Fujio Ito, PhD, MD, Junichi Miura, PhD, MD, Takao Tsuchiya, PhD, MD, Satoshi Otani, PhD, MD, Takahiro Saito, PhD, MD, Atsushi Nishimagi, MD. Iwase General Hospital
Introduction: In laparoscopic inguinal hernia repair, tack fixation to the iliopubic tract, vascular triangle (triangle of doom) and nerve triangle (triangle of pain) cannot be performed, which consequently leads to concerns regarding the recurrence of indirect inguinal hernias with large inguinal rings due to postoperative eversion or displacement of the lower part of the mesh. To avoid migration or displacement of the mesh after the repair procedure until it becomes adherent to the surrounding tissue through scarring, we perform suture closure of the enlarged inguinal ring or mesh suturing to the hernia orifice and find these methods to be useful in preventing recurrence of the hernia. Here, we report our findings.
Materials and Methods: Thirty patients who underwent laparoscopic hernia repair (transabdominal preperitoneal/totally extraperitoneal) for indirect inguinal hernia with >3 cm hernia orifices were investigated. After examining the peritoneal dissection area, inguinal ring closure was performed using one of the following three methods:
Method 1. Suture closure using the preperitoneal fascia
When the inguinal ring is about 3-4 cm and sufficient preperitoneal fascia remains after dissection of the peritoneum, or when the iliopubic tract cannot be exposed easily, the preperitoneal fascia is approximated with purse-string sutures or continuous sutures to close the hernia orifice.
Method 2. Suture closure of the transverse aponeurotic arch and iliopubic tract
This method is used when the hernia orifice exceeds 4 cm or the lateral triangle is enlarged, and when approximation of the transverse aponeurotic arch and iliopubic tract is feasible. Without getting close to the course of the genitofemoral nerve or lateral femoral cutaneous nerve, the iliopubic tract is exposed and visualized at the center of the inguinal ring and 2-3 sites are sutured to reduce the size of the inguinal ring. Importantly, the iliopubic tract is superficially sutured.
Method 3. Mesh suturing to the transverse aponeurotic arch and iliopubic tract
When the hernia orifice exceeds 4 cm but approximation of the transverse aponeurotic arch and iliopubic tract is structurally not feasible, the mesh is sutured to the hernia orifice with low tension sutures.
Results: Using the above three methods, inguinal ring closure was achieved in all cases with enlarged inguinal rings; the patients are recovering well without chronic pain or recurrence.
Discussion: By only suturing sites that can be safely visualized without performing tack fixation, it was feasible to safely close large inguinal rings.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95025
Program Number: P599
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster