Prevention and recovery for peritoneal injury during totally extraperitoneal inguinal hernia repair: A single-center retrospective cohort study

Abstract

Background During totally extraperitoneal (TEP) repair, peritoneal injury (PI) may result in technical difficulty due to the imparied working space inside the preperitoneal space. We aimed to clarify the factors causing PIs by focusing on the size of the hernia and to provide the prevention and recovery method for PI.Methods A total of 71 inguinal hernia with unilateral TEP repairs were classified by the size of hernia; Small group (<1cm, n=16) and Large group (≧1cm, n=55). Patient characteristics and surgical outcomes were analyzed retrospectively. TEP procedure was broke down into five phases (e.g. Phase 3 was a period from starting the dissection to transection of hernia sac) in the PI cases of the Large group (n=21). Common site of PI, maneuver and recovery method were further analyzed.Results Operative time (P<0.0001) and PI rate (P=0.015) were higher in the Large group. PI cases in the Large group showed a higher PI rate in Phase 3 (P=0.036) and PI mostly occurred by a sharp dissection of the medial side of hernia sac with using an ultrasonically activated device. In terms of recovery methods, pre-tied suture loop ligation and endoscopic suturing tended to be faster than doing nothing and conversion to TAPP but showed no significance (P=0.059).Conclusions Hernia size and a sharp dissection during the medial side of the hernia sac may be important factors causing PIs. A careful dissection combined with an appropriate blunt dissection is required for the prevention of PI because of the strong adhesion at the medial side and thin peritoneum in most cases of large hernia sacs. In cases of PI, extension of operative time could be prevented by ligation or suturing of the peritoneal defect.