Introduction
Peritoneal tear (PT) is a frequent surgical problem, with an incidence of 47% in patients undergoing laparoscopic totally extraperitoneal (TEP) inguinal hernioplasty. Large scrotal hernias, history of inguinal region surgery, and surgical inexperience are risk factors (1). PT may result in pneumoperitoneum. The loss of the surgical view prevents extensive peritoneal mobilization, which is the primary technical step of TEP inguinal hernioplasty (2). It is the most common reason for the conversion of TEP inguinal hernioplasty to other hernioplasty procedures (3). Most surgeons consistently have recommended the routine closure of PTs whenever feasible to prevent potential postoperative complications, such as bowel herniation and obstruction (1). However, there has not been a consensus about the location or size of peritoneal defects that require repair. Pretied suturing, loop ligation, endoscopic stapling, and endoscopic suturing are techniques for closing PTs. All methods are equally successful without complication. However, they prolong the operation time and require surgical experience. Thus, it is fundamental to initiate PT management with a laparoscopic approach to complete TEP inguinal hernioplasty successfully (3). In this study, we aimed to describe a new extracorporeal peritoneal knotting (ECPK) technique to close PTs during TEP inguinal hernioplasty.
Methods
This retrospective study enrolled patients who underwent elective TEP inguinal hernioplasty at the University of Health Sciences Turkey, İstanbul Training and Research Hospital, Clinic of Surgery between 2015 and 2019. The study included patients who developed PTs during surgery that were closed with the ECPK technique. Patient demographics, body mass index (BMI), perioperative findings, PT size, and procedure success were documented. Hernia types were identified intraoperatively according to the European Hernia Society (EHS) groin hernia classification system (4).
The study was approved by the Ethics Committee of University of Health Sciences Turkey, İstanbul Training and Research Hospital and was performed in accordance with the Declaration of Helsinki (approval number: 2569, date: 30.10.2020). Written informed consent was obtained from all patients.
Surgical technique
A standard technique of laparoscopic TEP procedure was performed, as previously described by Bittner et al. (1). Routine urinary catheterization was not performed, as the patients were asked to urinate before the surgery to empty the bladder. Moreover, 1 gram of cefazolin was given intravenously on the induction of general anesthesia. A 10 mm trocar was inserted into the preperitoneal space with a direct open access technique. Blunt dissection was performed with a 30° telescope to create an extraperitoneal space. Two 5 mm trocars were inserted at the midline between the first trocar and pubis under direct vision. Extensive preperitoneal dissection was performed by a combination of blunt stripping and dissection using sharp scissors. In female patients, the round ligament was preserved routinely.
When a peritoneal defect occurred, the defect site was clamped by a laparoscopic grasper (Figure 1a, b). The dissection was continued to provide adequate free space around it. If there was progressive loss of the working space, a Veress needle was inserted through the subumbilical incision into the peritoneal cavity to decrease the intraperitoneal pressure. Nevertheless, the whole pelvic floor dissection was as meticulously completed as possible. After sufficient free space was provided around the defect, gas insufflation was stopped and the preperitoneal area was desufflated. While the preperitoneal space was closing, the grasper holding the PT has removed gently into the skin from the nearest trocar incision (Figure 1c). The peritoneum was held under the defect with a mosquito forceps and knotted with 3-0 vicryl stitch (Figure 1d). While the preperitoneal space was insufflated, the repaired peritoneum was pushed back into the operation field with a grasper (Figure 1e,f). Endoscopic stapling or suturing was performed when the ECPK technique failed. A polypropylene 12x15 cm mesh was placed and stapled with tacker clips to Chooper’s ligament and the anterior abdominal wall. Suction drains were not used routinely.
Statistical Analysis
In the descriptive statistics of the data, mean, standard deviation, median, lowest value, highest value, frequency, and ratios were used. Statistical analyses were performed using SPSS Statistics for Windows (version 21.0, IBM Corp., Armonk, NY).
Results
The ECPK technique was performed on 10 patients (male: 7, female: 3). The mean age and BMI of the patients were 43.9±3.3 years and 26.4±1.6 kg/m2, respectively. None of the patients had a history of inguinal hernia surgery. All had a unilateral inguinal hernia, with five on the right and five on the left side. The x groin hernia classification system was LII in three patients, LIII in four patients, and McIII in three patients. The median peritoneal defect size was 1 cm, which ranged from 1 cm to 3 cm. PT occurred during the dissection of the hernia sac from the spermatic cord or the round ligament. The technique was successful in eight patients. In two patients with BMI >30 kg/m2, the peritoneal defect did not reach the extracorporeal area (Table 1). However, none of them required conversion to either transabdominal preperitoneal hernioplasty or open hernioplasty, in which PTs could be repaired with the endoscopic stapling technique. No significant postoperative surgical complications were recorded. All patients were discharged the day after the surgery.
