Extended Totally Extraperitoneal (eTEP) Hernia Repair Technique

The Extended Totally Extraperitoneal (eTEP) hernia surgery repair technique is a novel and advanced approach for the treatment of ventral and inguinal hernias. eTEP is a minimally invasive approach that can be performed laparoscopically or with robotic assistance, rather than being an open surgery technique. This technique was first introduced by Jorge Daes in 2012 and has since been adapted and refined by other surgeons for various types of hernias, including ventral hernias. The eTEP technique is characterized by its minimally invasive approach, which involves creating a large surgical workspace in the extraperitoneal space without entering the abdominal cavity. This is achieved through a series of surgical maneuvers and strategies aimed at enhancing the extraperitoneal work area and allowing for the placement of a larger surgical mesh to repair the hernia defect.

The eTEP Hernia Repair Technique Procedure Steps

The procedural steps for an eTEP (Extended Totally Extraperitoneal) hernia repair can vary depending on the type of hernia being treated (inguinal, ventral, or lumbar). However, the general steps for the eTEP approach are as follows:

1. Accessing the Extraperitoneal Space: The first step involves entering the extraperitoneal space, which is the space outside of the peritoneal cavity where the organs are located. This is typically done through a small incision and various methods are used.
2. Creating a Surgical Workspace: Once access is gained, the surgeon creates a large surgical workspace in the extraperitoneal space or retrmoscular space by dissecting and separating the tissues to expose the area where the hernia is located.
3. Hernia Sac Reduction: The hernia sac and its contents are then reduced, meaning they are pushed back into the proper anatomical position.
4. Defect closure: the hernia defect is closed, and the abdominal wall is tightened by placating the rectus muscle.
5. Mesh Placement: A mesh is placed in the retromuscular space to reinforce the area and prevent the hernia from recurring. The mesh is usually cut to the size of the space and therefore requires little to no fixation which can reduce post-operative pain.
6. Wound closure: After the mesh is positioned correctly, the surgical workspace is deflated, and the incisions are closed.
7. Postoperative Care: The patient is typically allowed to consume clear liquids a few hours after surgery and may be discharged within 48–72 hours, depending on their recovery.

 Key Features of eTEP Hernia Surgery

• Minimally Invasive: The eTEP technique is minimally invasive, providing lower overall complication rates, decreased wound complications, and shorter hospital stays compared to traditional open hernia repair methods.
• Mesh Placement: It allows for the placement of mesh in the retromuscular space, which is believed to offer better outcomes in terms of recurrence. Typically a larger mesh is placed in that space that covers and strengthens the majority of the abdominal wall. the retromuscular space is well vascularized leading to better mesh integration and less infections. Also mesh placement in this space requires little to no mesh fixation resulting in less pain. Lastly, placement of mesh outside the abdominal cavity leads to less chances of adhesions to intestine and scarring.
• Component Separation: For defects too wide to be closed without tension, a component separation procedure, specifically the posterior rectus sheath release is performed identical to a Rives-Stoppa repair. In cases of larger defects, a Transversus Abdominis Release (TAR) can be performed for further release. This enables tension-free closure of the hernia gap and achieves greater mesh overlap.
• Versatility: The eTEP approach can be adapted for various types of hernias, including ventral, inguinal, and lumbar hernias, making it a versatile technique for hernia repair.

 Advantages of eTEP Technique for Hernia Repair

• Reduced Risk of Complications: The extraperitoneal approach reduces the risk of intestinal injury, lessens the need for visceral retraction, and minimizes the frequency of postoperative ileus and intraperitoneal adhesions.
• Enhanced Recovery: Early discharge and enhanced recovery are possible due to diminished pain and a greater likelihood of early mobilization and unrestricted movement.
• Economic Benefits: The use of mesh in the eTEP technique is not only effective in reducing recurrence rates but is also cost-effective. the mesh used in the retromuscular space does not require a special coating and is typically costs less.

What are the success rates of eTEP hernia repair?

Here are the key findings from a recent study, explained in laypersons’ terms:

The study involved surgeons who did eTEP hernia surgery on 150 patients over three years.

Out of the 150 patients:

• 73 (48.7%) had incisional hernias (hernias that happen at an old surgery scar)
• 48 (32%) had primary hernias (hernias that happen for the first time)
• 29 (19.3%) had recurrent hernias (hernias that came back after being fixed before)

Most of the patients were females (74%). Primary hernias happened equally in males and females, but incisional and recurrent hernias were more common in females.

For smaller hernias, doctors used a method called eTEP RS (Rives-Stoppa). For larger hernias, they used eTEP TAR which also relaxes some muscles to help close the hernia.

The eTEP RS repair took about 2 hours to do, while eTEP TAR took about 3.5 hours.

After the surgery:

• Only 5.8% of patients had fluid collect under the skin (seroma)
• Only 3.3% felt some bulging or discomfort in the upper belly
• No patients got infections or had the hernia come back during the surgery study.

This study shows the eTEP method worked well to repair different kinds of hernias, even complicated ones, with few problems afterward. The study reports it is a good option, especially for hernias on the sides of the belly. Surgeons need a lot of special training to do it well.

Dr. Mazen Iskandar is thoroughly trained and experienced in eTEP surgery. You can view a video of Dr. Iskandar performing a complex eTEP procedure (Note: contains images of surgery).

What types of hernias can be repaired with the eTEP technique? 

The eTEP (Extended Totally Extraperitoneal) technique can be used to repair various types of hernias, including:

• Ventral Hernias: The eTEP technique was initially devised to tackle large groin hernias but has been extended to include ventral hernias, where the mesh is placed in the retromuscular space.
• Incisional Hernias: It is also used for incisional hernias, which can occur as a complication of laparotomies.
• Recurrent Hernias: The eTEP approach is suitable for recurrent hernias, offering a minimally invasive option for patients who have had previous hernia repairs.
• Atypical Sited Hernias: The technique has been successfully used for atypically sited hernias such as lumbar, subcostal, and Pfannensteil hernias.
• Lateral Hernias: eTEP is particularly useful for managing unusual lateral hernias such as subcostal (L1) and iliac (L3) hernias, which are close to fixed bony structures and require adequate mesh overlap.

