Page 49 - Read Online

Page 4 of 8 Burton et al. Mini-invasive Surg 2021;5:26 https://dx.doi.org/10.20517/2574-1225.2021.26

CONTAMINATED OR INFECTED WOUND
For emergent or urgent cases in which there is gross contamination with pus or stool, a mesh free repair is
necessary. Because laparoscopic inguinal hernia repair necessitates mesh use while open inguinal hernia
repair can be performed both with and without mesh, an open tissue repair is the technique of choice for
inguinal hernias in the setting of infection or stool spillage. Although biologic and absorbable synthetic
meshes have been used in these settings, it should be cautioned that these meshes are not FDA approved for
[21]
use in an infected field . For emergent or urgent cases with strangulated bowel requiring resection, where
contamination is negligible, mesh use has been shown in small cohort studies to have acceptable surgical
site infection rates [22,23] . For contaminated settings, the senior author often prefers to utilize the Bassini or
McVay tissue repair technique after wound irrigation and/or bowel resection. In cases of incarceration with
possible strangulation, diagnostic laparoscopy with placement of ports for a TAPP repair is utilized to allow
for intraabdominal evaluation of bowel. If viable, a TAPP repair is performed with a macroporous
polypropylene mesh. If not viable, bowel resection is performed, and an open Lichtenstein repair is
performed if contamination is well controlled; otherwise, a Bassini or McVay tissue repair is performed.

RECURRENT INGUINAL HERNIA
In recurrent hernia cases, the operating surgeon benefits from knowing the manner of the prior repair and
utilizing the non-violated plane. Where the prior repair was performed using an open approach with
[20]
anterior mesh, a laparoscopic technique is the recommended course . Where the prior repair was
performed using a laparoscopic approach with preperitoneal mesh, an open approach with anterior mesh is
recommended . In patients with multiply recurrent groin hernias where both anterior and preperitoneal
[20]
planes have been violated, subsequent repair methods should be based on surgeon expertise. For these
difficult scenarios, the senior author first reviews all old operative notes and obtains recent pelvic imaging
with a CT scan for evaluation of anatomy. Based on this information, a repeat open repair may be tried on
patients with a hostile abdomen or operative notes demonstrating a previous difficult MPO dissection.
Otherwise, a repeat preperitoneal approach is tried, usually with the utilization of the robotic platform,
which the author finds to be helpful in both visualization and ease of retraction of the peritoneal flap.

CONTRAINDICATIONS (AND RELATIVE CONTRAINDICATIONS) TO LAPAROSCOPY
The ability to perform an open repair under local or regional anesthesia negates any risk that could arise
with general anesthesia. The insufflation of laparosocpy requires general endotracheal anesthesia (GETA)
and thus any patient population in which GETA is contraindicated cannot undergo laparoscopic inguinal
hernia repair. The higher risk of intra-abdominal adhesions and scarred tissue planes of patients with prior
pelvic and/or abdominal surgeries can make laparoscopic approaches more difficult and potentially increase
morbidity. For these reasons, open repair is often the repair method of choice as it rarely violates the
abdominal cavity or requires extensive pelvic dissection. However, there are published studies in the
appropriately skilled and experienced surgeon’s hands, demonstrating that laparoscopic repair is safe and
feasible in patients with prior pelvic and lower abdominal surgeries [24,25] .

MORE THAN JUST A UNILATERAL INGUINAL HERNIA
The Stoppa repair is the only open repair that allows bilateral groin hernia repair through the same incision
as a unilateral repair and does not require bilateral groin incisions. For patients with symptomatic bilateral
inguinal hernias, laparoscopic repair allows repair for both the right and left sides through the same three
small trocar incisions. Indeed, in our practice, all patients without contraindications to laparoscopy and
with bilateral groin hernias are offered a minimally invasive approach for repair. For patients with suspected
contralateral hernias, a TAPP repair is offered to allow for contralateral inspection during initial camera
insertion. TEP repair can also be performed, but contralateral exploration requires dissection of tissue