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Pre Peritoneal Laparoscópica

Pre Peritoneal Laparoscópica



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Published by marquete72
Hernia Laparoscopia preperitoneal
Hernia Laparoscopia preperitoneal

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Published by: marquete72 on Jan 21, 2009
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Laparoscopic Transabdominal PreperitonealHerniorrhaphy
Robert J. Fitzgibbons, Jr, MD
The overwhelming success of laparoscopic cholecystec-tomy resulted in the retraining of general surgeons sothat they became experienced and facile in the principlesof therapeutic laparoscopy. Soon many surgeons began toapply their newly developed skills in laparoscopy toother commonly performed general surgical operationsin hopes of achieving the same benefits as were realizedwith laparoscopic cholecystectomy. Inguinal herniorrha-phy was no exception. The two commonly performedlaparoscopic herniorrhaphies, the transabdominal preperi-toneal (TAPP) and the totally extraperitoneal (TEP), aremodeled after the conventional preperitoneal operationspopularized by Stoppa, Reeves, Nyhus I and others. Themajor difference is that the preperitoneal space is enteredthrough three trocar sites rather than a large conven-tional incision. The ensuing radical dissection of thepreperitoneal space with the placement of a large prosthe-sis is similar to the conventional preperitonea! operation.Laparoscopic inguinal hernia repair has the followingpotential advantages: (1) less postoperative discomfort/pain; (2) reduced recovery time, allowing earlier returnto full activity; (3) easier repair of a recurrent herniabecause the repair is performed in tissue that has notbeen previously dissected; (4) the ability to treat bilateralhernias; (5) the performance of a simultaneous diagnos-tic laparoscopy; (6) the highest possible ligation of thehernia sac; (7) and an improved cosmesis. Numeroussingle center, multicenter, and comparative studies haveproven that an inguinal hernia can be repaired using thelaparoscopic method (Tables 1-3). The question thatmust be answered now is should an inguinal hernia berepaired using the laparoscopic method. Skepticism ex-ists among many surgeons concerning the benefits oflaparoscopic herniorrhaphy because the severity of pos-sible complications and the precise indications are amatter of considerable debate.An extensive discussion of the advantages and disad-
From the Department of Surgery, Creighton University School of Medicine,Omaha, NE.Address reprint requests to Robert J. Fitzgibbons, Jr, MD, Department ofSurgery, Creighton University School of Medicine, 601 North 30th St, Suite 3740,Omaha, NE 68131.Copyright 9 1999 by WB. Saunders Company1524-153X/99/0102-0006510.00/0
vantages of the laparoscopic approach compared with theconventional operation is beyond the scope of thisarticle. The question cannot be answered definitivelyuntil the results of several randomized, prospectivecomparative trials that are now either ongoing, or indevelopment, are completed. The purpose of this reviewis to describe the technical details of the TAPP procedure.
Anatomical Considerations
A thorough knowledge of the anatomy of the groin froman opposite perspective to what is normally taught, thatis, proceeding from deeper structures to more superficial,is critical to a successful laparoscopic inguinal herniorrha-phy. A laparoscopic view of a left direct hernia can beseen in Figure 1. The most important anatomical land-marks are the medial umbilical ligament, the inferiorepigastric vessels, and the internal ring. The vas deferensand the internal spermatic vessels converge at the inter-nal ring to form the cord structures. Cooper's ligamentand the symphysis pubis are not always visible laparoscop-ically but can easily be defined by palpation withlaparoscopic instruments. Figure 2A is a cadaver prepara-tion of the right groin with the peritoneum and preperito-neal fatty tissue stripped away. The inferior epigastricvessels, the symphysis pubis, the Cooper's ligament, thevas deferens, and the internal spermatic vessels areimportant landmarks to be exposed during the course ofa laparoscopic TAPP procedure, and, therefore, knowl-edge of their location is crucial for the laparoscopicsurgeon intent on performing this type of repair. Also ofimportance are the anastomotic pubic branches, becausetroublesome bleeding will ensue if they are damagedduring the dissection of Cooper's ligament. A structurethat is not routinely exposed during a laparoscopic TAPPherniorrhaphy but nevertheless must be appreciated, isthe iliopubic tract because this marks the inferior bound-ary for staple placement when affixing the prosthesislateral to the internal spermatic vessels. The genitofemo-ral nerve and the lateral femoral cutaneous nerve exit thepelvis close to the inferior surface of the iliopubic tract.Figure 2B is the same cadaver photograph with meshstapled in place in a desirable position for performing alaparoscopic preperitoneal herniorrhaphy. The reason
Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 169-184
Robert J. Fitzgibbons, Jr
why placing staples below the level of the iliopubic tractlateral to the internal spermatic vessels frequently resultsin troublesome neuralgia is obvious. Two other nerves,the ilioinguinal and the iliohypogastric, although lying ina more superficial plane between the external andinternal oblique muscles, may also be injured if staplesare placed too deeply, especially when using a vigorousbimanual technique (see Fig 3). Finally, the laparoscopicsurgeon should be aware of the location of the externaliliac vessels and the femoral nerve. Although thesestructures would generally be considered outside thenormal field of dissection, injuries to them are particu-larly debilitating.
Patient Selection
All adult patients with inguinal hernias who are candi-dates for general anesthesia can be considered candidatesfor the laparoscopic TAPP inguinal hernia repair. At thepresent time, however, it is not clear that there aresufficient advantages for patients with uncomplicatedinguinal hernias to outweigh the major disadvantages ofthe procedure, which include (1) a laparoscopic accident,(2) bowel obstruction secondary to adhesions or aninternal or a ventral hernia, and (3) increased cost.Currently, we do not recommend laparoscopy for everyhernia (ie, unilateral and nonrecurrent). However, cer-tain types, such as those that are recurrent, bilateral, orotherwise complicated are particularly suited for thelaparoscopic approach. Absolute contraindications in-clude any sign of intra-abdominal infection or coagulop-athy. Relative contraindications include intra-abdominaladhesions from previous surgery, ascites, or previous"space of Retzius" surgery because of the increased risk ofbladder injury. Severe underlying medical illness is also arelative contraindication because of the added risk ofgeneral anesthesia. These patients are better suited for aconventional operation under local anesthesia. An incar-cerated sliding scrotal hernia is a relative contraindica-tion, especially when it involves the sigmoid colon,because of the high risk of perforation during thedissection.
Table 1. Noncomparative Trials of Laparoscopic Inguinal Hernia Repair (LIHR)Hernias recurrent Recurrence Length ofat enrollment Hernia rate follow-upAuthors Year Technique (%) (n) (%) (mos)Corbitt 1 1991 TAPP 12 100 0 18Arregui et al2 1992 TAPP, extra 14 147 1.3 NAHawasli 3 1992 TAPP, mushroom plug and patch 10 143 1.4 7Begin 4 1993 Extra 53 200 0.5 18Fitzgibbons et al5 1993 TAPP, extra, IPOM 14.5 867 4.5 34Geis et al 6 1993 TAPP 11 450 0.6 30Himpens 7 1993 TAPP 17 100 2 NANewman et ai8 1993 TAPP 14 102 NA 1Quilici et al 9 1993 TAPP 5 173 0 NAWheeler 1~ 1993 TAPP, mesh plus plug 5 135 0 18Felix et a111 1994 TAPP, single or double buttress 13 205 0 21Paget 12 1994 TAPP 15 222 1.8 18Panton and Panton ~3 1994 TAPP 18 106 0 12Rubio
1994 IPOM NA 120 48 0Felix et aP 5 1995 Extra, balloon, CO2 8 382 0.3 9Felix et a115 1995 TAPP 14 733 0.3 24Ferzli and KieP 6 1995 Extra, balloon, CO2, blunt 11 326 1.6 22Kald et a117 1995 TAPP 17 200 3.5 24Kavic 18 1995 TAPP 10 244 1 34Phillips et aP 9 1995 Variety 1.6 3229 1.6 22Ramshaw et al2~ 1995 TAPP 14 290 2.1 NARamshaw et al2~ 1995 TEP 16 118 0.5 NAVoeller et al2~ 1995 Extra, balloon, CO2 12 365 0 15Batorfi et
a[ 22
1997 TAPP 32 160 3.1 NALitwin et a123 1997 TAPP NA 632 0 14Schmidt and Anta124 1997 TEP 0 20 0 10Sievers et a125 1997 TAPP NA 776 3.9 NABarry et a126 1998 TAPP NA 206 3.0 29Bittner et 8.127 1998 TAPP 0 3,400 0.5 NACohen et a128 1998 TEP 33 144 0 40Felix et a129 1998 TAPP/TEP NA 7,661 0.4 36Ferzli et al 3~ 1998 TEP NA 237 3.2 NAHussein et a131 1998 TEP NA 803 1.5 24Kiruparan and Pettit32 1998 TAPP NA 215 1.4 30Sayad et a133 1998 TAPP/TEP 0 11,222 2.7 NAToouli et a134 1998 TAPP NA 58 7 15Abbreviations: NA, information not available; IPOM, intraperitoneal onlay mesh procedure.