What kind of hernias cannot be treated with eTEP? 

There are certain situations where the eTEP technique might not be the best choice or could be contraindicated:

• Strangulated Hernias: While there is a case report showing the feasibility of the eTEP technique in an emergency setting for a strangulated incisional hernia, the general use of eTEP in the emergency repair of strangulated hernias, especially when bowel resection is required due to necrosis, might be limited. This is because the presence of bowel necrosis or infection is a contraindication for the use of this technique in such emergency situations.
• Hernias with Bowel Necrosis or Infection: The eTEP technique might not be suitable for hernias where there is significant bowel necrosis or infection, as the presence of these conditions could complicate the minimally invasive approach and might necessitate a more direct and open surgical intervention to address the issue adequately.
• Hernias Requiring Immediate Bowel Resection: In cases where immediate bowel resection is necessary due to the condition of the herniated tissue, the eTEP approach may not be the most appropriate choice. The need for immediate and direct access to the bowel for resection might favor a more traditional open approach.
• Patients with Extensive Previous Abdominal Surgeries: Although not explicitly mentioned as a contraindication, patients with extensive scarring and adhesions from previous abdominal surgeries might present a higher risk of complications due to the difficulty in creating the extraperitoneal space without causing injury to the bowel or other structures.

Final Thoughts

The eTEP hernia surgery repair technique represents a significant advancement in the field of hernia repair. Its minimally invasive nature, combined with the strategic placement of mesh and the potential for component separation, offers a comprehensive solution for hernia repair that is associated with improved patient outcomes, including reduced complication rates, faster recovery times, and lower recurrence rates. Surgeons seeking to adopt this technique should have detailed knowledge of the anatomy of the extraperitoneal space and undergo formal training, ideally including practice on fresh cadavers under mentorship, to ensure the safety and effectiveness of the procedure.

 

 

source https://iskandarcenter.com/hernia-surgery/extended-totally-extraperitoneal-etep-hernia-repair-technique/

How to Avoid Constipation After Hernia Repair

Undergoing hernia repair surgery is an important step towards regaining your health and improving your quality of life. Dr. Iskandar and the team at The Iskandar Complex Hernia Center understand that post-operative recovery is just as crucial as the surgery itself. One common concern many patients face after hernia repair is constipation, a condition that can add discomfort and delay recovery. In this article, we’ll share effective strategies to prevent constipation, ensuring a smoother and more comfortable recovery process.

10 Tips to Avoid Constipation After Hernia Repair

Ensuring a comfortable recovery after hernia repair surgery at The Iskandar Complex Hernia Center involves managing post-operative constipation effectively. Dr. Iskandar and his team prioritize patient education on preventive measures to maintain digestive health. Here are 10 strategies to maintain regular bowel movements and ensure a comfortable recovery:

1. Enhance Digestion with a Fiber-Rich Diet
   • Incorporate foods high in fiber, such as berries, avocados, beans, and whole grains, into your meals. These options help soften stool and promote regular bowel movements, counteracting the constipating effects of less nutritious comfort foods.
2. Avoid narcotic pain medicine
   • Narcotic pain medicine can induce constipation. Medications like Tylenol and non-steroidal anti-inflammatory drugs (ibuprofen, naproxen etc…) are preferred as they don’t cause constipation.
3. Stay Hydrated to Ease Bowel Movements
   • Drinking sufficient water softens the stool and is crucial for preventing constipation, especially important when taking prescribed pain medications, which can contribute to digestive sluggishness. Begin hydrating before your surgery and continue diligently post-operation.
4. Prune Juice: A Natural Constipation Remedy
   • Prune juice, rich in fiber and sorbitol, is effective for stimulating digestion and easing constipation. Aim for 8 to 10 ounces a day to help maintain regularity during your recovery, but remember that balance is key.
5. Introduce Yogurt into Your Diet
   • The beneficial bacteria in plain yogurt can improve digestive health and assist in preventing constipation. It’s a nutritious choice that supports bowel movements by enhancing your gut flora.
6. Utilize Olive Oil as a Dietary Aid
   • Olive oil can act as a natural lubricant in the digestive system, facilitating easier passage of stool. Whether added to meals or consumed directly, it’s an effective way to alleviate constipation.
7. Light Physical Activity to Stimulate Digestion
   • Following Dr. Iskandar’s recommendation, engage in short walks to promote digestive health without exerting undue stress on your recovery. Just 5 to 10 minutes of gentle walking can make a significant difference.
8. Consider Stool Softeners
   • Preparing with stool softeners before surgery, as advised, can provide a gentle solution to post-surgery constipation. Consult with your surgeon, Dr. Iskandar, for the appropriate timing and usage to soften stools.
9. Consultation for Laxative Use
   • For persistent constipation, discuss the possibility of laxatives with your hernia surgeon. While effective, laxatives should be a last resort due to their potential side effects and the need for a careful approach to post-operative care.
10. Encourage Natural Bowel Movements by Sitting on the Toilet
    • Regularly sitting on the toilet can trigger your body’s natural reflexes for bowel movements, providing a passive strategy to address constipation. This should be a patient, strain-free process, especially critical during hernia recovery.
11. Avoid Highly Processed Foods
    • During recovery, it may be tempting to indulge in comfort foods like pizza or burgers, but these can exacerbate constipation. Opting for less processed options and focusing on nutritionally rich foods aids in smoother digestion and overall health.

Will having a bowel movement after hernia repair be painful?

