Hernia is abnormal protrusion of an intra-abdominal organ or part of it through a weakness in the abdominal wall. Inguinal hernia is the hernia occurring in the inguinal region (which is one of the common site of occurrence). Surgery for hernia comprises of reducing the protruded content to its original position and repair of the weakness of abdominal wall with the help of a mesh. Mesh is a sheet (of varying sizes) of a synthetic material.
Laparoscopic surgery has the advantage of early return to normal activities because of earlier recovery in comparison to open surgery. Hernia surgery by laparoscopy is advanced procedure. There are mainly two laparoscopic hernia procedures for inguinal hernia: TEP and TAPP.
TEP (Total Extraperitoneal repair) is the laparoscopic hernia procedure, where the surgical process takes place outside the peritoneal(abdominal) cavity. TAPP (Trans-Abdominal Pre-Peritoneal) is the procedure, where the surgery takes place inside the peritoneal cavity. In both the procedures, 3(three) small holes(Ports) are made over the abdominal wall, through which, the instruments go in and surgery is performed.
TEP PORT POSITION
TEPP PORT POSITIONS
Although new laparoscopic approaches were developed to reduce risks seen with open repairs, a whole new set of problems, as well as some of the old ones, were experienced by patients. It was only when the laparoscopic surgeon completely understood the possible risks inherent to the laparoscopic repair and the causes of these complications that postoperative morbidity could be decreased and the surgeon could handle the complications that cannot be avoided. In multi-institutional reviews and single-center studies, complication rates after laparoscopic hernia repair vary from 5% to 13%, but the definition of complication differs widely among studies. The incidence of major complications (approximately 1% for experienced surgeons), however, is consistent across these large studies and is similar to that reported for open hernia repairs.
Risks associated with laparoscopic inguinal hernia can be divided into some broad groups:
A) Risks because of the anatomy: Performing a successful laparoscopic hernia surgery requires a thorough knowledge of the anatomy of the pelvis and groin as viewed through the laparoscope. Surgeons, who are not well acquainted with this, may find it difficult to deal with the hernia or to deal with the vital structures which is very crucial to prevent inadvertent injury to them. However, TEP is known to cause comparatively less injury to the vital structures than TAPP. (As peritoneal cavity is not breached in TEP).
B) Risks related to the technique:
Small Intestinal Obstruction- It is most commonly due to adhesion of the intestine to the mesh or the tackers (Nail-like fixating device used to fix the mesh). But, with experience, the incidence of such complication has decreased than the past. If precaution is taken to avoid contact of the intestine with the mesh or tackers, this complication can be completely prevented.
Bleeding- There are certain blood vessels in the area of hernial orifice. Because of limited access to the bleeding site and high flow rates of those vessels most likely to be injured, bleeding must be controlled quickly or avoided completely.
C) Risks inherent to repair:
Seroma: it is the condition of accumulation of fluid in the empty space left after repair of hernia (the space previously occupied by hernia) in about 2% to 10% of cases. Normally the seroma subsides of its own in about three months’ time. The shape and site of seroma is that of the hernia present before. It looks like a recurrence, hence there is every possibility of patients being frightened. They should be counseled properly beforehand.
Urinary Retention: Urinary retention is seen in approximately 2% of patients after open or laparoscopic hernia repair and is probably related to the group of patients undergoing the procedure and the technique itself. It is generally seen in male patients elder than 50years because of the enlarged prostate. This can be very well managed on an outpatient basis.
Mesh Infection: Mesh infection is usually a delayed complication. Utmost care should be taken by the surgeon from aseptic and antiseptic point of view to prevent this complication.
No complication mentioned above is life threatening. It is possible to reduce all the above-mentioned risks in laparoscopic hernia repair. A thorough knowledge of the anatomy and the operative approach, along with advanced laparoscopic skills play vital role in reducing the chance of a significant complication.