Laparoscopic TAPP Herniorrhaphy
Table 2. Early Laparoscopic Versus Conventional Herniorrhaphy: Comparative TrialsType ofAuthors Study Intervention ResultsStoker et a135 Prospective, randomized TAPP vs Nylon darn 6 vs 18 pain tabletsPain analogue score 1.8 vs 3.1Return to activity 14 vs 28 daysT CostEarlier return to activity 92% vs 29% at 14 daysEarlier return to work 73% vs 14% in 3 weeksI PainT CostEarlier return to workNo difference in pain medication1" Costl Time off workI Pain medicationl ComplicationsHospital days better1" CostEarlier return to activity (7 vs 14 days)Earlier return to work (10 vs 21 days)No difference in analgesic requirements or pain scaleReturn to work 9 vs 17 daysImproved SLR at I week1" CostOral narcotics (5 vs 16 doses)1" Return to normal activity (7.5 vs 18.5)Cost not mentionedSF-36, pain analogue scores better earlyNo difference in return to workT Complication rate1" CostBetter quality of lifeI Postoperative narcoticsBetter quality of life at I monthT Satisfaction with LH1" CostExtra vs Lichtenstein and Stoppa's repair l Pain scores (63 vs 35)1 Analgesia doses (2.5 vs 2.0)I Wound complicationsTAPP vs Lichtenstein I Incidence of wound abscesses (0 vs 6, P = .03)1" Resumption of normal activity (6 vs 10 days)1" Return to work (14 vs 21 days)
Resumption of athletic activities (24 vs 36)I Recurrence rate (3% vs 6%, P = .05)Cornell and Kerlakian36 Prospective vs historical TAPP vs (not stated)Brooks 37Prospective, nonrandomized TAPP vs tension-free (plug)Millikan et a138Prospective, nonrandomized TAPP vs varietyWilson et a139Prospective, nonrandomized TAPP vs LichtensteinPayne et ai4~Prospective, randomized TAPP vs LichtensteinVogt et a141Prospective, randomized IPOM vs tension-freeLawrence et
Prospective, randomized TAPP vs Nylon darnBarkun et a143Prospective, randomized TAPP vs variousWright et a144Liem et a145Prospective, randomizedProspective, randomizedAbbreviations: 1, decrease in; 1", increase in; vs, versus; SLR, straight leg-raising; SF-36, Short Form Health Status Survey-36; LH, laparoscopicherniorrhaphy.Reprinted with permission from the MRC Laparoscopic Groin Hernia Trial Group: Laparoscopic versus open repair of groin hernias: A randomised.Lancet 354:185-190, 1999.Table 3. A Summary of More Recent Comparative, Prospective, Randomized Trials of Laparoscopic (LIHR) and ConventionalInguinal Hernia Repair (CIHR)Hernias LH vs OH Follow-UpAuthors Year (n) Intervention Recurrence (mos)Champault et a147 1997 100 vs 100 TEP vs Stoppa 6.0% vs 1.0% 36Liem et al4s 1997 487 vs 507 TEP vs anterior repair 3.0% vs 6.0% 24Sarli et a151 1997 64 vs 66 TAPP vs Lichtenstein 0 vs 0 36Aitola et a146 1998 24 vs 25 TAPP vs Lichtenstein 13% vs 8.0% 18Dirksen et a148 1998 114 vs 103 TAPP vs Bassini 7 vs 22 24Khoury49 1998 169 vs 146 TEP vs mesh plug 2.5% vs 3.0% 36Paganini et al5~ 1998 52 vs 56 TAPP vs Lichtenstein 1 vs 0 28Tanphiphat et a152 1998 60 vs 60 TAPP vs Bassini-modify 1 vs 0 32Wellwood 53 1998 200 vs 200 TAPP vs Lichtenstein 0 vs 0 3Beets et al s4 1999 56 vs 52 TAPP vs PMR 7 vs 1 34Lucas and Arregui 55 1999 292 vs NA TAPP/TEP 2 vs NAJuul and Christensen 56 1999 138 vs 130 TAPP vs Shouldice 4 vs 3 12Abbreviations: LH, laparoscopic herniorrhaphy; NA, not available; OH, open herniorrhaphy; PMR, preperitoneal mesh repair.

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