After hernia repair surgery, it’s normal to experience some level of pain and discomfort, particularly in the area of the repair when moving, which may affect how easily you can have a bowel movement. This could happen anytime from one to ten days after the surgery. Anesthesia used during surgery can also slow the gastrointestinal tract. It’s important to avoid straining or forcing a bowel movement during this time to prevent excess pressure on the hernia repair. Instead, we advise patients to relax, perhaps with a book or phone in hand, to allow the body to proceed naturally.

Having a bowel movement after hernia repair surgery is a common concern among patients at The Iskandar Complex Hernia Center, primarily due to the potential discomfort . Dr. Iskandar and his team are committed to ensuring that each patient’s recovery process is as smooth and pain-free as possible, emphasizing the importance of managing expectations and following post-operative guidelines to minimize discomfort.

To manage pain and encourage gentle bowel movements, we recommend several strategies. Utilizing stool softeners post-surgery can soften stools, making them easier to pass without straining. Maintaining hydration and adhering to a high-fiber diet are also key in preventing constipation, which in turn facilitates smoother bowel movements. Moreover, engaging in light physical activities, such as walking, can stimulate the digestive system, supporting regular bowel movements without overexertion.

Always communicate openly with your surgeon about any concerns or unusual symptoms so that you can receive personalized advice and support. Dr. Iskandar and the team at The Iskandar Complex Hernia Center are here to guide you through your recovery, ensuring a comfortable and safe return to normalcy.

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More FAQ’s About How to Avoid Constipation After Hernia Repair

What foods should I avoid to prevent constipation after hernia repair?

Dr. Iskandar recommends avoiding foods that can exacerbate constipation following hernia repair. These include highly processed foods, red meat, dairy products, and sweets. Such foods are low in fiber and can slow down digestion. He advises focusing on a balanced diet rich in fruits, vegetables, and whole grains to support smoother bowel movements and a more comfortable recovery.

What are some natural remedies to relieve constipation after hernia repair?

To naturally relieve constipation after hernia repair, Dr. Iskandar suggests several effective remedies. Increasing your intake of water and fiber-rich foods is fundamental. Additionally, warm liquids in the morning, such as herbal tea, can stimulate digestion. Gentle exercise, like walking, is also beneficial. Dr. Iskandar may recommend specific herbal supplements or probiotics, but it’s important to consult with him before trying any new remedy to ensure it complements your recovery plan.

What specific foods should I eat to prevent constipation after hernia repair surgery?

Dr. Iskandar recommends focusing on a diet rich in fiber to prevent constipation post-hernia repair. Incorporate fruits like pears and apples, vegetables such as leafy greens and carrots, whole grains, and legumes. Dietary fiber helps maintain the health of the gastrointestinal tract and facilitates the passage of human feces. Eating fiber rich foods help increase stool bulk and promote regular bowel movements.

Can I use over-the-counter laxatives immediately after my hernia surgery to prevent constipation?

Dr. Iskandar advises against using over-the-counter laxatives to encourage defecation without prior consultation. While they may seem helpful, they can interfere with your recovery process. It’s best to discuss with him about the safest options for your specific case.

How does water intake influence constipation after hernia repair?

Adequate hydration is crucial for preventing constipation after hernia repair, as explained by Dr. Iskandar. Water helps soften stool, making it easier to pass. He recommends drinking at least eight glasses of water a day to facilitate bowel movements and aid recovery.

Is it normal to feel pain during bowel movements after hernia repair surgery?

Some discomfort or slight pain during the first few bowel movements post-surgery is normal. Analgesic medications, such as Ibuprofen and Paracetamol, can alleviate pain associated with bowel movements post-surgery. However, Dr. Iskandar emphasizes that extreme pain, nausea or fever is not and could indicate complications. If you experience significant pain, contact The Iskandar Complex Hernia Center immediately.

How long after hernia repair surgery can constipation last?

Constipation duration varies among patients, but it’s generally temporary. Dr. Iskandar notes that most patients see improvement within the first week as they adjust their diet and hydration levels and gradually increase physical activity.

Are there any specific exercises I can do to prevent constipation after my hernia repair?

Dr. Iskandar recommends gentle walking as the safest exercise to prevent constipation post-surgery. Start with short walks and gradually increase as comfortable. Avoid strenuous activities that strain the abdomen until he clears you for such exercises.

How does pain medication after hernia surgery affect constipation?

Pain medications, especially opioids, can lead to constipation by slowing down the digestive system. Certain narcotics, a type of prescription drug used for pain management after surgery, can lead to constipation as a side effect, which is why it is important to closely manage medication intake. Dr. Iskandar advises staying hydrated, eating fiber-rich foods, and discussing stool softeners as preventive measures during your recovery period. Docusate is an example of an over-the-counter drug that can be used under the guidance of Dr. Iskandar to soften stools and prevent straining during bowel movements.

Can stress after hernia repair surgery contribute to constipation?

Yes, stress can impact your digestive system and contribute to constipation. Dr. Iskandar encourages practices such as deep breathing, meditation, or gentle yoga to manage stress and support a healthy digestive process during your recovery.

What are the signs that constipation after hernia repair is severe and requires medical attention?

If you experience no bowel movements for more than three days, severe abdominal pain, bloating, or symptoms of bowel obstruction, Dr. Iskandar stresses the importance of seeking immediate medical care to prevent complications.

Can altering the timing of pain medication intake help manage constipation after hernia repair?

Adjusting the timing of your pain medication can sometimes help, but it should not be done without consulting Dr. Iskandar. He may offer alternative pain management strategies or adjust your medication to alleviate constipation without compromising pain control.

source https://iskandarcenter.com/hernia-surgery/how-to-avoid-constipation-after-hernia-repair/

Combo Robotic eTEP Recurrent Incisional Hernia Repair with Spine Access for L4-L5 ALIF Video

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Transcript of Narration

Presenting a robotic eTEP recurrent incision hernia repair in combination with spine axis for an L4-L5 anterior lumbar  antibody fusion ALIF.

