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JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 21, Number 3, 2011


Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2010.0257

Repeat Laparoscopic Totally Extraperitoneal Hernia


Repair After Primary Laparoscopic Totally
Extraperitoneal Hernia Repair for Inguinal Hernia
Hiroki Uchida, MD,1,2 Toshifumi Matsumoto, MD,1,2 Yuichi Endo, MD,1,2
Tetsuya Kusumoto, MD,1,2 Yoichi Muto, MD,1,2 and Seigo Kitano, MD, FACS3

Abstract

Introduction: Although laparoscopic totally extraperitoneal hernia repair (TEP) is reported to have a low recurrence rate, few reports address treatment for contralateral occurrence after primary TEP. Most studies on
surgical treatment for recurrent inguinal hernia reported on laparoscopic transabdominal preperitoneal repair.
The aim of this study was to evaluate the efficacy of repeat TEP for contralateral occurrence after primary TEP
for unilateral inguinal hernia.
Methods: We retrospectively reviewed the medical charts of 215 patients undergoing TEP performed between
April 2003 and May 2009. We employed a similar approach to that of standard TEP for primary hernia.
Results: Twenty eight of 215 patients who underwent unilateral TEP also underwent repeat TEP for contralateral-side hernia occurring after primary TEP. The initial hernia was on the right side in 15 patients and on the
left side in 13. The initial hernia was indirect in 26 patients and direct in 2. Mean duration of primary TEP to
contralateral occurrence was 54.4 months. Mean operation time for the contralateral occurrence was 73.3 minutes, and there was little intraoperative blood loss. Three patients were converted to an anterior approach
because of insufficient surgical field due to injury of the peritoneum. Although the inferior epigastric artery and
vein were divided in 4 patients, there were no difficulties during surgery. The postoperative course in all patients
was uneventful.
Conclusions: TEP after primary TEP for contralateral occurrence is feasible. Repeat TEP might be an alternative
technique for new occurrence of contralateral inguinal hernia after primary TEP.

Introduction

fter the introduction of endoscopic hernia repair by


Ger in 1982, the number of laparoscopic totally extraperitoneal hernia repairs (TEPs) has been constantly rising.1
The laparoscopic approach has been associated with less
postoperative pain, shorter hospital stay, and low recurrence
rate.24 Some studies reported that recurrence rates ranged
from 0.3% to 8.5%,5 and the rate of contralateral occurrence
was about 1%.6,7 As the period of postoperative surveillance is
extended, it is thought that the number of patients with recurrence or with a new hernia on the contralateral side will
increase.
Laparoscopic technique as the treatment for recurrent
hernia has been reported to be superior to open anterior

repair.811 Although laparoscopic transabdominal preperitoneal repair (TAPP) for recurrence after primary TEP or
TAPP has also proven feasible,8,12,13 only a few studies have
reported on TEP for recurrence after primary TEP. Felix et al.
reported that TEP after primary TEP is virtually impossible.12
Therefore, the purpose of this study was to review our experience with TEP of contralateral hernia recurrence after a
primary TEP.
Patients and Methods
From April 2003 to May 2009, 215 TEPs had been performed for inguinal hernia in Beppu Medical Center. Of
these, 30 TEPs were performed for bilateral inguinal hernia, 157 TEPs for primary inguinal hernia, and 28 TEPs for

Department of Surgery, National Hospital Organization Beppu Medical Center, Beppu, Japan.
Clinical Research Institute, National Hospital Organization Beppu Medical Center, Beppu, Japan.
Department of Gastrointestinal Surgery, Oita University Faculty of Medicine, Yufu, Japan.

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3

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UCHIDA ET AL.
Table 1. Distribution of Laparoscopic Totally
Extraperitoneal Hernia Repairs

Table 3. Operative Results


Parameter

No.

Range

Operative time (minutes)


Blood loss (g)
Conversion to anterior approach
Resection of the inferior
epigastric artery and vein
Postoperative complications

73.3
8.6
3
4

27157
190

No.
Primary TEP
Bilateral
Unilateral
Repeat TEP

187
30
157
28

Total

215

TEP, laparoscopic totally extraperitoneal hernia repair.

contralateral occurrence. We retrospectively reviewed the


cases of the 28 patients who underwent TEP for contralateral
hernia occurrence (Table 1). Twenty-three of those 28 patients
had undergone primary TEP before April 2003 and 5 had
developed contralateral inguinal hernia from April 2003 to
May 2009.14 The follow-up period was between 1 and 72
months (median 35.9 months). The surgeons, each experienced over 10 years, were considered to be experienced in
laparoscopic gastrointestinal surgery.
Our approach to these contralateral occurrences was not
markedly different from that of standard TEP. A small paraumbilical incision was made and the ipsilateral anterior rectus
sheath was opened. The extraperitoneal space was created
without exposing the primary repair using a PDB 1000
(Covidien). There was no additional dissection. Carbon dioxide gas was insufflated to an intraperitoneal pressure of
10 mmHg to create a surgical field. The ENDOPATH XCEL
5-mm port (Ethicon Endo-Surgery) was made on the ipsilateral rectus or lower midline. We used polypropylene threedimensional mesh to cover the inguinal bed and ProTackTM
(Autosuture; Tyco Healthcare) to fix the mesh.
Results
A total of 28 TEPs were performed for inguinal hernia
occurring on the contralateral side after primary TEP. The
patients comprised 26 men and 2 women with a mean age of
63.7 years (range: 2388 years) (Table 2). Of the contralateral
hernias, 27 were indirect hernias and 1 was a direct hernia.
The mean period to contralateral occurrence was 54.6 months
(range: 2131 months) after primary surgery. The mean operation time was 73.8 minutes (range: 25217 minutes) and the
conversion to anterior repair was made in 7 of 157 patients
who had undergone primary TEP for unilateral inguinal
hernia. There were no significant difference in operation time
and rate of conversion by using MannWhitney U test and w2
test.
Table 2. Patient Characteristics
Characteristic

No.

