the previous surgery on the medial side. However, all but one of the patients in our study who had previously undergone RALP had an indirect hernia; after laparoscopic diagnosis of the indirect hernia, we performed hernia repair mainly by dissecting the lateral space around the internal ring. In the one patient with a direct hernia, we attempted to dissect the medial side of the hernia defect, but dissection toward the pubic symphysis was impossible because of the hard scar tissue; therefore, we had no alternative but to repair the hernia using the intraperitoneal onlay mesh technique [9]. If a direct hernia is confirmed on laparoscopy, we recommend open repair because of the risk of injury to the urinary bladder when laparoscopically dissecting the scar tissue on the medial side. A direct hernia after RALP is very difficult to repair with the TAPP procedure. Such a hernia should not be repaired using the intraperitoneal onlay mesh technique if the operator is unfamiliar with this procedure. Because we used the TAPP approach for indirect hernias (with the exception of a direct hernia in only one case), the operation procedure was standardized. Moreover, the operation time was shortened as the learning curve progressed. The difficulty of dissection was reduced by minimizing the dissection of hard scar tissue on the medial side.
Conclusions In the present study, laparoscopic TAPP inguinal hernia repair after RALP is feasible. TAPP repair for indirect hernias may be a valuable alternative to open hernioplasty. However, the follow-up period was too short to assess the prevention of recurrence. Another problem is that the mesh size is smaller and a direct hernia is very difficult to repair with the TAPP procedure. Further prospective studies are necessary to validate the feasibility and safety of TAPP inguinal hernia repair after RALP. Compliance with ethical standards Conflict of interest Masahiro Sakon, Yasushi Sekino, Masao Okada, Hitoshi Seki, and Yasuhiro Munakata have no conflicts of interest or financial ties to disclose.
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Funding No specific funding was received for this study. Ethical approval This study was approved by the Human Ethics Review Committee of the Nagano Municipal Hospital. Human and animal rights Our procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national). Informed consent Informed consent was obtained from all patients included in the study.
References 1. Peitsch WK (2014) A modified laparoscopic hernioplasty (TAPP) is the standard procedure for inguinal and femoral hernias: a retrospective 17-year analysis with 1123 hernia repairs. Surg Endosc 28:671–682 2. Bansal VK, Misra MC, Babu D, Victor J, Kumar S, Sagar R, Rajeshwari S, Krishna A, Rewari V (2013) A prospective randomized comparison of long-term outcomes: chronic groin pain and quality of life following totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repar. Surg Endosc 27:2373–2382 3. Wang WJ, Chen JZ, Fang Q, Li JF, Jin PF, Li ZT (2013) Comparison of the effects of laparoscopic hernia repair and Lichtenstein tension-free hernia repair. J Laparoendosc Adv Surf Tech A 23:301–305 4. Claus CMP, Coelho JCU, Campos ACL, Cury Filho AM, Loureiro MP, Dimbarre D, Bonin EA (2014) Laparoscopic inguinal hernioplasty after radical prostatectomy: is it safe? Prospective clinical trial. Hernia 18:255–259 5. Wauschkuhn CA, Schwarz J, Bittner R (2009) Laparoscopic transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: is it safe? Results of prospectively collected data of more than 200 cases. Surg Endosc 23:973–977 6. Dulucq J-L, Wintringer P, Mahajna A (2006) Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or previous lower abdominal surgery. Surg Endoscopy 20:473–476 7. Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ (2002) Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg 89:1062–1066 8. Stranne J, Johansson E, Nilsson A, Bill-Axelson A, Carlsson S, Holmberg L, Johansson J, Nyberg T, Ruutu M, Wiklund N, Steinech G (2010) Inguinal hernia after radical prostatectomy for prostate cancer: results from a randomized setting and a nonrandomized setting. Eur Urol 58(5):719–726 9. Czudek S, Mec V, Riha D, Matloch J, Branny J (2001) Methods of intraperitoneal placement of mesh in laparoscopic surgery of inguinal hernias (IPOM—Intraperitoneal Onlay Mesh). Rozhl Chir 80:30–34