So this is a patient who had a recurrent hernia following colectomy. The hernia was 5 cm and was below a previously placed mesh. We obtained access to the… Given that we normally do spine access for L4 or L5 from the left side to avoid the IVC, we planned on a right-sided eTEP with three trocars at the semi lunar line, as well as a pre-costal axis, which is later used as an assistant trocar. Also, the patient had a left lower quadrant colostomy.

Right side, in order to have good visualization of the retroperitoneal axis, that’s going to be done over on the left side. The patient had quite a bit of adhesions into the retromuscular space related to previous mesh fixation. The literature is very useful in those instances. You can see here some mesh fixation sutures. After the docking on the right side, we have incised here the right posterior rectus sheath and entering the prepared needle space behind the falsiform and identified the contralateral left-sided posterior rectus sheath and will incise and enter the left posterior rectus sheath.

One of the challenges was mobilization of the previously placed mesh. And here we are taking some adhesions into the preperitoneal space and reducing the lower hernia and incising the left posterior rectus sheath. Then the hernia contents which mostly contained omentum and preperitoneal fat were completely mobilized and reduced. And we proceeded with the vision of the posterior rectus sheath. Here is the patient’s previous colostomy site where there is a defect in the posterior rectus sheath which will be reconstructed at the end of the dissection.

We then proceeded with developing the left space of Bogros and posterior rectus sheath release, similar to a bottoms up TAR. We would want to release the posterior rectus sheath to the lever of L4-L5 which had been marked using fluoroscopy at the beginning of the case. Similar to a TAR again, very similar dissection here. And then entering the correct plane here in front of the psoas, the idea was to try to mobilize as much as possible, given the patient’s central obesity and to minimize the amount of dissection needed in a small hole and to minimize the length of the incision that was needed.

This exposure won’t allow us to reach the spine unless the patient is in a lateral position. But we were able to complete a good amount of dissection, which greatly facilitated the exposure once we made our lower abdominal incision.

Here I’m just showing some pictures of the setup that we had. We had a large room that had all the spine instruments and the robot. And as you can see here, we placed the cage between L4 and L5. On the right side, you can see the cage behind the left common iliac. And then using that incision, we placed a 30 by 18 centimeter medium-weight polypropylene mesh into the retromuscular space. Thank you for watching.

source https://iskandarcenter.com/hernia-surgery/combo-robotic-etep-recurrent-incisional-hernia-repair-with-spine-access-for-l4-l5-alif-video/

The Bassini Hernia Repair Technique

The Bassini hernia repair, developed by Italian surgeon Edoardo Bassini in the late 19th century, represents a significant historical advancement in the surgical treatment of inguinal hernias. Although this hernia repair technique has largely been replaced by modern methods, particularly tension-free mesh repairs, it remains a critical part of surgical history and education.

The Bassini repair was revolutionary, reducing hernia recurrence rates dramatically compared to prior methods. It is based on the anatomical reconstruction of the inguinal canal by suturing the conjoint tendon to the inguinal ligament, aiming to restore the normal anatomy without the use of mesh.

The Foundation of Tension-Free Repair

Unlike the tension-free repairs that have become the standard in modern hernia surgery, the Bassini technique relies on creating tension by suturing tissues together. This was intended to restore the integrity of the inguinal canal’s posterior wall but contrasts sharply with the principles of tension-free repair that minimize recurrence and postoperative pain.

The Role of Surgical Technique and Mesh Integration

The key features of the Bassini repair include its avoidance of prosthetic materials and its reliance on the patient’s own tissues to repair the hernia defect. This method does not utilize mesh, setting it apart from contemporary techniques, which use synthetic materials to reinforce the repair site and support tissue integration.

The Bassini Technique Procedural Steps

The procedural steps involved in the historic Bassini technique included:

1. Initial Incision and Canal Exposure: The surgery commences with a precise skin incision along the inguinal canal, stretching from the pubic tubercle to the midpoint of the inguinal region. This strategic incision grants the surgeon access to both the inguinal canal and the hernia sac.
2. Locating and Preparing the Hernia Sac: Within the confines of the inguinal canal, the hernia sac is meticulously identified and isolated from adjacent tissues, including, in males, the spermatic cord. This isolation is crucial for the subsequent steps of repair.
3. Management of the Hernia Sac: The sac may undergo an inspection after being opened, followed by either reduction (repositioning into the abdominal cavity) or excision (removal), with the sac’s neck securely ligated to prevent recurrence.
4. Reinforcement of the Canal’s Posterior Wall: The essence of the Bassini repair lies in suturing the conjoint tendon—a fusion of the internal oblique and transversus abdominis muscles—to the inguinal ligament (also known as Poupart’s ligament). This suturing extends from the pubic tubercle to the internal ring, carefully excluding the rectus abdominis muscle and the fascia transversalis from the suture line.
5. Narrowing the Internal Ring: Adjustments to the internal ring may be made to reduce the risk of an indirect hernia making a comeback. This is achieved by narrowing the ring judiciously to avoid impinging on the spermatic cord’s pathway.
6. Layered Closure of the Inguinal Canal: Following the structural reinforcement, the inguinal canal is meticulously closed in layers, with special attention to the realignment of the external oblique aponeurosis. This step ensures the integrity of the repair and the anatomical restoration of the inguinal region.
7. Finishing Touches: The procedure concludes with the skin being sutured or stapled shut, followed by the application of a sterile dressing to the wound site.

Advantages and Considerations

The Bassini method offered advantages such as avoiding mesh-related complications, but it also presented significant disadvantages, including higher recurrence rates and increased postoperative pain due to the tension on sutured tissues. These limitations have led to its decline in use in favor of tension-free mesh repairs.

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Types of Hernias Suitable for the Bassini Technique

The Bassini repair was historically utilized for indirect and direct inguinal hernias. These are hernias that appear in the groin area, either following the pathway of the inguinal canal (indirect) or resulting from a weakness in the inguinal canal floor (direct).

