A new strategy for laparoscopic repair of inguinal hernia developped after robot-assisted laparoscopic radical prostatectomy

Toshihiro Ogawa, MD, Hitoshi Idani, MD, FACS, Soichiro Miyake, MD, Hisanobu Miyoshi, MD, Hiroyuki Araki, MD, Kazutaka Takahashi, MD, Toshihiko Fujita, MD, Naoki Mimura, MD, Yasuhiro Komatsu, MD, Kenji Yamaguchi, MD, Hiroaki Inoue, MD, Hiroshi Ota, MD, Yasuo Nagai, MD, Hijiri Matsumoto, MD, Michihiro Ishida, MD, Daisuke Sato, MD, Noriaki Tokumoto, MD, Yasuhiro Choda, MD, Takashi Kanazawa, MD, Masao Harano, MD, Yasutomo Ojima, MD, Hiroyoshi Matsukawa, MD, Shigehiro Shiozaki, MD, Masazumi Okajima, MD, FACS, Motoki Ninomiya, MD. Department of Surgery Hiroshima City Hospital

Background: Surgical procedures for inguinal hernia developed after robot- assisted laparoscopic radical prostatectomy (RALP) have not yet been established. We have introduced a new strategy for laparoscopic repair of inguinal hernia after RALP and evaluated the outcome.

Surgical technique: Under general anesthesia, 3 trocars was inserted at the same position as transabdominal preperitoneal approach (TAPP). Bilateral inguinal legion was observed carefully and bilateral hernia repair was performed when the hernia was detected at the contralateral side. At first, preperitoneal space was dissected laterally and then medially enough to detect the Cooper’ ligament and pubic bone. After the preperitoneal space was fully dissected, 14X10 cm mesh was inserted and fixed with absorbable tacks. When the Cooper’s ligament was detected but the medial preperitoneal space could not be further dissected due to scar formation caused by dissection during RALP, parietex composition mesh was fixed to the Cooper’s ligament and medial and cephalad side was directly fixed to the abdomen and the caudal side was sutured and covered with peritoneum (partial intraperitoneal onlay mesh: PIPOM). When the Cooper’s ligament could not be detected at all, hernia was repaired by anterior approach.

Methods: From April 2014 to August 2015, seven patients with inguinal hernia developed after RALP underwent laparoscopic repair in our hospital and its outcome was evaluated.

Results: Mean age of patients was 70.4 years old. There were 4 right indirect hernias, 1 left indirect hernia and 2 bilateral indirect hernias (one of which was combined with left direct hernia). Two bilateral hernias were diagnosed by laparoscopy. TAPP, PIPOM and anterior approach were performed on 3, 3 and 1 patients, respectively. Operation time was 142 min for TAPP, 150 min for PIPOM (including 2 bilateral repair) and 144 min for anterior approach.

Postoperative pain was minimum and well controlled by NSAIDS, which disappeared within a week. Hospital stay was 3.5 days. Seroma was occurred in  two patients which treated conservatively. During the follow-up period of 8 months, there has been no recurrence.

Conclusion: Our new strategy including TAPP and PIPOM is safe and effective although further examination in a large number of patients and long term follow up will be needed.

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