MINISTRY OF EDUCATION AND TRAINING

MINISTRY OF HEALTH

HANOI MEDICAL UNIVERSITY

DO MANH TOAN
APPLICATION OF LAPAROSCOPIC TRANSABDOMINAL
PREPERITONEAL ON INGUINAL HERNIA TREATMENT WITH
ARTIFICIAL MESH IN VIET DUC HOSPITAL
Major: Surgical Gastroenterology
Code: 62720125

THESIS SUMMARY
Thesis advisors:
1. Assoc.Prof-D.M. Nguyen Duc Tien
2. Assoc.Prof-D.M. Trinh Van Tuan

HA NOI – 2019


Thesis was completed at:
Ha Noi Medical University
Thesis advisors:
1. Assoc.Prof-D.M. Nguyen Duc Tien
2. Assoc.Prof-D.M. Trinh Van Tuan.

Reviewer 1:
Reviewer 2:
Reviewer 3:


TAPP procedure is easier to learn and to master the technique; the operative
conversion rate is lower and the procedure’s education curve is shorter
thanks to a larger operation areas. However there are some potential
postoperative complications of approaching the abdominal cavity like organs
injury, trocar’s port hernia, bowel obstruction...We conducted the research:
“Application of laparoscopic TAPP on inguinal hernia treatment with
artificial mesh in Viet Duc Hospital” with 2 targets:
1. Describe the indications and applications of laparoscopic TAPP to
inguinal hernia treatment.
2. Evaluate results of laparoscopic TAPP treatment of inguinal hernia
with artificial mesh.
STRUCTURE
The thesis include 127 pages, 36 tables, 10 charts, and 111 references (71
foreign documents). Introduction: 2 pages; literature reviewing 34 pages,
research subjects and methodology 23 pages; results: 23 pages; discussion :
42 pages; conlusions : 2 page and suggestions 1 page.


2
NEW CONTRIBUTIONS OF THE THESIS
Our study involved 95 male patients with 104 hernias treated with
laparoscopic TAPP using artificial meshes in Viet Duc Hospital from October
of 2015 to April of 2018
This is the first research about applying and evaluating results of
laparoscopic TAPP treatment of inguinal hernia in Vietnam.
Indication: TAPP procedure can be used to treat most inguinal hernia
types in adults.
In terms of applying TAPP procedure: 100 % patients underwent
general endotracheal anesthesia and the procedure was done in 6 steps. We
used 3 trocars in 97.9 % cases and 4 trocars in 2.1 % cases. Preperitoneal

area from the intraperitoneal route include:
- Surgical layers: peritoneal, Transverse fascia, transversus abdominis
muscle.
- The median umbilical fold, the medial umbilical fold, the lateral umbilical fold
- Praeperitoneal space: include preperitoneal retropubic space (space of
Retzius) and extraperitoneal space posterior to the transverse fascia (space of
Bogros)
- Anatomical structures in the extraperitoneal space: nerves, vessels, the vas
deferens/the round ligament of the uterus, Cooper’s ligament, Iliopubic tract
1.1.3. Anatomical application in TAPP
Laparoscopic surgeons emphasized structures in the dangerous triangle:
triangle of doom and the triangle of pain, which can be damaged
intraoperatively.
1.2. Physiobiology of the groin
There are 2 mechanisms that protect the abdominal walls from hernia
formation:
- Shutter mechanism at the inguinal canal of the internal oblique aponeurosis
and transversus abdominis muscle
- Squeezing action at the internal ring
1.3. Pathophysiology of inguinal hernia
Causes leading to inguinal hernia
- present of patent processus vaginalis
- Muscles and facias of inguinal walls are weaken
- Failure of Shutter mechanism at the inguinal canal
- Abdomnial cavity pressure increase
1.4. Hernia classifying: Gilbert’s, Rutkow and Robbins, and Nyhus’
classifications.
1.5. Diagnosis: based on clinical symptoms and ultrasonic images.
1.6. Inguinal hernia repair with TAPP technique
1.6.1. Indication and contra-indication

