Feasibility of single incision endoscopic totally extraperitoneal hernia surgery under local anesthesia.

Norihito Wada, MD, PhD, Toshiharu Furukawa, MD, PhD, Yuko Kitagawa, MD, PhD

Department of Surgery, School of Medicine, Keio University

Background: Laparoscopic hernia repair is considered to be a minimally invasive surgery for inguinal hernia. Pneumoperitoneum during laparoscopic surgery, however, requires muscle relaxation and general anesthesia. On the other hand, open surgery with anterior approaches, such as open Lichtenstein repair, can be safely performed under local anesthesia and ensures early recovery and safety especially for the elderly patient with comorbidities. We developed a novel technique for single-incision endoscopic totally extraperitoneal (TEP) inguinal hernia surgery feasible even under local anesthesia. Here, we show the short term outcomes of this procedure.

Patients and Methods: From January to August 2012, a consecutive group of 15 adult patients with bilateral inguinal hernia was included in this study. Patients with obesity, inguinoscrotal hernia, irreducible hernia or coagulopathy were excluded from this study. We used 0.5% lidocaine with epinephrine as local anesthetics. Conscious sedation was achieved by giving intravenous pethidine hydrochloride and flunitrazepam. A single incision of 30 mm in the lower abdomen was made and a wound protector with sealing silicon cap was placed. We have used three 5 mm trocars with a 5 mm flexible laparoscope. A flat self-fixating mesh with resorbable microgrip was installed and spread over the inguinal area of preperitoneal space. No tacking devices were used.

Results: The mean ± SD age was 59.9 ± 9.1 and male sex was 100%. The mean operating time was 157 ± 31 min. The mean total local anesthetic volume was 20.1 ± 3.9 ml. The mean total dose of pethidine hydrochloride and flunitrazepam were 54 ± 18 and 0.6 ± 0.4, respectively. Intraoperative and immediate postoperative complications were not observed except for 4 cases (26.7%) of minor seromas which was treated conservatively without aspiration. Pneumoperitoneum due to peritoneal injury was occurred in 1 case (6.7 %) and managed by inserting a flat silicon disk to maintain the preperitoneal space during the operation. During median follow-up of 4 months, we had no hernia recurrence or complications other than minor seromas.

Discussions: Short term outcomes of single-incision endoscopic TEP surgery for inguinal hernia were similar to those of conventional TEP or open hernia repair even under local anesthesia. Surgical invasiveness in this procedure would be reduced because the incision was made in the lower abdomen and area of dissection in the retroperitoneal space is smaller than TEP surgery using umbilical port. Cosmetic results were excellent with scars being hidden in the pubic hair. Post-operative recovery was rapid and patients can walk to the bathroom by themselves due to light sedation and local anesthesia. The cost for this surgery is lower than conventional TEP surgery due to the omission of balloon dilator and tacking devices. This novel procedure is a promising strategy to reduce the invasiveness of hernia repair not only surgically but also anesthesiologically.

Session: Poster Presentation

Program Number: P294

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