|HOW I DO IT
|Year : 2020 | Volume
| Issue : 2 | Page : 71-74
Laparoscopic total extraperitoneal obturator hernia repair in critical challenging patients
Junsheng Li, Xiangyu Shao, Tao Cheng, Zhenling Ji
Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing, China
|Date of Submission||27-Feb-2020|
|Date of Decision||06-Mar-2020|
|Date of Acceptance||13-Mar-2020|
|Date of Web Publication||11-May-2020|
Dr. Junsheng Li
Department of General Surgery, Affiliated Zhongda Hospital, Southeast University, Nanjing 210009
Source of Support: None, Conflict of Interest: None
AIM AND PERSPECTIVE: Obturator hernia is an uncommon surgical disease, a condition predominantly affected the elderly, emaciated, female patients. Various surgical procedures have been used to treat this disease, including open and laparoscopic approaches; however, in some special conditions, the technique is still challenging.
METHODS: The technique details of total extraperitoneal (TEP) repair in the treatment of obturator hernia in critical challenging conditions were described.
RESULTS: The challenging obturator patients had high risk of comorbidities, including massive ascites, partial intestinal obstruction, malnutrition, and previous abdominal surgeries. All the procedures were successful; patients had no modality and recurrences and chronic pain. One patient developed wound dehiscence and healed with bedside suture.
CONCLUSION: The present report justifies the feasibility of TEP obturator hernia repair in challenging conditions.
Keywords: Laparoscopic repair, obturator hernia, total extraperitoneal
|How to cite this article:|
Li J, Shao X, Cheng T, Ji Z. Laparoscopic total extraperitoneal obturator hernia repair in critical challenging patients. Int J Abdom Wall Hernia Surg 2020;3:71-4
| Introduction|| |
Obturator hernia is an uncommon but important category of abdominal wall hernia, which accounts for <1% of all hernias. Patients with obturator hernias are usually elderly, frail, and physically inactive women and are often associated with a variety of comorbidities, such as cardiovascular disease, chronic pulmonary diseases, malnutrition, and massive ascites., The majority of obturator hernia patients presented as intestinal obstruction with no previous operation,,, and the classical and pathognomonic Howship–Romberg sign occurred in only 25%–50% of patients, which characterized by the pain in the medial aspect of the thigh. A variety of approaches have been described for the treatment of obturator hernias, including open abdominal approach, obturator approach, laparoscopic approach, inguinal and retropubic approach, or the combinations of these approaches., The standard open approach carries a high risk of morbidity and mortality, especially in the elderly with compromised pulmonary and cardiac function., Laparoscopic technique is a major advance in the management of obturator hernia; favorable results have been reported in the literature. Laparoscopic obturator hernia repair can be accomplished either through the transabdominal preperitoneal approach (TAPP) or total extraperitoneal approach (TEP). TAPP has the advantage of making diagnosis and inspection of the bowel viability and can be performed in either elective or emergent situation. TAPP is also indicated as an exploration procedure in those patients without diagnosis made before the surgery.
During TAPP procedure, the peritoneal cavity has to be entered; however, in some conditions, such as the presence of massive ascites, intense intra-abdominal adhesion following previous operations, the TAPP procedure was not safe, or not feasible. The advantage of TEP procedure is that peritoneal cavity was not entered and was used in various indications; therefore, TEP approach is the appropriate alterative approach in patients to whom entering the abdominal cavity should be avoided. In the present study, we described the application of TEP procedure in the management of obturator hernias in patients with critical challenging condition.
| Methods and Results|| |
This group of patients had three patients associated with various critical challenging disease: the first patient was a 69-year-old malnutritional woman with bilateral obturator hernias, also had polycystic liver disease, and polycystic kidney disease with massive uncontrolled ascites (body mass index [BMI] 25.3) [Figure 1], [Figure 2], [Figure 3]; the second case was a 91-year-old female of left obturator hernia (BMI 19), and she had partial intestinal obstruction at the time of presentation; the third patient was a 76-year-old malnutritional woman (BMI 20.3), who had two times of abdominal surgery (intestinal resection anastomosis and appendectomy) and had suffered severe pain for the last 2 years, which could only be occasionally alleviated by pethidine. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this retrospective study, formal consent is not required.