1.7.1. Researches on indication and surgical technique
Litwin and others (1997) declared: The procedure can be carried out for
indirect, direct, femoral or combined hernias, both primary and recurrent.
Incarcerated hernias can usually be reduced and repair performed in standard
fashion. Strangulated hernias can also be repaired provided the contents are
reducible and sterile. The operative approach was similar for all hernias.
Relative contraindications to the TAPP procedure included the following:
unsuitability for general anesthesia; age under 18 years; multiple previous
lower abdominal operations; an intraabdominal inflammatory process, such as
active Crohn’s disease; previous intra-abdominal preperitoneal surgery, such as
retropubic prostatectomy; and strangulated hernia with necrotic gut. About the
procedure, 3 trocars were used: a 12-mm port was placed in the subumbilical
position, a 10- mm port was placed on the side of the hernia and a 5-mm port
on the contralateral side. A curvilinear incision was made in the peritoneum,
starting laterally and carried superomedially to the level of the obliterated


5
umbilical vessel (lateral umbilical ligament). A flap of peritoneum was created
medially by blunt dissection inferiorly to expose Cooper’s ligament. An
indirect sac was usually reduced by blunt dissection, but if the sac was large it
can be transected with electrocautery. 10 × 14-cm piece of Marlex mesh was
used. It was placed as flat as possible against the abdominal wall, and the
indirect, direct and femoral spaces were covered broadly. The mesh was stapled
to Cooper’s ligament and to the superomedial and superolateral corners.
Reperitonealization was carried out by stapling the peritoneal edges together.
In 2014 Memon and his research partners highlighted the advantages of
TAPP in cases of recurrent hernia, bilateral hernia and hernia discovered
accidentally while treating another disease with laparoscopic surgery. In terms
of technique, Memon’s procedure was similar to Litwin’s except for: usage of

minutes; pain levels after surgery were mild (86.08 %), medium (11.25%) and
severe (2.67%). Epigastric vessel injury was seen intraoperatively in 1.98 %
cases. Early postopetative complications included: Inguinal seroma (1.99%),
scrotal hematoma (1.32%), urinary retention (4.63%), testicular effusion (1.32
%). Long term complication was pins and needles at the groin (3.31 %).
Recurrent rate was 0.66 %.
RESEARCH SUBJECTS AND METHODOLOGY
2.1. Research subjects
95 over -18 – year – old – male patients that were diagnosed with
inguinal hernia ( first time hernia, recurrent hernia, one-side and bilateral
hernia, direct, indirect and combination hernia), and that had ASA score of I,
II or III, and that were treated with laparoscopic TAPP at Viet Duc Hospital
from 10/2015 to 04/2018.
* Exclusion criterias
- Serious internal disorders like cardiac failure, respiratory failure, COPD,
blood clotting diseases.
- Recurrent hernia after TAPP, TEP and Lichtenstein procedures
- Multiple previous lower abdominal operations; previous intra-abdominal
preperitoneal surgery, such as removal of ureteral - pelvic segment stone
- Intra-abdominal inflammatory process, such as active Crohn’s disease...
2.2. Research methodology
2.2.1. Research design: prospective descriptive interventional study.
2.2.2. Sample size calculation
The sample size was calculated using the following formula:
n = Z²(1-α/2)

p(1- p)
Δ²

where n is the required sample size

* Follow up
- Pulse, blood pressure, temperature.
- Postoperative pain: assessing pain level with VAS scale.
- Recovery after surgery (movement, normal daily activity, hospitalization
length)
- Early complications and management: surgical site infection, subcutaneous
emphysema, urinary retention, Inguinal seroma and hematoma, Testicular
effusion, bowel obtruction, trocar port hernia, mesh infection
* Patient care after surgery: changing bandages; use analgesics and
antibiotics.
2.2.3.6. Patient follow up after hospital discharge
- Follow up after 3 months, 12 months and further postoperatively via email,
telephone and dicrect examining.
- Content : Late complications, including pain or pins and needles at the
groin area, painful testicular and spermatic cord, loss of libido, postoperative
bowel obstruction, port hernia, mesh infection, allergy to mesh, recurrence


8
2.2.4. Research variables
2.2.4.1. Clinical characteristics of researching group: age, genders, job,
disease duration, BMI, combined diseases, reasons for hospital admission,
clinical symptoms.
2.2.4.2. Inguinal hernia classifications
- Type of inguinal hernia (primary / recurrent hernia),
- Hernia position (left / right side or bilateral hernia).
- Anatomical relation type (direct / indirect / Pantaloon hernia); Nyhus’s
classification (type 1, type 2, type 3A, 3B and type 4A, 4B)
2.2.4.3. Operation technique
- Anesthetiazation : general endotracheal anesthesia