Types of Hernias Not Typically Repaired with the Bassini Technique

The Bassini technique is not suitable for repairing femoral hernias, incisional hernias, umbilical hernias, hiatal hernias, or large or complex hernias. These types of hernias require different surgical approaches, often involving mesh or more advanced techniques due to their anatomical locations or complexities.

Comparison of the Bassini Tension-Free Mesh Hernia Repair with Other Techniques

When compared to the Lichtenstein tension-free mesh repair and other modern techniques, the Bassini repair has fallen out of favor due to its higher recurrence rates and the postoperative discomfort associated with tension repairs. Tension-free mesh repairs, including the Lichtenstein method, provide more durable reinforcement of the inguinal canal and allow for quicker recovery times with less postoperative pain. Laparoscopic mesh repairs offer a minimally invasive alternative with even faster recovery, although they require general anesthesia, contrasting with the local or regional anesthesia that can be used for the Bassini repair.

In contrast, the Shouldice repair, another tension-based method, offers an improved recurrence rate over the Bassini technique through a more complex four-layer reconstruction but still does not match the effectiveness of tension-free mesh repairs.

Dr. Iskandar’s Thoughts

Bassini is mostly used these days in the emergency setting as a bailout option when mesh-based repairs are not doable due to the risk of infection, as in the case of strangulated hernias. It is rarely performed in the elective setting, where the shouldice method is preferred in my practice. 

Conclusion

In summary, the Bassini hernia repair technique, while an important step in the evolution of hernia surgery, has been largely superseded by methods that reduce the risk of recurrence and enhance patient recovery. Its use in modern surgical practice is limited to specific scenarios where mesh is contraindicated or unavailable. The development and adoption of tension-free mesh repairs have set a new standard in hernia surgery, reflecting ongoing advancements in surgical techniques and materials.

source https://iskandarcenter.com/hernia-surgery/the-bassini-hernia-repair-technique/

Lichtenstein Tension-Free Mesh Hernia Repair

The Lichtenstein tension-free mesh repair is a pioneering surgical technique developed in the 1980s by Dr. Irving L. Lichtenstein. This method has transformed the landscape of inguinal hernia surgery, offering patients a highly effective treatment option with a focus on reducing recurrence rates and facilitating a quicker return to daily activities. This article delves into the key features, benefits, and considerations of the Lichtenstein repair, shedding light on why it’s considered a gold standard in hernia surgery.

The Foundation of Tension-Free Repair

At the heart of the Lichtenstein method is the principle of a tension-free repair. Traditional hernia repairs, which involved suturing the hernia defect closed under tension, often resulted in higher recurrence rates due to the forces exerted on the repair site during normal activities. The Lichtenstein technique avoids this pitfall by using a synthetic mesh to bridge the defect, distributing forces evenly and significantly lowering the risk of the hernia re-opening.

The Role of Surgical Technique and Mesh Integration

The surgical procedure for the Lichtenstein repair is meticulous and standardized, involving a small incision in the groin to expose the hernia, preparation of the hernia sac, and the strategic placement of a synthetic mesh over the defect. This mesh is then secured to the surrounding healthy tissue, extending beyond the edges of the defect to ensure comprehensive coverage and integration with the body’s tissues.

The success of this method is also attributed to the mesh’s ability to integrate with the patient’s tissues. Made from materials like polypropylene, the mesh acts as a scaffold that encourages tissue ingrowth, resulting in a stronger, integrated repair site that is less likely to succumb to the pressures that caused the hernia initially.

The Lichenstein Hernia Repair Technique Procedural  Steps

Below is a procedural breakdown of the Lichtenstein hernia repair:

1. Incision and Direct Exposure: Initiating with a skin incision over the hernia site in the inguinal region, typically spanning 6-8 cm, this allows surgeons ample access to the inguinal canal and the hernia sac.
2. Hernia Sac Identification and Dissection: The surgeon locates the hernia sac within the inguinal canal and delicately separates it from adjacent tissues, taking care to preserve nearby structures such as the spermatic cord in male patients.
3. Management of the Hernia Sac: The sac is then either repositioned into the abdominal cavity (reduced) or surgically removed (excised) if reduction is not feasible or the sac is compromised.
4. Mesh Preparation: A piece of synthetic polypropylene mesh is tailored to the appropriate size to cover the hernia defect comprehensively. It is custom-shaped, including a slit to accommodate the spermatic cord, ensuring total defect coverage through overlap.
5. Mesh Placement: The mesh is positioned over the hernia defect, ensuring it lies snug against the abdominal wall, covering the defect and extending beyond its periphery in all directions to secure a broad reinforcement area.
6. Securing the Mesh: With sutures, staples, or adhesive, the mesh is affixed in place, anchored medially to the pubic tubercle, inferiorly to the inguinal ligament, and superiorly to the internal oblique muscle and conjoint tendon, avoiding nerve proximity to mitigate postoperative discomfort.
7. Incision Closure: The surgical site is closed in layers with the deeper layers sutured first, followed by skin closure using sutures or staples, and finally dressed.

Advantages and Considerations

The Lichtenstein tension-free mesh repair boasts several advantages, including a reduced risk of recurrence, lower postoperative pain, quick recovery, and the possibility of performing the surgery under local anesthesia. These benefits make it an appealing option for both surgeons and patients alike.

However, it’s important to recognize that the Lichtenstein repair, while versatile, is not suitable for all types of hernias or patients. Factors such as the patient’s overall health, the specific characteristics of the hernia, and the surgeon’s expertise play crucial roles in determining the most appropriate surgical approach. Moreover, as with any procedure involving mesh, there’s a small risk of complications such as infection, mesh migration, or chronic pain, though these are relatively rare.

