Inguinal hernia is a common disease that does not heal itself once it occurs and does not stop developing, but only gets worse. The larger the hernia is the later it is treated and the more likely it is to recur, so it must be treated as early as possible after the disease. The only way to cure the disease is to surgically repair the defect in the groin area.
Inguinal hernia repair surgery has undergone decades of development and has evolved from traditional tension suture repair to tension-free repair, both of which are open surgeries requiring non-absorbable sutures to maintain the strength of the abdominal wall, prone to recurrence, easy infection of the incision, and strong local foreign body sensation. At present, with the rapid development of lumpectomy technology, lumpectomy repair of inguinal hernia has a tendency to overtake open tension-free repair as the mainstream surgery, and in some larger hospitals, it has even surpassed traditional open surgery and become a routine procedure.
There are two types of laparoscopic hernia repair procedures: transperitoneal hernia repair (IPOM) and total extraperitoneal repair (TEP), which is the procedure that is the focus of this article. This procedure has the following disadvantages.
First, because of the large space in the abdominal cavity, the patch needs to be fixed with metal staples, which causes significant postoperative pain, and in some patients, the pain lasts for a long time. Due to the obstruction of the peritoneum, the local anatomical relationships cannot be seen clearly and there is a risk of nailing the patch to the blood vessels and nerves;
Secondly, the large intra-abdominal space increases the possibility of hernia recurrence due to easy displacement of the patch;
Third, the direct contact between the patch and the intestinal canal can increase the chance of abdominal adhesions and even intestinal obstruction and intestinal perforation; fourth, this procedure requires a double-sided patch (one side is smooth and touches the intestinal canal and the other side is rough and touches the peritoneum), and the material cost is very high, and even the cheapest patch costs about 10,000 yuan, which increases the economic burden of patients.
Because of the above disadvantages, this type of surgery is now less often used for inguinal hernia repair and more often used for incisional hernia repair.
Laparoscopic TEP surgery is a new surgical modality developed in recent years. Instead of entering the abdominal cavity, the TEP procedure creates a small space in front of the innermost layer of the abdominal wall, the peritoneal layer, into which the patch is placed to flatten and cover the defective area of the abdominal wall, so that the patch is sandwiched between the peritoneal layer and the other layers of the abdominal wall like a sandwich, without sutures or staples to fix it. The laparoscopic TEP procedure has considerable advantages over other surgical approaches.
(1) This procedure places the patch on the deep side of the abdominal wall defect, so that the patch is first subjected to pressure from the abdominal cavity, so it is closest to the normal physiological anatomy of the human body and most consistent with the principle of mechanical stress;
(2) This procedure can be completed by making only one 10mm and two 5mm incisions under the umbilicus, and the incisions are glued together, so the postoperative scar is very small and does not affect the aesthetics of the abdominal wall;
③The incision is far away from the surgical area and incision infection rarely occurs, which is more advantageous for diabetic patients because the incision is not easy to heal and the incidence of postoperative infection is high;
④Some patients have bilateral hernias, and this procedure allows bilateral hernia repair with the same incision;
⑤ There are three hernia sites in the inguinal region, and this procedure can repair these three sites at the same time to prevent the occurrence of other hernias in the future;
(6) No sutures or staples are needed to fix the patch, no nerve damage is possible, and there is no long-term postoperative pain;
(7) Since the space for surgical separation is small and the patch is held in place, even if it is not fixed by staples, the chance of displacement is small and the recurrence rate after surgery is extremely low;
(8) Since the patch is placed under direct lumpectomy, there is no cover of peritoneal layer, and the anatomical structure of local tissues and organs is clearly distinguished, so it is not easy to cause damage to other tissues;
The operation does not enter the abdominal cavity and the patch does not come into contact with the intestinal canal, which reduces the occurrence of abdominal adhesions and intestinal perforation of intestinal obstruction;
⑩Since the operation is less traumatic, patients recover quickly, and most of them can be discharged from the hospital 1-2 days after the operation.
When the surgeon has mastered the technique, it can be used to repair recurrent hernia, sliding hernia and even incarcerated hernia, which are more difficult to operate. Especially in recurrent hernia, the patient has changed the structure of the inguinal region after the previous surgery, the anatomical relationship is unclear, the defect area is large, and the abdominal wall is weak, so that another anterior approach surgery can easily damage the spermatic cord and affect fertility, and also has a high recurrence rate after surgery. The advantage of treating recurrent inguinal hernia with laparoscopic TEP technique is that instead of treating the operated area externally, a patch is placed internally to cover the defective area, which avoids the disadvantage of unclear anatomical relationship around the original inguinal canal and achieves the best placement of the patch from the mechanical and physiological anatomical points of view, thus greatly reducing the recurrence rate after surgery.
Laparoscopic complete extraperitoneal repair is currently the best surgical procedure in the world for the treatment of inguinal hernia, but this procedure has a long learning curve due to the difficulty of the operation and requires the surgeon to have more experience in open surgery as well as skilled laparoscopic surgical skills to deal with various situations that may arise during the procedure. The increased difficulty of the operation limits the popularity of this technique, and it is currently performed on a large scale only in some large hospitals in major cities.