- Evaluation of long term result was based on Trinh Van Bao’s standard
+ Very good: no complication, no recurrence
+ Good: pain or pins and needles at the groin area, painful testicular and
spermatic cord healed by internal treatment.
+ Medium: loss of libido, postoperative bowel obstruction, port hernia, mesh
infection, allergy to mesh, recurrence
+ Bad: recurrent hernia
2.2.4.5. Relations
- Relation between direct/ indirect inguinal hernia and age /BMI
- Relation between hernia position and surgical time, time of recover to daily
activity and to work, length of hospital stay
- The relevance between direct/indirect hernia and perioperative complication.
2.2.5. Data analysis
We used SPSS software version 16.0 to analyse the data.
Convention on patients with bilateral hernia: symptoms were recorded
once (intra / post-operative complications and findings of re-examination after
surgery).
Chapter 3
RESULTS
From 10/2015 to 04/2018 we applied 104 laparoscopic TAPP repairs for 95
hernia patients and found the following results.
3.1. General characteristics of researching group
3.1.1. Age and genders: 100 % patients were male at the average age of 50.6
y/o (19 – 86). Inguinal hernia was seen the most commonly in group of patients
aged from 50 to 70 y/o, with 34.7 %.
3.1.2. Patient’s job: Light workload (54.7%), heavy workload (25.3%) and
others (20%).

Chart 3.1. Patient’s job
Comment: Percentage of patients who had light workload was 54.7%.

1
1.1
Total
13
13.8
Comment: 13.8% had undergone a lower abdomen surgery previously.
3.1.8. Clinical symptoms
Major symtom was a lump in the groin (84.2%); hernia lump in the
scrotum was seen in 15.8%. All patients had larger superficial ring.
3.2. Inguinal hernia classification
3.2.1. Primary and recurrent inguinal hernia
Table 3.5. Primary and recurrent inguinal hernia
Types of inguinal hernia
Number of patients
Percentage
Primary hernia
85
Left side
6
Recurrent
Right side
3
hernia
Bilateral
1
Total
95
Comment: Most cases (89.4%) were primary hernia.

89.4

Type 4A
4
3.8
Type 4B
6
5.8
Total
104
100.0
Comment: Nyhus’s 3 was the type that was the most common among research
patients. 9.6 % cases was Nyhus’s 4 (recurrent hernia).


12
3.2.5. ASA classification

Chart 3.7. ASA classification
Comment: there were 93.7% patients, whose ASA score were I and II.
3.3. Factors related to the application of TAPP
3.3.1. Anesthetiazation : 100 % general endotracheal anesthesia
3.3.2. Locations and number of trocars used
Table 3.7. Locations and number of trocars used
Locations and number of trocars Number of patients Percentage
2 trocars 10mm – 1
70
trocar 5mm
3 trocars
1 trocar 10mm – 2
23
trocars 5mm

Bilateral hernia
1 mesh
Total

Mesh size
(10-15 x 15)cm
(6-10 x 1014)cm
(10-15 x 15)cm
(6 x 11) cm
(8 x 15)cm
(10 x 20)cm

Number
of patients
80

Percentage
84.2

6

6.3

5
2
1
1
95

5.2

Pantaloon hernia case (120-340 minutes).
3.4.2. Intraoperative complications
There were 2 complications during operation, which included 1 case of
Epigastric vessel injury – 1.1 % and 1 case of bladder injury on a bilateral
inguinal hernia with recurrent hernia on the right patient (1.1 %) because of
abdominal adhesions.
3.4.3. Postoperative complications
Table 3.12. Postoperative complications
Postoperative complications
Number of patients Percentage
surgical site infection
1
1.1
subcutaneous emphysema
1
1.1
inguinal seroma
4
4.2
inguinal hematoma
3
3.1
painful testicular and spermatic cord
3
3.1
Total
12
12.6
Comment: Early postoperative complication were obsered in 12.6 % cases
included inguinal seroma (4.1 %) and hematoma (3.1 %), painful testicular and

35.8
4
4.2
38
40.0
1 days
38
40.0
4
4.2
42
44.2
2 days
10
10.5
0
0.0
10
10.5
3 days
4
4.2
1
1.1
5
5.3
≥ 4 days
86
90,5
9

(days)
23
24.2
4
4.2
27
28.4
1 – 3 days
45
47.4
4
4.2
49
51.6
4 – 6 days
18
18.9
1
1.1
19
20.0
≥ 7 days
86
90.5
9
9.5
95
100.0
Total
4.8 ± 2.0

patients

%

Number of
patients

%

8
8.4
0
0.0
8
8.4
3 days
33
34.7
2
2.1
35
36.8
4 days
27
28.4
5
5.3
32
33.7
5 days

