How to Treat Recurrence After TEP

How to Treat Recurrence after TEP

George S. Ferzli, M.D., F.A.C.S.Professor of Surgery

SUNY Health Sciences CenterBrooklyn New York

George Al-Khoury,M.D.

THREE OPTIONS

– Open inguinal approach– TAPP– TEP

Repair of recurrences after endoscopic repair

Study Cases Primary TEP Repair

Felix 1998 34 11 TAPP 29Open 4

Knook 1999 34 9 TAPP

Leibl 2000 46 0 TAPP

Chowbey 2003 6 6 TAPP 4

Tamme 2003 23 23 TEP 2TAPP 3Open 18

Richards 2004 8 0 TEP 1Open 7

Ferzli 2004 12 12 TEP



















EERPE after TEP/TAPP

• Stolzenburg et al. (2005)

• 750 cases of endoscopic extraperitoneal radical prostatectomy (EERPE)

• 14 had prior laparoscopic hernia repair– 8 TEP (2 bilateral)– 6 TAPP

Stolzenburg J. et al: EERPE in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair. World J Urol 23:295-299, 2005.


• 1 conversion to transperitoneal approach– Prior bilateral TEP

• 2 bladder injuries managed intraoperatively– 1 prior TAPP– 1 prior TEP

• 1 inferior epigastric vessel injury



• More technically challenging – Access into extraperitoneal space

• Port placement modification

– Dissection of extraperitoneal space• Lymph node dissection is not recommended on

side or previous mesh placement• Recognize and manage complications early

• EERPE after TEP/TAPP is feasible for the experienced surgeon


TEP after TEP14-year experience

• September 1991 to September 2005

• 1526 TEP procedures done– 1156 male patients– 786 unilateral / 370 bilateral– 141 for recurrence (12.2%)– 21 of 141 recurrence were after prior TEP


• 22 TEP after contralateral TEP– Primary hernia repair 13 months – 12 years

prior– Mean operative time 36 min (20 – 100)– Mean age 56 years (35 – 84)


• 21 TEP after TEP– After 1995– 18 indirect hernias– 3 direct hernias– Mean operative time 47 min (31 – 120)– Mean age 52 years (29 – 79)

Results

• No bladder injuries– 1 suspected but none found– Jackson Pratt drain placed

• No bowel injuries

• No blood transfusions

• No preperitoneal hematomas

• No mortalities

• All discharged on the day of surgery

RESULTS

• Peritoneal tears– 7 of our patients (33%)– 1 leading to conversion

• 7 required ligation of epigastric vessels– 1 patient’s bleeding led to conversion due to

obscured operative field

Conversions to open

• 5 of 21 cases (24%)

• Reasons to convert:– Space of Retzius cannot be opened (3) – Peritoneal tear causes loss of working space

(1)– Bleeding obscures operative field (1)

PATIENT POSITION

BLUNT FINGER DISSECTION

LIMITED SPACE

7 STEPS

CARDINAL RULES

TOTAL ANATOMY

MESH PLACEMENT

EPIGASTRIC VESSELs

• NEED a drawing with epigastric vessels and hernia medial and lateral and also that if there is a hernia then there is no adhesions

INDIRECT

INDIRECT 2

DIRECT

Lipoma

Video tapes

Conclusion

• TEP after TEP is a feasible option

• Steep learning curve for TEP because of unfamiliar anatomy

• Key to successful TEP is knowledge of the anatomy

• Mastery of the anatomy recommended before attempting TEP after TEP

Conclusion 2

TEP technique – indirect hernia

• Management of sac– Invaginate and reduce– Transect and close proximal end

• Management of cord– Total parietalization with posterior wall is

necessary

TEP technique – indirect hernia

• Cord structures dissected in direction perpendicular to the structures

• Medial approach:– Sweep cord structures posteromedially while holding

sac superolaterally

• Lateral approach:– Pivot hernia sac medially and posteriorly, while

sweeping cord posterolaterally

• Alternate between medial and lateral approaches

TEP technique – direct hernia

• Redundant thickened transversalis and peritoneal sac are demarcated by rolled edge or fold

• Gentle traction and counter traction

• Rarely requires sharp dissection

• Clean adherent tissue off edge of hernia defect

To reduce hernia recurrence

• Mesh must fully cover all potential hernia defects

– Internal inguinal ring– Femoral canal– Hesselbach’s triangle– Obturator canal

TEP after TEP

• Blunt finger dissection and camera dissection– Keep camera in midline as anterior as possible– Dissection plane is anterior to old mesh

• Limited visualization– Small working space: Retzius and contralateral space

does not open up– Pubic tubercle obscured from view by adhesions– Branches of epigastric vessels ligated– External palpation and pulling on testicle to help

orientation

TEP after TEP

• Sharp dissection without cautery• Loss of anatomical landmarks• Epigastric vessels lead to the hernia

– Direct hernia medial to epigastric vessels– Indirect hernia lateral to epigastric vessels– If there is a hernia there will be no adhesions around

it.

• Dissection of sac as described for primary repair• Oversize Mesh placement


• Small case series • Technical choices

– Open tension-free Lichtenstein repair– TAPP

• Some have concluded that TAPP is the only possible endoscopic repair choice for these hernias– Liebl et al. (2000) – Felix et al. (1998)

TEP after TEP

• Technical concerns– Prior preperitoneal mesh placement

• Open and laparoscopic

– Re-entry of preperitoneal space limited– Experience of urologists and vascular

surgeons– Some cases impossible – Steep learning curve

TEP after TEP

• Tamme et al. (2003)• 5203 TEP repairs over 7.5 years• 29 of these recurred (0.6%)

– Recurrence rate of first 2 years 1.8% (n = 15/825) – Subsequent recurrence rate 0.3%

• 2 of 29 recurrences treated with TEP after TEP

• TEP recommended for recurrent hernias – but no specific comment on TEP after TEP

Tamme C. et al: TEP: Results of 5203 hernia repairs. Surg Endosc 17:190-195, 2003.

TEP after lower abdominal surgery

• Paterson et al. (2005)• Retrospective review• 47 patients with inguinal hernia• Prior lower abdominal surgery

– 20 appendectomy– 10 lower midline– 18 suprapubic– 5 paramedian

TEP after lower abdominal surgery

• TEP repairs for all 47 hernias– 35 unilateral – 12 bilateral

• 2 conversions to open• No complications• No early or late recurrences

• TEP can be carried out safely in the presence of scars from previous lower abdominal surgery

Paterson H. et al: Totally extraperitoneal laparoscopic repair in patients with previous lower abdominal surgery. Hernia June 24, 2005.


• Cause of recurrence– Missed hernia – Migration of mesh

TEP technique

• Positioning– Supine, slightly flexed, slight Trendelenburg– Arms tucked– Monitor at feet

• General endotracheal anesthesia• Rectus fascia incision over left or right

rectus muscle• Blunt extraperitoneal finger dissection in

midline toward pubic symphysis

TEP technique

• 3 ports– 10-mm infraumbilical camera port– 2 lower midline 5-mm ports

• CO2 insufflation to 10 mm Hg

• 10-mm 30-degree operative scope

• 5-mm trocars inserted under vision

• Sharp lysis of adhesions without cautery

TEP technique

• Anatomical landmarks– Midline pubic symphysis – Cooper’s ligament– Hesselbach’s triangle– Transverse abdominis muscle

• For better visualization– Divide small branches of epigastric vessels– Maintain excellent hemostasis

Health & Medicine

How to Treat Recurrence After TEP