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inguinal hernia, crural hernia, hernia, laparoscopy, laparoscopic inguinal hernia
Inguinal hernia in laparoscopy, why?

Laparoscopic surgery of inguinal hernia 

When, after diagnosis, I propose to a patient to operate on his inguinal hernia laparoscopically, it is natural for me to be bombarded with questions.

In fact, inguinal hernias can be operated on under local anesthesia using relatively simple, widely standardized, and highly effective techniques.

Laparoscopic inguinal hernia, inguinal hernia surgery, inguinal hernia, inguinal hernia pain, inguinal hernia surgery,

However, there are many considerations in favor of laparoscopic inguinal hernia repair., that chart the way in choosing the technique.

The first comes from a long way back; from 1647 even, the year when French physicist and mathematician Blaise Pascal discovered his famous law.

In his experiment, Pascal introduced a 10-meter-long pipe into a barrel filled with water, then filled the pipe with water as well: the result was that the pressure inside the barrel increased so much that it broke.

Applied to hernia surgery, Pascal's law tells us that when the mesh we use to repair a hernia is placed on the inner surface of the herniated defect area, it is the same pressure present inside the abdomen that anchors it to the abdominal wall; whereas if we place it on the outer surface, the pressure tends to make it detach.

So operating aninguinal hernia laparoscopically means to perform a surgery in which the repair is more stable than that done "from the outside." And this is a very, very good reason to propose the surgery of repairing the inguinal hernia in laparoscopy..

Another important reason is that by operating on aninguinal hernialaparoscopically, we are able to diagnose the possible presence of other wall defects, which are often present in these patients and not looked for or not seen by the examiner-such as, for example, an umbilical hernia or a contralateral inguinal hernia, i.e., on the other side, a crural hernia-and repair them during the same surgery.

TAPP hernioplasty - plug

Third, equally central reason: laparoscopic inguinal hernia surgery causes much less postoperative pain than surgery performed conventionally.

What's more, many (most) surgeons who operate openly have the habit of using "plugs ," which are sort of "plugs" of plastic material that are inserted into the inner inguinal ring for the purpose of reducing its size. This is a very bad habit, because these plugs have an unpleasant tendency to migrate, often ending up inside the abdominal cavity and causing adhesions with the intestinal loops, which, in the most serious cases, can end up injured by these plastic boulders, up to intestinal perforation.

In the photograph above, here is what we found in one of our last surgeries: a plug that had entered the abdominal cavity, causing severe adhesions with peritoneal fat and intestinal loops. And it was not the firsttime.

Remember: if you are going to have surgery for aninguinal hernia, ask the Surgeon if he plans to use a plug; if he says yes, think about it!

So, summing up:

LAPAROSCOPIC INGUINAL HERNIA:

Better repair of the herniated defect, with larger mesh and optimal tightness
Ability to diagnose and repair other hernias that escaped diagnosis during surgery
Less postoperative pain

These are the reasons - and they are not a few! - to propose laparoscopic inguinal hernia repair surgery. Add to this the fact that, for years now, the scientific community of surgeons dealing with the abdominal wall has established that laparoscopic inguinal hernia surgery represents the "gold standard" for the treatment of this frequent, bothersome and sometimes very serious condition.

However, probably following ingrained habits that make open inguinal hernioplasty surgery a surgery that can be performed by any surgeon, even those who are not particularly specialized in abdominal wall surgery, and also because laparoscopic inguinal hernia surgery is by no means simple, but involves a long and arduous learning curve, today the vast majority of surgeons do not engage in laparoscopic inguinal hernia surgery. Obviously, to the great detriment of the patient.

Laparoscopic inguinal hernia surgery in my center

laparoscopic inguinal hernia

For years I have been working to make my center, the St. Catherine of Siena Clinic in Turin, Italy., a Center of Excellence for the treatment of abdominal wall pathologies, particularly insisting on minimally invasive laparoscopic surgery. I introduced, first in Europe, the endoscopic diastasis surgery of the rectus abdominis muscles (of which I now hold the largest case history in the world) and, first in the world, the surgery of large laparoceles by endoscopy, with an original technique derived from the Carbonell-Bonafé technique, also with preoperative preparation with botulinum toxin and progressive pneumoperitoneum for the reconstruction of the space in the abdominal cavity (techniques well known and widely used abroad, but practically unknown in Italy; in this, too, excuse my lack of modesty, I arrived first...). Continuing on the path of offering the patient the best possible therapeutic choices, and in line with international recommendations, I have decided to offer inguinal hernia repair by laparoscopy to all my patients.. Operationally, for the patient this involves general anesthesia instead of local, and one night of hospitalization.

How does the surgery take place? You can take a look at the video below to understand the basic surgical steps forlaparoscopic inguinal hernia repair.

How to get enrolled for this surgery? Simply schedule an appointment or a video consultation.

VIDEOCONSULTO TORINO - CLINICA SANTA CATERINA DA SIENA STUDIO DE MEDICA - CHIVASSO

Otherwise, you can contact me with the form below:

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What our patients think of us is much more important than what we say.

Dr. Salvatore Cuccomarino
Cuccomarino, MD
Medical Surgeon Specialist in General Surgery
19 Villa della Regina Street
Turin,Turin
10131
EN
Phone 0118199300

 

Laparoscopic recurrent inguinal hernia
Recurrent inguinal hernia? better laparoscopy

Recurrent inguinal hernia: what is it?