Timing of
One side hernia
Bilateral hernia
General
return to
(n = 86)
(n = 9)
(n = 95)
Number of % Number of %
Number of
%
work
patients
patients
patients
(weeks)
37
38.9
7
7.3
44
46.2
1 - ≤ 2 weeks
23
24.2
1
1.1
24
25.3
3 - ≤ 4 weeks

Table 3.25. Long term postoperative complication


17
Long term
postoperative
complication

3 months

12 months

n

%

n

%

Chronic inguinal pain

5

5.3

7

7.5


3
3.3
spermatic cord
Loss of libido
3
3.1
3
3.2
3
3.3
Total
17
17.8
17
18.2
11
12.1
On the 3rd month of postoperative period 11 patients (11.6%) had pain and
regional numbness at inguinal area and the number of patients who complained
about painful testicular and spermatic cord and loss of libido were both 3
accounting for 3.1 %.
After 12 months 02 of the mentioned inguinal-pain-and-numbness-patients
no longer felt numbness but only pain, which reduced the number of patients
with inguinal pain to 07 patients (7.5%) at this time.
At the time of the last follow-up visit in July 2018, which was 18.4 months
after surgery on average, 03 patients had no more pain and 03 patients did not
have any symptoms of numbness. Thus, the total number of patients with
chronic pain and inguinal numbness was 5, accounting for 5.5%.
3.5.2. Recurrency
- Number of patients who had inguinal numbness and pain were 05 (5.3%).

hernia was seen in 33.2 % and both sides hernia was seen in 28.1 %. In Baca’s
report in 2000. 38.7 % inguinal hernia were on the patient’s right side; 33.2 %
were on the left side and 28.1 % were on 2 sides. Our observation, which was
shown in chart 3.5, resulted that the rate of left inguinal hernia was higher than
that of right inguinal (47.4 % compared with 43.1 %) and the rate of bilateral
inguinal hernia was 9.5 %.
4.2.3. Type of inguinal hernia
Studies have shown that TAPP surgery can be used for any type of hernia.
Mayer et al (2016) showed the rate of indirect hernia was 60.34%. the rate of
direct hernia was 28.79% and saddlebag hernia rate was 10.87%. Chart 3.6
gave information that indirect hernias occurred in 57.7% cases. direct hernia
occcurred in 36.5% cases; and saddlebag hernia occurred in 5.8% cases.
Eventually no surgical conversion was required in our research.
4.2.4. ASA classification
There are various options of surgical treatment for inguinal hernia.
Laparoscopic TAPP surgery required general endotracheal anesthesia. so
surgeons often apply the procedure for patients whose ASA score ranged from I
– III. Muschalla studied 787 patients and their ASA score was I in 26.2 %. II in
61.3 %. III in 11.5 % and IV in 1.1 %. In our research TAPP technique was
indicated to those with ASA I (40.0%). ASA II (54.7%) and ASA III (6.3%)
(chart 3.7).
4.2.5. Previous incision at lower part of the abdomen
An agreement was made among surgeons that laparoscopic approach in
TAPP procedure had more advantage in cases who had previous lower


19
abdominal operations compared to anterior approach in open surgery. Because
the laparoscopical operation area did not relate to any tough tissue bands of the
scar so there would be less complication. As shown in table 3.3 there were 10

surgeon could cut the hernia sac at the internal inguinal ring level. and left the
distal part of the sac where it was. Chart 3.8 showed that we treated hernia by
pulling the sac into the abdomen in 86.3% cases and cut the hernia sac in
13.7% cases.
4.3.5. Mesh size
The majority of authors said that in TAPP surgery. the artificial mesh must
be sized (10 x 15) cm to ensure that the mesh covered fully all possible
herniation positions. thus limiting recurrence. Table 3.8 informed that in the