|Figure 1: The port site in the markedly distended abdomen of the polycystic liver disease and polycystic kidney disease patient|
Click here to view
|Figure 2: Computed tomography scan showed the massive ascites and poly liver cysts reached the level of pelvic cavity|
Click here to view
|Figure 3: Computed tomography showed the bilateral obturator hernias (arrows)|
Click here to view
Technique aspects of total extraperitoneal procedure
The diagnoses of obturator hernias were confirmed by computed tomography scan. All the procedures were performed under general anesthesia. The access was obtained through the infraumbilical incision and retrorectus approach. Due to the very thin or distended abdominal wall of these patients [Figure 1], the operator's left index figure was inserted into the infraumbilical incision above the posterior rectus sheath to guide the placement of the second trocar. The second and third 5-mm working ports were placed in the midline with an equal distance from the umbilicus and pubic tubercle; the carbon dioxide pressure was set to 12 mmHg. The preperitoneal space was dissected gradually with the laparoscopic scope, without the use of a dissection balloon. The round ligament in the obturator hernia side was clipped and divided [Figure 4]. The preperitoneal cavity is dissected approximately 2 cm dorsally beyond the Cooper's ligament, and the obturator orifice was revealed after the obturator hernia sac was reduced [Figure 5]. Then, the obturator hernias were repaired with two pieces of three-dimensional lightweight polypropylene meshes (3D Max Light, BARD, USA), and the mesh sized 10.3 cm × 15.7 cm [Figure 6]. There was very little bleeding during the operations. The postoperative recovery was uneventful; the port sites are shown in [Figure 1]. The patients were discharged on postoperative day 3–5, and there is no wound infection. The first patient with massive ascites had the infraumbilical incision dehiscence due to high abdominal pressure and was re-admitted for incision suture, and discharged satisfied thereafter. No chronic pain and recurrence occurred in all patients during the follow-up period (3–22 months).
|Figure 6: Bilateral obturator hernias were repair with lightweight meshes (arrows indicated the reduced right and left hernia sacs)|
Click here to view
| Discussion|| |
Obturator hernia, also called “the skinny old lady hernia,” is a condition predominantly affecting the elderly, emaciated female patients. Risk factors for obturator hernias include a broader pelvis, wide obturator canal, and history of pregnancies. Various procedures have been reported for obturator hernia repair, including different types of open and laparoscopic approaches. Laparoscopy theoretically can shorten hospital stay, fasten postoperative recovery, and decrease perioperative cardiovascular and pulmonary complications. Although the advantage of laparoscopic repair is generally accepted, there is a wide difference in the indications between the methods of TAPP and TEP techniques. TAPP for obturator repair was well described by Tucker in 1995, which consists of a diagnostic laparoscopy and hernia reduction, followed by the elevation of peritoneal flap and placement of polypropylene mesh covering the obturator canal. TAPP has the advantage of making diagnosis and inspection of the bowel viability and can be performed in both elective and emergency and in those patients without diagnosis being made before operation; therefore, TAPP has wider indication than TEP and can be safely used in emergency cases for both diagnosis and treatment. In the present series, all patients were performed electively, and there was no need to detect the bowel viability. Therefore, TAPP was not used in the present cases.
In addition, the peritoneal cavity has to be entered and disturbed in TAPP, the prerequisite of TAPP procedure is the placement of laparoscopic instruments into the abdominal cavity at the umbilical level, and a sufficient intra-abdominal working space for manipulating the instruments; therefore, TAPP is obviously not suitable in patients with massive ascites and large and multiple liver cysts, which reached the level of the pelvic cavity (as in the first case).
Different opinions exist regarding the use of TEP for incarcerated obturator hernia repair, and TEP was believed not suitable for patients with intestinal obstruction or in patients whose bowel viability is not clear. However, TEP has the advantage of easy access to the obturator foramen, another notable advantage of TEP approach is that the procedure is performed completely in the extraperitoneal cavity, and the instruments ports could be placed far below the umbilicus level. In the present study, we described the technical aspects of TEP procedure in some challenging conditions; in the first case, the 69-year-old woman was emaciated by the long-standing polycystic liver disease and polycystic kidney disease, and she had massive ascites; in this condition, TAPP procedure or an open approach was obviously unacceptable. To avoid the injury to the enlarged liver cyst and also avoid the repair process being performed in the field of massive ascites, the TEP procedure was used.
