This is the case of a 75-year-old Japanese woman who presented with black vomiting of 5 days’ duration. Physical examination revealed a right inguinal bulge and sharp pain. Computed tomography revealed a right strangulated femoral hernia with no intestinal ischemia...
Posted July 7,2019 in General Medicine.
Surgical treatment of inguinal and femoral hernia has radically changed over the years. Recently, discussions on inguinal and femoral hernia repair have focused not only on the rate of recurrence but also on chronic pain [1,2]. Laparoscopic repair is associated with less postoperative pain, faster return to normal activities, and less chronic pain than classic open, tension-free mesh repair . Totally extraperitoneal hernia repair (TEP) and the transabdominal preperitoneal approach (TAPP) are effective methods of laparoscopic primary inguinal and femoral hernia repair. In TAPP, we can diagnose the type of hernia by intraperitoneal observation. However, covering the hernia with a big mesh is difficult, and the field of vision is limited by the intestinal tract. In TEP, the covering mesh and the field of vision are not influenced by the intestinal tract; however, intraperitoneal observation cannot be performed. In cases of intestinal incarceration, intraperitoneal observation may be necessary to confirm the presence of intestinal damage after reduction. Because the intestinal tract is expanded by the ileus, securing a clear field of vision is difficult. In this situation, TEP is useful for the surgical procedure. Hence, using the advantages of TEP and TAPP is important for the treatment of femoral hernia in patients at risk of intestinal ischemia and is complicated with ileus. Hence, we performed single-incision totally extraperitoneal hernia repair with intraperitoneal inspection (iSTEP) in our patient with this presentation .
Compared with the conventional anterior approach, laparoendoscopic repair results in less postoperative pain, fewer postoperative complications, lower recurrence rates, early discharge, and faster return to normal daily activities . However, Kckerlinget al.reported that univariable and multivariable analyses did not reveal any significant difference between TEP and TAPP with regard to intraoperative and perioperative complications . TEP and TAPP have advantages and disadvantages, and it is important to use TEP and TAPP properly based on individual cases. In our patient, treatment with only TEP or TAPP was difficult.
We compared the advantages and disadvantages of each procedure. In TAPP, intraperitoneal observation can diagnose the type of hernia and confirm repair after the application of the covering mesh. However, covering with a proper big mesh and dissecting the abdominal wall side are difficult, and the field of vision is limited if the intestinal tract has adhesion. Additionally, Gasset al.reported that the postoperative length of hospital stay after TAPP was longer than that of TEP . Meanwhile, wide dissection is possible in TEP; furthermore, application of the covering mesh and dissection of the abdominal wall side are easy. Some studies have reported lower pain in TEP, because the mesh is placed from the outside of the peritoneal cavity [8,9]. However, it is impossible to diagnose the type of hernia or confirm repair after the application of the covering mesh because intraperitoneal observation cannot be performed. Furthermore, the operative time is longer than that of TAPP because of the increased difficulty in dissection and limited workspace [5,7]. However, it is difficult to evaluate this factor because it is often dependent on the surgeon . In our patient, intraperitoneal observation was necessary to check for intestinal nonischemia. In the case of incarcerated femoral hernia, the viability of the bowel segment is determined on the basis of color, peristalsis, and congestion. If observation of the intraperitoneal cavity reveals an intestinal incarceration in the femoral hernia sac, forceps are inserted from the same incision site, and the intestine is returned to the abdominal cavity without increasing the number of trocars used. Moreover, if intestinal ischemia is present, intestinal resection is required with a multichannel access port in the peritoneal space at the same umbilical incision.
However, securing a clear field of vision was difficult in our patient because of ileus. Hence, we performed iSTEP to use the advantages of TEP and TAPP. In iSTEP, intraperitoneal observation can diagnose the type of hernia and confirm mesh coverage in cases where the hernia extends not only to direct and indirect inguinal lesions but also to femoral and obturator lesions. Furthermore, it is possible to view the inguinal region without overlooking coexisting lesions, and extensive dissection, covering with the mesh, and dissection of the abdominal wall side are easy through intraperitoneal observation in combination with iSTEP . Additionally, because it is a laparoendoscopic single-site surgery, all the procedures can be performed using the same incision. Hence, intraperitoneal operation and preperitoneal operation can easily be changed to obtain excellent cosmetic outcomes. Although the operative time is longer than that of conventional procedures and multiport laparoscopic surgery, the blood loss is equivalent, and the outcome is excellent with respect to postoperative complications [11,12,13]. Mesh repairs may result in no recurrence and may reduce the time until normal daily activities are resumed. However, nonmesh repair is less likely to cause infection. Therefore, the type of repairmesh or nonmesh repairshould be carefully selected for the treatment of strangulated femoral hernia with bowel resection .
We report a case of a patient who underwent successful iSTEP for strangulated femoral hernia who was at risk for intestinal ischemia after repositioning.