Current guidelines recommend that surgical treatment of recurrent inguinal hernia should avoid the anatomical difficulties caused by the primary surgery, and that the recurrence repair should be done via a different surgical approach to that used during the primary repair.

1. CLINICAL VALUE OF THE
LAPAROSCOPIC
TRANSABDOMINAL
PREPERITONEAL TECHNIQUE
IN RECURRENT INGUINAL
HERNIA REPAIR
Dr/ Mohamed Tageldin Mohamed Sayed
GS Specialist
KFSH

2. Authors: Yuchen Liu, Yilin Zhu, Jinxin Cao, Jie Chen,
Zhenyu Zou, Minggang Wang
■ Received 16 June 2019,
■ Revised 23 November 2019,
■ Accepted 4 December 2019,
■ Available online 10 January 2020.
■ Published on Asian Journal of Surgery
■ By Department of Hernia and Abdominal Wall Surgery,
Beijing Chaoyang Hospital, Capital Medical University, Beijing,
PR China
a

3. Introduction
■ Inguinal hernia recurrence is a common problem. Previous
studies have reported recurrence rates after surgical treatment
of primary inguinal hernia ranging from 1.1% to 33.0% and that
re-recurrence of inguinal hernia after recurrence repair occurs
in 11.7% to 30.0% of patients.
■ Current guidelines recommend that surgical treatment of
recurrent inguinal hernia should avoid the anatomical
difficulties caused by the primary surgery, and that the

4. ■ Still, considering long learning curve, occurrence of special
complications, need for general anesthesia, and the associated
high cost, transabdominal preperitoneal (TAPP) technique is an
important choice to treat recurrent inguinal hernia.
■ Few studies have evaluated TAPP repair for recurrent hernias.
■ Clinically, there is still insufficient understanding, a low
prevalence rate, and a lack of experience with the TAPP
technique in the treatment of recurrent inguinal hernia. The
present study retrospectively analyzed the data of TAPP repair,
and explored its clinical value in the treatment of recurrent

5. Objective
■ To assess the clinical value of the laparoscopic
transabdominal preperitoneal (TAPP)
technique in recurrent inguinal hernia repair.

6. Methods
■ The clinical data of 354 patients with recurrent inguinal
hernia who underwent TAPP surgery from June 2010 to
June 2016 at the Department of Hernia and Abdominal
Wall Surgery, Beijing Chaoyang Hospital, Capital Medical
University, were retrospectively analyzed.

7. Exclusion criteria:
Excluded were those with
■ tissue repair primary
■ irreducible hernia
■ incarcerated hernia
■ contraindication cases for general
anesthesia/laparoscopy

8. Surgical procedure
■ The patients underwent general anesthesia and were placed
in the Trendelenburg position.
■ Pneumoperitoneum was established, and the air pressure
was maintained at 12–14 mmHg.
■ A 10-mm laparoscope was inserted.
■ Under laparoscopic monitoring, two 5-mm operating trocars
were inserted at the medioclavicular level of the umbilicus.

9. ■ Opening of the peritoneum was started above the hernial
opening and extended arcuately, and the preperitoneal space
and hernial sac were dissected.
■ A 10 cm × 15 cm piece of polypropylene mesh was used in all
but two patients, in whom biological mesh was used.
■ Biological mesh was chosen because the risk of contamination
from primary operation, including suture and mesh.
■ Complete anatomical dissection of the preperitoneal space was
carried out to enable flat placement of the mesh, which covered
the myopectineal orifice.

10. ■ The pneumoperitoneal pressure was reduced to 8–10 mmHg
during peritoneum closure to reduce the peritoneal tension
during suturing.
■ The peritoneum was sutured continuously using 3-0 VICRYL.
■ Exsufflation was performed under direct visualization, and
any trocar incision larger than 5 mm was closed in layers with
absorbable surgical suture.