Although obturator could be repaired by primary closure or covered with adjacent organ viscera such as the broad ligament of the uterus or ovary,, several recurrences occurred after such repairs. Hernia repair using prosthesis is generally thought to have a lower recurrence rate than repair without using prosthesis. It has been reported that recurrence rates at 3 years after obturator hernia repair were 0% for mesh repair and 22% for nonmesh repair (P = 0.048). Recently, using a prosthetic mesh for the repair of an incarcerated groin hernia is also considered safe, and the current trend in obturator hernia repair is using prosthetic mesh.
| Conclusion|| |
In the present study, we introduced the feasibility of obturator hernia repair in critical challenging condition with TEP technique. Our experience indicated that the TEP procedure in these cases was not only feasible but also safe and necessary.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stamatiou D, Skandalakis LJ, Zoras O, Mirilas P. Obturator hernia revisited: Surgical anatomy, embryology, diagnosis, and technique of repair. Am Surg 2011;77:1147-57.
Igari K, Ochiai T, Aihara A, Kumagai Y, Iida M, Yamazaki S. Clinical presentation of obturator hernia and review of the literature. Hernia 2010;14:409-13.
Avaro JP, Biance N, Savoie PH, Peycru T, Pauleau G, Richez P, et al
. Incarcerated obturator hernia: Early diagnostic using helical computed tomography. Hernia 2008;12:199-200.
Cali RL, Pitsch RM, Blatchford GJ, Thorson A, Christensen MA. Rare pelvic floor hernias. Report of a case and review of the literature. Dis Colon Rectum 1992;35:604-12.
Tchupetlowsky S, Losanoff J, Kjossev K. Bilateral obturator hernia: A new technique and a new prosthetic material for repair – Case report and review of the literature. Surgery 1995;117:109-12.
Martínez Insua C, Costa Pereira JM, Cardoso de Oliveira M. Obturator hernia: The plug technique. Hernia 2001;5:161-3.
Otowa Y, Kanemitsu K, Sumi Y, Nakamura T, Suzuki S, Kuroda D, et al
. Laparoscopic trans-peritoneal hernioplasty (TAPP) is useful for obturator hernias: Report of a case. Surg Today 2014;44:2187-90.
Murai S, Akatsu T, Yabe N, Inoue Y, Akatsu Y, Kitagawa Y. Impacted obturator hernia treated successfully with a Kugel repair: Report of two cases. Surg Today 2009;39:821-4.
Terada R, Ito S, Kidogawa H, Kashima K, Ooe H. Obturator hernia: The usefulness of emergent computed tomography for early diagnosis. J Emerg Med 1999;17:883-6.
Naude G, Bongard F. Obturator hernia is an unsuspected diagnosis. Am J Surg 1997;174:72-5.
Li J, Shao X, Cheng T. Laparoscopic total extraperitoneal superior and inferior lumbar hernias repair without traumatic fixation: Two case reports. Int J Abdom Wall Hernia Surg 2019;2:25-9. [Full text]
Tucker JG, Wilson RA, Ramshaw BJ, Mason EM, Duncan TD, Lucas GW. Laparoscopic herniorrhaphy: Technical concerns in prevention of complications and early recurrence. Am Surg 1995;61:36-9.
Maricevich M, Farley D. A pseudo-TEP repair of an incarcerated obturator hernia. Int J Surg Case Rep 2011;2:290-2.
Ng DC, Tung KL, Tang CN, Li MK. Fifteen-year experience in managing obturator hernia: From open to laparoscopic approach. Hernia 2014;18:381-6.
Karasaki T, Nomura Y, Tanaka N. Long-term outcomes after obturator hernia repair: Retrospective analysis of 80 operations at a single institution. Hernia 2014;18:393-7.
Sawayama H, Kanemitsu K, Okuma T, Inoue K, Yamamoto K, Baba H. Safety of polypropylene mesh for incarcerated groin and obturator hernias: A retrospective study of 110 patients. Hernia 2014;18:399-406.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]