20
one side hernia group we used mainly (10-15 x 15) cm mesh accounting for
84.2%; mesh sized (6-10 x 10-14) cm usage accounted for 6.3%. In bilateral
inguinal hernia we used two separate meshes (7.3%) or a large one that covered
from the right to the left (2.2%).
4.3.6. Mesh placement and fixation methods
In order to put an artificial mesh into the preperitoneal cavity easily. we
curl the mesh like a cigarette roll to a half of the mesh. using a single knot of
vicryl 3/0 to fix the mesh before rolling the rest of it and put it into the
abdomen through the 10mm trocar. The mesh was spread on the spermatic cord
in a way that all angles of the mesh was located under the peritoneum and the
mesh covered all the possible hernia positions as well as overlapped on the
fixation points (Cooper ligaments; 2cm beyond hernia position). Today. the
issue of mesh fixation is still being debated. Many authors have proved that the
main cause of recurrent hernia is not non-fixed meshes but many other factors
such as technical errors. hernias omission. small mesh usage. ... We made
fixation with protacks in 60.0% patients; suturing in 15.8% patients and we did
not fix the mesh in 24.2% cases.
4.3.7. Reperitonealization and ports closure technique
Most authors closed the peritoneum with running suture Vicryl to make

blood vessels and nerves injury. However. recent studies have noted that when
the surgeon is proficient in laparoscopic surgery. the rate of these complications
is low. Jacob et al (2015) showed the incidence of complications in one-sided
and bilateral inguinal hernia groups are respectively: bleeding (0.99% and
0.84%); vascular lesions (0.31% and 0.33%); intestinal lesions (0.13% and
0.14%); bladder injury (0.14% and 0.99%). In our research. intraoperative
complication included bleeding from the epigastric vascular - 01 patient (1.1%)
. which was processed by clips; bladder injury -1 patient (1.1%) due to scarring
of the preperitoneal space of the recurrent hernia patient; the injured bladder
was sutured with 2 layers and the urinary catheter was maintained in 11 days.
4.4.3. Postoperative complications
After TAPP surgery. common complications were inguinal seroma.
inguinal hematoma. swelling and painful testicular. subcutaneous emphysema
Inguinal regional seroma is caused by rough careless dissection that
damaged blood vessels. lymphatic vesels in the pre-peritoneal space.
Moldovanu had 6% of his research group suffering from seroma. In our
research there 04 inguinal seroma patients (4.2%).
Inguinal hematoma is often caused by rudimentary careless hernia sac
dissection from the spermatic cord or lack of hemostatic control with small
blood vessels in the preperitoneal space. Le Quang Hung’s data: inguinal
hematoma (2.2%). scrotal hematoma (1.1%). Our study had 03 inguinal
hematoma patients accounting for (3.1%).
Spermatic cord pain may occur due to the femoral genital nerve injury or
sympathetic nerve of the testicle when the the hernia sac is removed from the
spermatic cord. Our rate of this complication was 3.1%. These patients were
treated with anti-inflammatory and analgesic drugs.
4.4.4. Level of pain after surgery
Most studies reported that pain after TAPP surgery was usually at mild and
moderate pain level and that the level of pain decreased with time. Trieu Trieu
Duong’s result: mild and very mild pain (86.08%). moderate pain (11.25%).

4.5.1. Long term complications
In 2007 Nienhuijis and his team reported that the rate of patients who had
chronic pain was 11 % and that the rate of inguinal numbness was 9% after
inguinal hernia repairs that used artificial mesh. However, the pain and
numbness level was mainly mild and reduced gradually so patients did not need
any drugs to release the symptoms. In 2016 Muschalla and his team reported
results of following up their patients in 5 years that the rate of inguinal pain was
4.35 %, which included mild pain 2.77 %. medium pain 0.99% and severe pain
0.59 %. According to our findings shown in tbale 3.25, inguinal pain and
numbness was seen in 11.6 % patients on the 3rd month after surgery. The date
decreased to 5.3 % after average 18.4 months of following up. Trocar port
hernia and bowel obstruction complications were both rare in most researches.
We did not observed any patients that had these complication after following up
our patients in 18.4 months on average. In a group of 787 patients (1010
hernias) studied by Muschalla and his team there was 3.18% cases of port
hernia and 0.1 % cases of bowel obstruction.
4.5.2. Recurrent hernia
According to Lowham. recurrent rate after TAPP procedure was 0 – 2 %


23
and the second time hernia occurred mostly in the 1st year of postoperation.
Our rate of recurrence was 2.2 %.
4.6. Short term and long term result evaluation
4.6.1. Short term result evaluation
95/95 patients (100.0%) were followed up after the surgery.
The short term result was evaluated as “very good” (85.3%), “good”
(4.2%), “medium” (10.5%) and “bad” (0%).
4.6.2. Long term result evaluation
91/95 patients (95.8%) were followed up after the surgery.