Range

Age (years)
Sex
Male/Female
Type of primary hernia
Right/left
Direct/indirect
Duration of contralateral
occurrence (months)

63.7

2388

26/2
15/13
2/26
54.6

2131

Repeat TEP was applied to repair the contralateral inguinal


hernia after primary TEP in these patients. In 3 patients,
conversion to an anterior open procedure was made because
of injury to the peritoneum due to adhesions on the midline
preperitoneal space in 1 patient and due to difficulties in
dissecting the preperitoneal space with a blunt balloon-tip
cannula at the beginning of surgery in 2 patients. However,
these converted 3 cases had occurred in first 10 cases and there
were no convert after these sequential cases. The inferior
epigastric artery and vein were divided in 4 patients because
of bleeding in 2 cases and strong adhesion to peritoneum in 2
cases during the dissection of PDB 1000. There were no
postoperative complications (Table 3). There were no recurrences in these 28 patients after secondary TEP. The follow-up
period was between 1 and 70 months.
Discussion
Laparoscopic repair of recurrent hernia has been shown to
be effective.811 Many studies concerning the repair of recurrent hernia were reported after 1999, and most of the procedures reported were TAPP for recurrent hernia. In these
reports, several authors reported the feasibility of TAPP repair
for recurrence after primary laparoscopic hernia repair by
TAPP or TEP.8,12,13 Leibl et al. reported TAPP repair of the
recurrence in 46 of 5005 patients, and the total complication
rate was 10.9%.8 Felix et al. reviewed 35 recurrences in 10,053
hernias in 7661 patients, of which 29 were repaired by TAPP.
Four patients were converted to an open approach. They asserted that it was virtually impossible to reexplore an extraperitoneal repair extraperitoneally.12 However, Tamme et al.
reported on 5203 TEPs in 3868 patients, in whom 29 recurrent
hernias had been detected in 28 patients.15 Among these patients, 26 had primary hernia and 3 had recurrent hernias.
Reoperation had been performed for 23 recurrent hernias in
their institution, 18 by Lichtenstein technique, 3 by TAPP, and
2 by TEP. Ferzli et al. reported the repair of 1059 inguinal
hernias in 804 patients by means of TEP.7 Twenty patients had
recurrent hernia and underwent TEP. In these patients, 12
hernias were on the ipsilateral side, and 8 were on the contralateral side. Only 1 patient converted to an anterior approach, and there were no postoperative complications. They
concluded that TEP for recurrent inguinal hernia after primary TEP was entirely feasible as well as safe. In our cases, the
operation time for TEP after primary TEP was not prolonged
compared with that of the primary TEP, and there were no
postoperative complications in any patient. These results
suggest that, in general, reexploration of the extraperitoneal
space after primary TEP appears to be feasible.
We do not routinely perform bilateral examination to rule
out contralateral occult inguinal hernia because of low rate

REPEAT TEP FOR INGUINAL HERNIA


of contralateral occurrence. In our institution, only 5 (3.2%)
patients developed contralateral hernia in our 157 patients
undergoing primary TEP for unilateral inguinal hernia between 2003 and 2009.14 Koehler reported observing occult
contralateral hernia in 13% of patients when examined by
transabdominal diagnostic laparoscopy,16 and Thumbe and
Evans reported finding incidental defects in 22% of patients
during TAPP.17 However, Saggar and Sarangi reported that a
hernia developed on the contralateral side after only 6 of 446
unilateral repairs,6 and Ferzli et al. noted that 4 contralateral
hernias occurred after a primary unilateral endoscopic repair
in 549 patients.7 The contralateral occurrence rate after TEP is
low, and few reports mention laparoscopic repair for new
contralateral hernias. We start all contralateral occurrences as
TEPs; however, if we have some trouble, it is thought to
choose open method, not TAPP, because of possibility of intraoperative injury of intestinal tract and postoperative ileus.
In our patients, 3 (11%) of 28 patients converted to an anterior
approach because of difficulties in reexploring the preperitoneal space. The remaining 25 patients underwent TEP
without injury to the peritoneum, including division of the
inferior epigastric artery and vein in 4 patients. However,
none of our patients suffered ipsilateral recurrence after primary TEP. Reexploration of the ipsilateral peritoneal space
after primary TEP when the contralateral peritoneal space had
been created with a blunt balloon-tip cannula could be performed in only a few patients. Reexploration of the ipsilateral
peritoneal space after primary TEP is controversial, and further accumulation of data on ipsilateral recurrence after primary TEP is necessary.

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4.

5.

6.

7.

8.

9.
10.

11.

12.

13.

Conclusions
Repeat TEP had no longer operation time and no higher
conversion rate compared with primary TEP. It is thought to
be feasible for contralateral occurrence. Although it has some
difficulty during the dissection of the preperitoneal space,
repeat TEP might be an alternative method for contralateral
occurrence after primary TEP.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to:


Hiroki Uchida, MD
Department of Surgery
National Hospital Organization Beppu Medical Center
1473 Uchikamado
Beppu 874-0011
Japan
E-mail: ucchy@med.oita-u.ac.jp

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