Lobo, S. Hallazgo inesperado de cáncer de ovario en cirugía laparoscópica sobre masa anexial. Seclaendosurgery.com (en línea) 2003, no, 3. Disponible en Internet: http://www.seclaendosurgery.com/seclan3/art03.htm. ISSN: 1698-4412.
time has passed that there is now a substantial number of patients
with failed preperitoneal laparoscopic hernia repairs needing treatment.
We all know the reasons-limited experience of the original surgeon,
incomplete dissection, missed hernias, missed lipomas of the cord,
insufficient size of the prosthesis, insufficient overlap of the
prosthesis over the hernia defect, improper fixation in cases where
fixation was needed because of the size of the hernia, lifting of
mesh laterally and mesh migration especially in medial recurrences
(1). Most surgeons feel that the logical approach to such a patient
is to perform a conventional herniorrhaphy in the conventional inguinal
space. Makes sense! The conventional operation is safe and effective
and the surgeon is able to work in undissected tissue. So should
laparoscopic re-repair ever be considered?
Well, there are two groups of patients in whom the question is legitimate:
1) The multiply recurrent hernia patient where both spaces have
already been dissected and 2) The patient who insists on an endoscopic
re-repair by virtue of personal preference. The latter most commonly
comes up when the patient has had a previous conventional repair
on the opposite side.
One might make a case that surgeons should simply refuse the patients
request. However, several groups have devised specific surgical
strategies for approaching recurrent preperitoneal hernias laparosocpicaly
(2-4). These include general anesthesia, transabdominal approach
(no place for the TEP here!), three laparoscopic cannullae at the
level of the umbilicus, redissection of the preperitoneal space
leaving the old prosthesis in situ followed by completion of the
coverage of the myopectineal orifice with a new prosthesis. If no
hernia is evident from the laparoscopic vantage point, a pseudo
recurrence consisting of a lipoma of the cord or an encapsulated
seroma may account for the clinical findings.
Felix has suggested that a small counter incision in the groin is
best in this situation to avoid the difficult preperitoneal dissection
but others prefer to address these from the preperitoneal space
(2). Medial recurrences which are invariably near the pubic tubercle
are treated by opening the peritoneum at least 3 cm above the hernia
defect in unscarred tissue. Dissection proceeds medially and inferiorly
widely opening the space of Retzius to the opposite tubercle. It
is necessary to identify the opposite tubercle because this will
assure sufficient overlap by a new prosthesis. By staying in unscarred
tissue while identifying and freeing the bladder one avoids injury
to the structure which is the major complication. Once the space
of Retzius is opened, dissection proceeds laterally across the ipsilateral
pubic tubercle and the hernia defect. It is difficult to separate
the peritoneum from the old prosthesis but nevertheless is relatively
safe because there are really no structures in harms way until the
internal ring is reached. Once sufficient overlap is achieved, a
new prosthesis is fastened in place. Lateral recurrences are more
difficult because of the scarring at the internal ring caused by
the old prosthesis and the recurrent sac. Bittner opens the preperitoneal
space above the hernia defect and gets behind the previous prosthesis
so that an en bloc mobilization of peritoneum and prosthesis from
the transversalis fascia can be accomplished (3). Dividing the inferior
epigastric vessels facilitates this. The identification and mobilization
of the lateral hernia sac can then be safely done after separation
of the cord structures. A new mesh is then slit and positioned around
the cord in the opposite direction of the original. A second unslit
mesh is placed over the first again reinforcing the entire myopectineal
orifice. Finally, the prosthesis must be covered. Peritoneum is
best but sometimes it is so shredded that an omental flap is necessary.
So just who should be performing these operations? Any surgeon who
has attempted this difficult procedure knows the significant risk
for complications including bladder injury, damage to the cord structures
and even major vascular injury. Indeed the most experienced group
in the world with this procedure reported two bladder injuries and
one cord damage in 46 patients (6.5%). Although admittedly self-serving,
I believe this procedure should only be performed in specialty centers
with sufficient experience.
- Lowham AS, Filipi CJ, Fitzgibbons
RJ Jr, Stoppa R, Wantz GE, Felix EL, Crafton WB. Mechanisms
of hernia recurrence after preperitoneal mesh repair. Traditional
and laparoscopic. Ann Surg 1997 Apr;225(4):422-31.
- Félix EL. A unified
approach to recurrent laparoscopic hernia repairs. Surg Endosc
- Leibl BJ, Schmedt CG, Kraft
K, Ulrich M, Bittner R. Recurrence after endoscopic transperitoneal
hernia repair (TAPP): causes, reparative techniques, and results
of the reoperation. J Am Coll Surg 2000 Jun;190(6):651-5.
- Knook MTT, Weidema WE, Stassen LPS, van
Steensel CJ. Laparoscopic repair of recurrent inguinal hernias
after endoscopic herniorrhaphy. Surg Endosc 13:1145-1147 (1999).