11. Results
■ Laparoscopic surgery was successfully completed in all 360 patients.
■ Among them TAPP were finished in 354 patients, while TAPP repair were
attempted but finally converted to open or TAPE repair in 6 patients.
■ The mean operation time was 54.7 ± 19.4 min (range 30–90 min),
■ mean duration of hospitalization was 4.7 ± 2.1 days (range 2–14 days),
■ mean duration of follow-up was 37.7 ± 12.4 months (range 12–60
months).
■ The rate of intraoperative injury was 4.5% (16/354),
■ the rate of postoperative complications was 13.6% (48/354).
■ No patient developed a foreign body sensation, wound infection,
intestinal obstruction, mesh infection, or chronic pain.
■ Two patients (0.6%) developed re-recurrence requiring reoperation, with
no further recurrence.

12. Discussion
Risk factors for recurrent inguinal hernia
■ There are numerous risk factors for the development of recurrent
inguinal hernia, including sex, age, tobacco use, high intra-
abdominal pressure (history of COPD or prostatectomy), collagen
metabolism, and limited surgical experience.
■ We found that most recurrences had occurred in a different location
to the primary hernia, mostly because the mesh was too small or
improperly placed, and so the mesh was not placed flat and

13. TAPP repair for recurrent inguinal hernia
■ Laparoscopic operations provide very good exposure of the complete
surgical field, enabling the surgical treatment of direct, indirect, and
femoral hernias with a very high degree of accuracy, less postoperative
pain, rapid recovery, and fewer complications compared with the open
repair.
■ Laparoscopic technology can provide clear visualization that not only
helps to confirm the diagnosis, but also ensures real-time adequate
observation of the surgical site, which enables the surgeon to confirm the
suitability of the surgical plan and ensure the safety of the operation.
■ In laparoscopic TAPP repair, the abdominal cavity is filled with CO2,
providing adequate space for the operation; furthermore, the surgical
incision is small and is not located in the groin area, resulting in minimal
postoperative pain, rapid recovery, and few wound infections.
■ TAPP repair is reportedly as safe and effective as open tension-free repair
of recurrent inguinal hernias, and has been included by many experts as a
surgical option for recurrent inguinal hernia.

14. ■ However, we need to emphasize that recurrent hernia repair is
complicated and extremely difficult, especially after a failed repair via the
posterior repair; to avoid serious consequences, it is essential to strictly
understand the surgical indications, standardize the procedure, prevent
iatrogenic damage, and ensure that minimal force is used intraoperatively.
■ In our study, 16 patients experienced vascular, bladder, and spermatic
cord injury caused by severe adhesion of the anterior peritoneal space and
intraoperative anatomical displacement.
■ All 16 patients had either experienced recurrence at least twice, or had
undergone primary repair via the open preperitoneal repair.
■ In such patients, the anatomical structure of the inguinal region is unclear,
and the peritoneal space is densely adhesed and easily damaged during
the dissection.
■ No serious long-term complications or sequelae occurred in the present
series.

15. Operation details in TAPP for recurrent inguinal hernia
■ When using the TAPP technique for recurrent inguinal hernia
repair, surgeons should strictly follow the guidelines and
operational procedures.
■ It is especially important to achieve sufficient overlapping of the
myopectineal orifice to prevent re-recurrence.
■ We found that we were able to establish adequate
preperitoneal space in most patients by following the
laparoscopic surgical procedures and performing careful
dissection.
■ Compared with primary repair via the anterior approach (such
as plug repair, open preperitoneal repair, and the Lichtenstein
procedure) and via the posterior approach (such as laparoscopic
preperitoneal repair), the preperitoneal space in hernia

16. ■ The recurrence rate of TAPP repair for primary inguinal hernia
was low in our department.
■ However, using TAPP for recurrence after posterior repair is
still a challenging surgical procedure for us.
■ We recommend that TAPP repair for recurrent hernia after
posterior repair should only be used with extreme caution
and strict adherence to the surgical indications and
contraindications.
■ Surgical treatment should be tailored to the surgeon's
expertise and to patient- and hernia-related characteristics to

