Laparoscopic trans-peritoneal hernioplasty (TAPP) for the acute management of strangulated inguino-crural hernias: a report of nine cases.
BACKGROUND
Inguinal hernioplasty has always been one of the most commonly performed operations in clinical practice. In the last 15 years, thanks to the development of mini-invasive surgery, new video-endoscopic techniques for the treatment of inguinal hernia using trans-peritoneal (TAPP) and extraperitoneal (TEP) access have emerged. Both have a definite role in the treatment of bilateral and recurrent hernias, while the debate is still open about the treatment of primary mono-lateral hernias. In acute incarcerated hernia requiring an emergency operation, the endoscopic approach is uncommon and controversial, and even considered contraindicated. The aim of this publication is to verify the efficacy and the technical feasibility of TAPP operation by analyzing a consecutive series of patients operated on for incarcerated inguino-crural hernia associated with suspected visceral ischemic lesion in an emergency setting.


METHODS
From September 2004 to October 2005, 13 patients were operated on acutely for inguino-crural incarcerated hernia associated with suspected visceral ischemic damage. Four were excluded from the endoscopic treatment due to anesthesiologic contraindications or huge hernia dimensions. Nine patients were operated on using a trans-peritoneal approach (TAPP). Visceral mobilization and hernia reduction were obtained by incision and opening of the hernia ring. Visceral resection was performed in one case with intestinal ischemia following a prolonged observation time or "test time."


RESULTS
One case was associated with intestinal resection and incisional hernia repair, one with obturator hernia repair, and one with hepiployc appendix repair. None of the cases were converted to open technique, and no intra- or postoperative complications were recorded. Mean operative time was 72 min (35-180); mean hospital stay was 2.7 days (1-8). No recurrences were observed after a mean follow-up time of 18 months (8-24).


CONCLUSIONS
The TAPP procedure can be proposed for emergency treatment of inguino-crural incarcerated hernias, allowing not only hernia correction, but also visual control and the contestual treatment of the hernia content. TAPP is a more challenging procedure compared to the traditional open anterior approach and therefore requires an adequate laparoscopic training. Exclusion criteria are constituted by anesthesiologic contraindications or dimensional criteria of the hernia.
Legnani
G L
GL
General Surgery Unit, Policlinico San Pietro-Ponte San Pietro, Via Forlanini, 15, 24036 Ponte San Pietro, Bergamo, Italy. gianluca.legnani@grupposandonato.it
Rasini
M
M
Pastori
S
S
Sarli
D
D
D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D004630:Emergencies; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D006801:Humans; D007422:Intestines / Q000098:blood supply; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D013526:Surgical Mesh; D016896:Treatment Outcome