Types of Hernias Suitable for Lichtenstein Tension-Free Mesh Repair

The Lichtenstein tension-free mesh repair is primarily used for the repair of inguinal hernias, which are hernias occurring in the groin area. This includes:

• Indirect Inguinal Hernias: These hernias occur when the inguinal canal’s internal ring is compromised, allowing abdominal contents to protrude. It’s the most common type of inguinal hernia and can occur at any age.
• Direct Inguinal Hernias: These hernias result from a weakness in the floor of the inguinal canal and are more common in older men.
• Recurrent Inguinal Hernias: The Lichtenstein repair can also be used for hernias that have recurred after previous surgical repair, although some surgeons may prefer a laparoscopic approach in these cases.

Types of Hernias Not Typically Repaired with Lichtenstein Tension-Free Mesh Repair

While the Lichtenstein repair is versatile, there are certain types of hernias for which it is not typically used:

• Femoral Hernias: These hernias occur just below the inguinal ligament and may require a different surgical approach due to their location and the risk of vascular and nerve structures in the area.
• Incisional Hernias: These hernias occur at the site of a previous surgical incision and often require a more complex repair that may involve both mesh and component separation techniques.
• Umbilical and Ventral Hernias: These abdominal wall hernias are not typically repaired with the Lichtenstein technique, as they occur in different locations and may require different surgical approaches.
• Hiatal Hernias: These hernias involve the stomach protruding into the chest through the diaphragm and are not addressed with inguinal hernia repair techniques.

Complex or Large Abdominal Wall Hernias: Large or complicated hernias may require more complex reconstructive techniques that can involve mesh but are not performed using the Lichtenstein method.

In summary, the Lichtenstein tension-free mesh repair is most commonly used for inguinal hernias due to its effectiveness in this area. It is not the preferred method for other types of hernias, which may require different surgical approaches tailored to their specific anatomical challenges and considerations. The choice of hernia repair technique is ultimately determined by the type and location of the hernia, the patient’s overall health, and the surgeon’s expertise and preference.

Comparison of the Lichtenstein Tension-Free Mesh Hernia Repair with Other Techniques

When compared to other surgical options, such as laparoscopic mesh repair or other open mesh techniques, the Lichtenstein repair stands out for its simplicity, effectiveness, and adaptability. While laparoscopic repairs offer a minimally invasive alternative with potentially quicker recovery times, they require general anesthesia and are not suitable for all patients. Other open mesh repairs, varying in mesh placement and fixation, share the tension-free principle with the Lichtenstein method but may not match its low recurrence rates and overall reliability.

Dr. Iskandar’s Thoughts on the Technique

This technique has been reproducible across the world with lots of evidence and data on its safety and effectiveness. It is also suitable for the majority of inguinal hernia irrespective of their size. For that reason, it is the go-to open-repair technique for many surgeons. 

Conclusion

In conclusion, the Lichtenstein tension-free mesh repair remains a cornerstone in the surgical management of inguinal hernias. Its blend of a tension-free approach, meticulous surgical technique, and mesh integration with the patient’s tissues offers a durable solution that minimizes recurrence and enhances patient recovery. As with any medical procedure, the decision to opt for the Lichtenstein repair should be made after careful consideration of the patient’s specific situation and in consultation with a skilled surgeon.

View the entire hernia repair technique library.

 

source https://iskandarcenter.com/hernia-surgery/lichtenstein-tension-free-mesh-hernia-repair/

McVay Hernia Repair Technique

The McVay hernia repair, historically known as the Cooper’s ligament repair, is a surgical approach developed for the treatment of inguinal (relating to the groin) and femoral (relating to the upper thigh) hernias. Pioneered by Dr. Chester McVay, this technique is distinguished by its utilization of Cooper’s ligament, offering an alternative to other hernia repair methods. Despite the evolution of surgical practices favoring tension-free mesh repairs, understanding the McVay technique is crucial for surgeons, especially in scenarios where mesh use is contraindicated (not recommended) or unavailable.

Key Features of the McVay Repair

Anatomical Restoration

The essence of the McVay repair lies in its anatomical approach, which involves suturing the transversus abdominis arch (a muscle layer in the abdominal wall) and the conjoint tendon (a tendinous structure formed by the joining of two muscles) directly to Cooper’s ligament (the periosteum of the pubic bone). This method aims to reconstruct the groin’s anatomy robustly and durably.

Tension-Based Technique

Similar to the traditional Bassini repair, the McVay method is a tension repair. It requires suturing tissues under tension, which can increase the risk of postoperative discomfort and hernia recurrence compared to tension-free alternatives.

Efficacy in Femoral Hernia Repairs

The technique is notably effective for femoral hernia repairs due to its specific reinforcement of the femoral canal, addressing a common and challenging type of hernia.

The McVay Technique Procedural Steps

The McVay hernia repair, known as well for its designation as the Cooper’s ligament repair, represents a traditional surgical method primarily employed in the treatment of inguinal and femoral hernias. This technique emphasizes the anatomical restoration of the groin’s structure by suturing the transversus abdominis arch and the conjoint tendon directly to Cooper’s ligament. Below is a detailed walkthrough of the McVay technique’s procedural steps:

1. Initial Incision and Exposure: The procedure initiates with a surgical incision made over the hernia site within the inguinal region, aimed at exposing the inguinal canal and the herniated sac. The incision’s length is determined by the hernia’s size and the specific anatomical nuances of the patient.
2. Hernia Sac Identification and Dissection: The next phase involves identifying the hernia sac and meticulously dissecting it away from the adjacent tissues. In the context of inguinal hernias, the sac typically manifests, protruding through the inguinal canal, whereas, for femoral hernias, it emerges below the inguinal ligament via the femoral canal.
3. Hernia Sac Management: Following the dissection, the hernia sac is either repositioned back into the abdominal cavity—a process known as reduction—or surgically removed (excised) if repositioning is deemed unsafe.
   Suturing to Cooper’s Ligament: The cornerstone of the McVay repair involves the precise suturing of the transversus abdominis arch and the conjoint tendon to
4. Cooper’s ligament, utilizing non-absorbable sutures. This suturing extends from the pubic tubercle (a bony prominence on the pubic bone) laterally towards the femoral vein for inguinal hernias and is extended further laterally for femoral hernias.
5. Internal Ring Adjustment: An additional step may involve tightening the internal ring (an opening in the abdominal wall) to avert the recurrence of indirect inguinal hernias, accomplished by suturing the transversalis fascia (a layer of connective tissue) to the iliopubic tract (a fibrous band in the groin). This step is carefully executed to avoid constraining the spermatic cord in male patients.
6. Wound Closure: The surgical incision is methodically closed in a layered fashion, beginning with the fascia (connective tissue) and culminating with the skin closure, to ensure a robust support for the repair and to foster optimal healing conditions.

