The Combined Laparoscopic Approach to Incarcerated Inguinal Hernia

Background: The laparoscopic preperitoneal repair of inguinal hernias is an accepted and widely used approach, and several reports have demonstrated its advantages over an open repair. Incarcerated hernia is still considered an indication for an open repair, for several reasons, including the technical complexity, availability of trained laparoscopic surgeon for an emergent procedure, and the need to examine the incarcerated contents for signs of
ischemia.
Aim: To examine our experience with laparoscopic treatment of irreducible inguinal hernias, and present our approach which combines intra-peritoneal laparoscopic exploration, with
reduction of incarcerated contents, and totally extra-peritoneal repair of the hernia.
Methods: Over a period of 3 years 14 patients were operated, 9 males and 5 females. In 6 cases the incarceration was chronic. and the hernia contained fat only in four of them. The other 8 patients had acute incarceration, and the hernial sac contained bowel.
Reduction of the incarcerated contents was easily achieved by standard laparoscopy in all but one case, in which an open incision was needed for reduction. The incarcerated bowel, even if was ischemic, recovered in all cases after being returned to the abdominal cavity, and there was no need for resection. After contents reduction, the peritoneal gas was evacuated, and the operation was converted to a standard totally extra-peritoneal repair (TEP), using a pre-preitoneal prolene
mesh.
Results: All operations were completed by a laparoscopic repair, including the case in which an incision was needed to reduce omentum chronically adhered to the sac. In most cases reduction was straightforward and easy, in contrast to the difficulty in reducing the contents externally before surgery. In all cases the contents was either viable, or quickly recovered from ischemia after reduction, as observed by laparoscopy. Hospitalization was short in all cases (a day or two), and no infectious or other complications occurred.
Conclusion: The combined laparoscopic approach, both intra- and extra-peritoneal, allows for an adequate solution to incarceration of inguinal hernias, with taking advantage of each separate approach. The first part of the procedure enables easy reduction of the incarcerated contents, and controlling its viability. The second part enables a simple and standard repair, similar to an elective case. It should be noted that the intra-peritoneal part
does not force the surgeon to continue with this approach (TAPP), and the switch to TEP turns the operation into a familiar, simple and quick procedure.


Session: Poster

Program Number: P447

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