LPS IPOM in management of complicated inguinal hernias 徐偉峻 王偉林 陳嘉哲 湯堯舜 廖立民 黃宏昌 臺北醫學大學附設醫院 外科部 急症外傷外科

Disclosure I have nothing to disclose 2

Introduction LPS hernioplasty with synthetic mesh has introduced since the 1990s, common methods for such repairs could be classified under three broad categories: Total extraperitoneal (TEP) repair, Transabdominal preperitoneal (TAPP) repair Intraperitoneal onlay mesh (IPOM) repair 3

Introduction IPOM has same advantage to other LPS techniques in terms of postoperative pain and faster recovery. IPOM repairs allow exploration of the contralateral side that may show a non-symptomatic hernia in 11.2∼32.3% of the cases. The second hernia may be repaired simultaneously without affecting postoperative pain and course. Sayad P, Abdo Z, Cacchione R, Ferzli G. Surgical Endoscopy 2000;14:543-545.

Material and Methods Patients with incarcerated or recurrent hernia received LPS IPOM by a single surgeon from 2016.06 to 2017.01 were retrospectively reviewed The inclusion criteria were patients, 18 years old and above, who have been diagnosed inguinal hernia with incarceration requiring diagnostic laparoscopy, or patients with prior hernia repairs The exclusion criteria include contaminated surgical field (bloody ascites, gangrenous change of bowel, bowel perforation)

Material and Methods All patients received a 15×15 cm sized dual facing surgical mesh (PROCEEDTM Mesh, Ethicon Endo-surgery, Inc., Somerville, NJ) The mesh was further secured with a non-absorbable stitch on the corner of the mesh for transfascial fixation The edge was further secured with absorbable tacks at 2 cm interval (SECURESTRAP, Ethicon Endo-surgery, Inc., Somerville, NJ)

Patient Profile Patient demographic Number of patients 15 Number of hernias 16 Age (mean) 60.2 Gender (M/F) 10/5 Site of hernia   right 14 left 1 bilateral Type of hernia direct indirect pantaloon Previous surgery 5

Perioperative data Summary of perioperative data Surgical methods LPS   LPS 1 SILS 14 Operative time (average) Unilateral 45 mins Bilateral 60 mins Conversions Length of stay (average) 3.5 days

Complications Complications Intra-operative Post-operative Pain* 1 Post-operative   Pain* 1 Swelling/seroma Hematoma/bleeding Adhesion Ileus** Recurrence *Requiring oral analgesics 1 week after surgery ** Ileus during OPD follow up

Discussion LPS hernia surgery has gained worldwide acceptance and has become the first choice for inguinal hernia repair in many centers. The advantages include reduced pain and hospital stay, rapid convalescence, quicker return to work, better functional and cosmetic results. Dulucq JL, Wintringer P, Mahajna A. Surgical Endoscopy 2006;20:473-476. Toy FK, Smoot RT, Jr. Surgical Laparoscopy & Endoscopy 1991;1:151-155. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: 1991;1:269-277.

Discussion The size of the mesh should not be less than 10×15 cm so that entire myopectineal orifice (possible inguino-crural hernia sites) can be largely covered. This is utmost important in order to prevent recurrence. Catani M, De Milito R, Pietroletti R, et al. Hepatostroenterology 2004;51:1387-1392. Phillips EH, Rosenthal R, Fallas M, et al. Surgical Endoscopy 1995;9:140-144; discussion 144-145.

Discussion IPOM repair has concerns about relatively high recurrence rate and complication rate other than other LPS hernia, one study have shown with a median follow up of 51 months, no major complication has been reported, and with only one recurrence (1/50) IPOM repair is also acceptable in terms of operative times, easiness and length of stay. However, compared to other LPS surgery, IPOM repair is more expensive Journal of Minimally Invasive Surgery Vol. 17. No. 2, 2014

Limitations Our study have been performed retrospectively to relatively small number of patients, with short follow up time (average 6months)

Conclusion LPS IPOM repair for inguinal hernia is not a standard method, but it can be performed for specific cases of complicated inguinal hernia as an alternative option

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 Dual facing surgical mesh, with different characteristics on both sides: the parietal surface is rough with micro-pores in order to stimulate a strong fibroblastic tissue reaction the visceral surface is coated with anti-adhesive material in order to minimize tissue reaction, thus avoiding intestinal adhesions