Advantages and Disadvantages

Advantages of McVay Technique

• Anatomical Reconstruction: The McVay repair offers a strong, anatomy-based solution, particularly beneficial for both inguinal and femoral hernias.
• Non-Mesh Option: It provides an option for patients where mesh is contraindicated, unavailable, or not preferred, making it versatile in various clinical settings.

Disadvantages

• Postoperative Discomfort and Recurrence Risk: The inherent tension in the suture lines may lead to a higher likelihood of pain and hernia recurrence compared to tension-free mesh methods.
• Surgical Complexity: The technique demands a comprehensive understanding of pelvic anatomy and precise surgical skills, potentially limiting its use to more experienced surgeons.

Current Clinical Application

While the advent of tension-free mesh repairs has led to a decline in the McVay technique’s prevalence, it retains significance in certain contexts. It is particularly relevant for patients unable to undergo mesh repairs and in settings where mesh is not accessible. Its historical and educational value continues to enrich the surgical community’s knowledge, especially for managing femoral hernias and in situations where mesh alternatives are sought.

Comparative Analysis with Other Hernia Repair Techniques

McVay Technique vs. Lichtenstein Tension-Free Mesh Repair

The McVay repair’s tension-based approach contrasts with the Lichtenstein method’s tension-free, mesh-reinforced technique, which generally offers lower recurrence rates and reduced postoperative pain.

McVay Technique vs Laparoscopic Hernia Repair

Compared to minimally invasive laparoscopic techniques (surgery performed through small incisions using a camera), the McVay repair, being an open surgery, involves a larger incision and a potentially longer recovery period.

McVay Technique vs Shouldice Repair

While both the McVay and Shouldice repairs are tension-based, the Shouldice technique focuses on a four-layer reconstruction specifically for inguinal hernias, without employing mesh.

Dr. Iskandar’s Remarks

In current practice, the utility of McVay is mostly in emergency situations when there is a strangulated femoral hernia (a hernia that becomes trapped and loses blood supply). In that scenario, there is risk of mesh infection and a McVay repair would be the tissue method of choice to repair the femoral hernia.

Conclusion

The McVay hernia repair technique, with its unique application and historical significance, remains a valuable part of surgical education and practice. Although modern tension-free mesh and minimally invasive approaches have largely superseded it, the McVay repair persists as a viable option under specific circumstances. Its understanding is essential for surgeons, offering insights into the evolution of hernia repair techniques and providing alternatives in complex clinical scenarios.

See the entire hernia repair techniques library.

source https://iskandarcenter.com/hernia-surgery/mcvay-hernia-repair-technique/

Transabdominal Preperitoneal (TAPP) Hernia Repair

The Transabdominal Preperitoneal (TAPP) technique is a minimally invasive method that offers a quicker recovery and less pain than traditional hernia surgeries. This guide breaks down the TAPP procedure into understandable parts.

What is TAPP?

The TAPP technique repairs inguinal hernias using small incisions, cameras, and a mesh. It’s done by accessing the hernia from inside the abdomen but placing the mesh in the preperitoneal space (the area between the abdominal wall and the peritoneal lining).

The TAPP Hernia Repair Technique Procedure Steps

 

1. Preparation and Access: Surgeons begin by inflating the abdomen with gas (pneumoperitoneum) to create space for the operation. This is done through small cuts (incisions), where ports (thin tubes) are inserted for tools and a camera.
2. Incision and Exposure: A cut is made in the peritoneum (the lining of the abdominal cavity) to reach the preperitoneal space. This exposes the hernia and surrounding tissues.
3. Dissection and Hernia Reduction: The area around the hernia is carefully separated, and the hernia itself is pushed back into the abdomen.
4. Mesh Placement A synthetic mesh is placed over the hernia opening in the preperitoneal space. This mesh strengthens the area, preventing the hernia from recurring.
5. Securing the Mesh: The mesh may be secured with stitches, staples, or glue. Some methods avoid securing the mesh to reduce pain without increasing the risk of the hernia coming back.
6. Closing the Incision: The initial cut in the peritoneum is stitched or stapled shut, covering the mesh.
7. Finishing Up: The tools and ports are removed, and the small incisions are closed, often with stitches that dissolve over time.

Benefits of TAPP Hernia Repair

• Minimally Invasive: The TAPP approach results in less bodily disruption than traditional open surgery, leading to smaller scars and often more satisfying aesthetic outcomes.
• Reduced Pain Post-Surgery: Generally, patients report experiencing less discomfort following the TAPP procedure when compared to the aftermath of conventional open hernia repairs.
• Quicker Recovery Time: This method facilitates a faster healing process, enabling patients to resume their normal activities and return to work sooner.
• Low Recurrence Rates: Proper execution of the TAPP procedure is associated with a low risk of hernia recurrence, making it a reliable option for long-term repair.
• Capability for Bilateral Repair: TAPP is efficiently used for repairing hernias on both sides of the groin during the same operation, reducing overall patient trauma and recovery time.
• Opportunity for Intra-Abdominal Examination: The approach grants surgeons the ability to inspect the abdominal cavity for other potential issues, which can then be addressed simultaneously.