Discussion
Although reported rarely, PT is not a rare condition during hernioplasty procedures. Its incidence ranged from 0.4% to 67% and considered intraoperative complication, especially in TEP. It is the only disadvantage of the TEP procedures relative to open surgery (5) and is the most common reason for the conversion (3). It is two times more common in recurrent inguinal hernia surgery (2).
Three types of PTs are defined: Type I is a large tear that occurred early at the start of surgery and caused by balloon insufflation. Type II, which is the most common, is a small tear caused by blunt dissection of the hernia sac and peritoneum from the spermatic cord. Type III is created intentionally in congenital hernias. Conversion surgery is necessary for type I defects. More often, a type II defect does not affect the operative course, and the procedure is mostly completed with/without peritoneal decompression and closure of the PT (2). In a randomized multicenter trial, pneumoperitoneum developed in 7% of the patients with PT (1).
No consensus about the routine closure of PT that does not affect the operative course has been established. Some surgeons have reported that routine closure of PT is technically challenging and significantly prolonged the operation time. They believe that after desufflation, the redundant peritoneum folds upon itself and seals the PT quickly. In addition, they had not observed any intraoperative or postoperative complications during the early and long-term follow-up when they left it open in their series (2,6-8). By contrast, current guidelines (1) recommended closure of PTs whenever feasible to prevent potential complications such as adhesion and internal herniation. Meyer et al. (9) reported a laparoscopic pelvic exploration to repair a suspected PT (8).
Performing meticulous blunt traction and counter-traction with minimal use of sharp dissectors is the most crucial point to prevent PTs, especially during dissection of the hernial sac from the spermatic cord. Balloon dissection is considered during the learning period. However, the balloon is placed away from the scar tissue and distended with much less than the standard air volume or with saline in patients with the history of inguinal region surgery (1,10).
Surgical techniques for the closure of PTs are pretied suturing, loop ligation, endoscopic stapling, and endoscopic suturing. Lau et al. (3) found that all these techniques were equally successful without complication. Pretied suturing and loop ligation are safer than endoscopic suturing. However, it may be inadequate to close large defects and may need repeated interventions or an additional closure method (3). Endoscopic stapling is the fastest technique, but it is not suitable for large defects. Protrusion of staples into the peritoneal cavity may lead to visceral complications. Endoscopic suturing is the slowest to perform but the most effective method in patients with large defects. Nevertheless, laparoscopic suturing in a limited surgical space needs surgical experience and poses a minimal intraoperative complication such as vascular and visceral injury. Although an Endo stitch is a useful device for suturing within a minimal extraperitoneal space, it needs an additional 10 mm trocar and has a high cost (8) (Table 2).
The ECPK is a straightforward technique for repairing PTs and does not require surgical experience. In this technique, the PT is pulled out into the extracorporeal area and tied with simple knotting or per string method and then pushed into the preperitoneal area again. It did not have any complications. By contrast, it was more secure due to the removal of the peritoneal region with tears from visceral and vascular structures during the repairing procedure. Moreover, there is no need for any additional expensive surgical tools. However, this technique has a low success rate among obese patients. The thickness of subcutaneous adipose tissues prevents adequate peritoneal displacement into the extracorporeal area (Table 2).
Conclusion
ECPK is a useful peritoneal closing technique, especially in patients with low BMI and minimal abdominal subcutaneous adipose tissue thickness. Surgeons even without experience can efficiently perform it without complications. The rapid application of the technique and non-requirement of additional surgical devices may provide a cost-effective solution to PTs during TEP procedures without increasing the operation time.
Ethics Committee Approval: The study was approved by the Ethics Committee of University of Health Sciences Turkey, İstanbul Training and Research Hospital and was performed in accordance with the Declaration of Helsinki (approval number: 2569, date: 30.10.2020).
Informed Consent: Written informed consent was obtained from all patients.
Peer-review: Internally peer-reviewed.
Authorship Contributions: Surgical and Medical Practices - H.O., K.U.; Concept - H.O., K.U.; Design - H.O., K.U.; Data Collection or Processing - H.O.; Analysis or Interpretation - K.U.; Literature Search - H.O., K.U.; Writing - H.O., K.U.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.