17. Establishment of preperitoneal space
■ The peritoneal flaps must be dissected to create the
preperitoneal space.
■ The establishment of the peritoneal space and dissection of
both peritoneal flaps are the most important and difficult steps
in recurrent hernia repair via the TAPP repair.
■ Unlike in primary hernia repair, the inguinal region is unclear
and the peritoneal space is densely adhesed in patients with
recurrent inguinal hernia, which makes the establishment of the
preperitoneal space extremely difficult.

18. Treatment of the hernial sac
■ The treatment rules for the recurrent hernial sac are consistent
with primary hernia repair.
■ Complete mobilization of the hernial sac from the cremasteric
structures should be based on patient- and hernia-related
factors.
■ However, we consider that the occurrence of postoperative
seroma may be related to the treatment of the hernial sac. In
our series, postoperative seroma occurred in 27 patients, most
of whom had undergone transection of the hernial sac without
removal of the distal sac.
■ In the two patients who underwent conversion to open surgery,
the distal hernial sac was removed, and there was no obvious
postoperative seroma. However, further study is required to

19. Mesh placement
■ The requirements for mesh placement in recurrent hernia repair are
the same as for primary hernia repair.
■ It is recommended that a new mesh with sufficient overlapping of
the myopectineal orifice is placed, instead of incising and bridging
with the previous mesh.
■ In our study, two patients had a localized small abscess in the
primary mesh fixation using silk suture. Hence, biological mesh,
which is superior in contaminated fields, was used after the septic
foci were completely removed. These two patients recovered well,

20. Mesh fixation
■ The mesh fixation is especially important in recurrent hernia repair.
■ Insufficient mesh fixation may lead to early mesh displacement, mesh
folding, or mesh shrinkage, which may cause re-recurrence.
■ We spray chemical glue on the mesh, which is then pressed gently against
the underlying tissue; we use tacks for mesh fixation in patients with a
large medial hernia (hernia defect ≥ 3 cm), multiple recurrent hernias, or
recurrence after TAPE repair.
■ Irrespective of which fixation method is used, sufficient overlapping of the
myopectineal orifice is essential.
■ It is already widely known that tacks must not be placed in the regions of
the Doom triangle, and the lateral femoral cutaneous nerve, as this can
cause bleeding and severe complications such as postoperative pain.
■ The glue should be sprayed on the edge of the mesh, in spots as small as
possible, as tissue ingrowth in these areas is limited until the glue
degrades.

21. Intraoperative and postoperative complications
■ Intraoperative complications included abdominal wall vascular injury,
spermatic cord vascular injury, bladder injury, vas deferens injury and
intestinal injury were found in our study.
■ Abdominal wall vascular injury most caused by processing of Trocar
puncture. It is necessary of direct-vision during entering and extraction of
Trocar.
■ Spermatic cord vascular injury, bladder injury, vas deferens injury and
intestinal injury usually caused by adhesion between mesh and tissue. So a
experienced surgeon may avoid these kinds of injury possible than a junior
one.
■ The factors associated with chronic pain after hernia repair are the
performance of surgery by a surgeon with limited experience, the
application of tacks in the preperitoneal area during mesh fixation, and
excessive fixation.
■ In our series, 10 patients developed postoperative pain. They were all

22. Conclusion
■ Based on our experiences so far and the relevant literature and
guidelines, we conclude that TAPP repair for recurrent inguinal
hernia should only be performed by experienced surgeons in
strict accordance with the indications and contraindications of
the operation.
■ TAPP is recommended for recurrent hernia after anterior repair.
TAPP repair may also be an alternative treatment for recurrent
hernia after repair via the posterior repair; however, there is a
lack of adequate evidence-based support for this indication.
Our data suggests that the TAPP technique is particularly

23. Thank you