Limitations of TAPP Hernia Repair

• Technical Demands: The success of the TAPP method hinges on the surgeon’s expertise, especially in terms of mesh handling and placement.
• Risk of Injury to Internal Organs: The nature of this procedure, which involves navigating the abdominal cavity, carries a risk of accidental damage to internal organs.
• Postoperative Complications: Although infrequent, complications such as bowel obstruction, mesh migration, and chronic pain can occur, necessitating careful postoperative monitoring.
• Higher Costs: The requirement for specialized equipment and materials, including the use of robotic assistance for some surgeries, may render the TAPP procedure more costly than traditional methods.

Considerations for Mesh Use

• Mesh Type: The choice of mesh, typically polypropylene due to its durability, biocompatibility, and cost-effectiveness, plays a critical role in the outcome of the surgery. The decision between using synthetic or biological meshes can influence factors like chronic discomfort and the chance of hernia recurrence.

In summary, the TAPP hernia repair technique presents a significant advancement over conventional open surgeries, offering benefits such as diminished postoperative pain and expedited recovery. Nonetheless, it demands specialized skills from the surgeon and carries its own set of risks that must be carefully weighed. The selection of mesh material further influences the surgical outcome, underscoring the importance of tailored surgical planning.

Laparoscopic vs. Robotic TAPP

The steps for both laparoscopic (using special tools and a camera) and robotic TAPP (using a robot the surgeon controls) are similar. The main difference is the use of a robotic system in the latter, which may enhance precision and control.

Why Will a Hernia Surgeon Choose TAPP?

TAPP is less invasive than traditional surgery, leading to:

• Less postoperative pain
• Faster return to normal activities
• Lower risk of the hernia returning

What Types of Hernias are Suitable for TAPP?

Inguinal Hernias: These are hernias near the groin. TAPP is great here because it lets doctors place a special kind of patch (mesh) in just the right spot to cover the hernia.

Femoral Hernias: Similar to inguinal hernias but in a slightly different area, TAPP can also tackle these effectively.

Incisional Hernias (sometimes): If you’ve had surgery before and get a hernia at the scar site, TAPP might be an option, especially for smaller ones in the lower belly.

Hernia Types Not Typically Ideal for TAPP

Big or Complicated Hernias in the Belly Wall: If the hernia is really big or tricky, doctors might go for a different method that involves more detailed work.

Hiatal Hernias: These occur near the diaphragm (the muscle that helps you breathe) and need a different fix.

Umbilical Hernias: These are at the belly button and don’t fit the TAPP approach, but there are other laparoscopic (small incision surgery) methods that might work.

Understanding Your Options: TAPP vs. TEP

When it comes to repairing inguinal hernias with a minimally invasive approach, patients and surgeons often choose between two primary techniques: Transabdominal Preperitoneal (TAPP) and Totally Extraperitoneal (TEP) repair. Both methods have their unique advantages and considerations. Understanding the differences can help in making an informed decision tailored to individual needs.

TAPP (Transabdominal Preperitoneal) Repair

TAPP involves entering the abdominal cavity to place a mesh in the preperitoneal space, effectively reinforcing the weakened area. This approach allows the surgeon to have a broad view of the abdominal cavity, potentially identifying and addressing other abdominal issues if present. It is versatile and can be used for almost all types of inguinal hernias, including those that are recurrent or complicated by previous surgeries.

Advantages of TAPP:

• Comprehensive view of the abdominal cavity.
• Ability to handle complex and recurrent hernias.
• Familiar approach for surgeons experienced in laparoscopic procedures.

TEP (Totally Extraperitoneal) Repair

TEP, on the other hand, avoids entering the abdominal cavity altogether. The procedure is conducted entirely in the preperitoneal space, directly addressing the hernia without the potential complications associated with abdominal cavity access, such as injury to the intestines or other intra-abdominal organs.

Advantages of TEP:

• Reduced risk of complications related to abdominal cavity entry.
• Potentially shorter recovery time due to less invasive nature.
• Lower risk of developing adhesions, which are bands of scar tissue that can cause organs to stick together.

Choosing Between TAPP and TEP

The choice between TAPP and TEP is influenced by several factors, including:

• Surgeon’s Expertise and Preference: Some surgeons may prefer one technique over the other based on their training, experience, and the outcomes they’ve observed in their practice.
• Patient’s Medical History: Patients with previous abdominal surgeries may benefit more from a TEP repair to avoid potential adhesions in the abdominal cavity. Conversely, TAPP might be more suitable for identifying and addressing concurrent abdominal issues.
• Hernia Characteristics: The size, location, and whether the hernia is a recurrence can influence the choice of technique. TAPP might be preferred for complex or recurrent hernias due to the broader view it provides.
• Patient’s Lifestyle and Recovery Goals: Recovery times and post-operative pain can vary slightly between the two techniques, influencing patient preference based on their lifestyle and how quickly they wish to return to normal activities.

Dr. Iskandar’s Remarks on TAPP

This is an excellent minimally invasive repair. For women specifically, minimally invasive surgery is recommended as it allows mesh coverage of all potential hernia defects (indirect, direct, femoral, and obturator) as women have a higher chance of femoral and obturator hernias

Conclusion

In conclusion, the Transabdominal Preperitoneal (TAPP) hernia repair technique stands out as a minimally invasive option that offers numerous benefits, including reduced recovery time and lower risk of complications. It’s particularly effective for repairing inguinal and femoral hernias, making it a versatile choice for many patients. While it may not be suitable for all types of hernias, its ability to allow surgeons to place mesh in the preperitoneal space accurately makes it an invaluable option in the surgical toolbox. The decision to use TAPP over other methods depends on various factors, including the specific characteristics of the hernia and the surgeon’s expertise, highlighting the importance of a tailored approach to hernia repair.

See all the hernia repair techniques library.

 

source https://iskandarcenter.com/hernia-surgery/transabdominal-preperitoneal-tapp-hernia-repair/