L'inguinal hernia belongs to the large family of hernias of the abdominal wall and represents one of the most frequent diseases of surgical interest worldwide: it is estimated that hernias in general affect 5 to 7 percent of the population, and of these about 75 percent are inguinal hernias. In other words, about 2,736,000 people in Italy are affected by inguinal hernias. The majority of these patients end up undergoing surgery, which, in the first instance, is a relatively uncomplicated procedure that is performed under local anesthesia and requires only a few hours of hospitalization. However, in not a small percentage of cases, the repair, for a variety of reasons (ranging from errors in technique to the patient's failure to follow the rules imposed by the surgeon in the postoperative), fails; the hernia reforms: we speak, in this case, of recurrent inguinal hernia.

Recurrence: a frequent problem in inguinal hernias

Modern surgical techniques and the use of prostheses have substantially reduced the rate of recurrence after inguinal hernia surgery; however, a recent study, conducted on more than 46. 000 patients in Denmark, showed that the incidence of inguinal hernia recurrence continues to affect about 4 percent of patients; less than the double-digit percentages observed before the advent of mesh: but, taking into account the numbers reported earlier, theoretically in Italy alone,inguinal herniarecurrence affects more than 100,000 patients-a not a small city!

The problem then facing the Surgeon is: what is the correct treatment of recurrent inguinal hernia?

What is the correct treatment of recurrent inguinal hernia?

Most Surgeons treat therelapsed ing uinal hernia exactly as they had treated the primary inguinal hernia: that is, they operate on it anteriorly, redoing a surgical incision on the previous one, and trying to put a "patch" on it as best they can-very often "inventing" on the spot some variation of the most commonly used surgical techniques (which, in the act, also seems like a good solution). This, unfortunately, is conceptually wrong, as well as going against the indications of the main guidelines available today.

Operating a recurrent hernia with the traditional incision when the primary hernia has already been operated on anteriorly means re-injuring tissue over which the surgeon had already passed during the previous operation, in an area where the anatomy has been profoundly altered by the surgery undergone by the patient anyway, and where there are very intense fibrotic phenomena due to the presence of the mesh: the risk of vascular and nerve injury and postoperative pain increases, and by a great deal; the wall of the inguinal region is further weakened, and the risk of recurrence increases. The patient risks being entangled in an endless and painful odyssey.

Hernia recurrence: better laparoscopy

Le guidelines, in this case drawn up by the European Hernia Society, speak clearly: Recurrent inguinal hernia, guidelines, European Hernia Society

"If previously anterior: consider open preperitoneal mesh or endoscopic approach (if espertise is present)" - i.e., if the patient has previously been operated on anteriorly, open repair with mesh in the preperitoneal position (e.g., Stoppa's or Wantz's techniques) or the endoscopic technique are indicated, provided expertise is present, i.e., there is a Surgeon experienced in this procedure.

In fact, in Italy - for a thousand reasons, which it is not the case to analyze here - there are few Surgeons able to try their hand at inguinal hernia repair laparoscopically, especially if it is arecurrent inguinal hernia (and perhaps even fewer who are able to perform an operation with Stoppa or Wantz technique). These are difficult cases, with altered anatomy in any case (even if, "going from the inside," i.e., from the inner surface of the inguinal region, one is working in seemingly "virgin" territory), which can only be addressed by experienced surgeons. But the advantages are clear: one has the possibility of repairing the herniated defect with a significantly larger mesh than is used in traditional hernia surgery, placed in a "healthy" area than where the surgeon had previously worked; and not infrequently, one may find that one is actually not dealing with arecurring inguinal hernia, but with a new hernia, perhaps unnoticed during the previous surgery, or perhaps formed later; and that, lo and behold, there is also a hernia on the other side, in the other inguinal region, which neither the patient nor the surgeon had noticed, and which can be repaired during the same surgery, before it begins to bother. Not to mention that postoperative pain is significantly less than with traditional surgery, and the patient can return to his or her activities much more quickly.

The video of the surgical technique

And here, finally, is a video of a recent surgery I did for recurrent inguinal hernia, performed laparoscopically (T.A.P.P. technique, Trans Abdominal Pre Peritoneal). This was a utrasectomy patient in his fourth recurrent hernia (!!! That is, three other surgeons had already operated on him by going through the anterior route, evidently without great results). Not an easy surgery, as expected, but successfully concluded to the patient's satisfaction. The mesh, as prescribed by the guidelines, is placed in the preperitoneal space, but without the large incisions required for Stoppa or Wantz techniques (in fact, the patient will be left with three small scars, two 10 mm and one 5 mm...).

The patient was discharged the day after surgery, and had no discomfort or complications in the postoperative period. These results are obtained in the vast majority of cases of patients operated on laparoscopically. But - I repeat - laparoscopic inguinal hernioplasty , especially in cases of recurrent inguinal hernia, is not for everyone, and must be performed by an experienced surgeon.

Enjoy your viewing!

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Dr. Salvatore Cuccomarino
Cuccomarino, MD
Medical Surgeon Specialist in General Surgery
Corso Galileo Ferraris 3
Chivasso,Turin
100034
EN
Phone 0110438161