POLSKI PRZEGLĄD CHIRURGICZNY 2014, 86, 2, 73–76

10.2478/pjs-2014-0013

Simultaneous TAPP (transabdominal pre-peritoneal technique) for inguinal hernia and cholecystectomy – a feasible and safe procedure Andrzej Lehmann1, Jacek Piątkowski2, Mariusz Nowak2, Marek Jackowski2, Maciej Pawlak1, Mieczysław Witzling1, Maciej Śmietański1 General and Vascular Surgery Department, Ceynowa Hospital in Wejherowo1 Kierownik: dr M. Witzling Department of General Gastroenterological and Oncological Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń2 Kierownik: prof. dr hab. M. Jackowski Inguinal hernia repair and cholecystectomy are amongst the most common surgical procedures performed worldwide. In the recent decades, early disease detection has notably increased due to easily accessible ultrasound. The aim of the study was to assess the safety and the possibility of performing a simultaneous hernia repair and cholecystectomy using the laparoscopic approach. Material and methods. Eight patients (M=100%) with inguinal hernia (3 with bilateral hernia) and cholelithiasis were included in the study. The presence of gallstones was confirmed by imaging. Mean age of the patients was 61.75 years (ranging from 47-72). Simultaneous laparoscopic cholecystectomy and transabdominal pre-peritoneal hernia repair was performed in all patients. Postoperative complications were analyzed to assess the safety and feasibility of the procedure. Results. Mean operating time was 55 minutes (ranging from 30-60) and average length of stay was 3.625 days (ranging from 2-7). In order to perform a cholecystectomy, 1-2 additional trocars were used. No intra-operative complications were observed. At a follow-up visit on postoperative day 7, a small hematoma (10 ml of blood was punctured) in the right groin was noted in one patient. Another patient developed fever postoperatively, treated conservatively with antibiotics. Conclusions. Simultaneous TAPP and cholecystectomy proved to be a safe and feasible procedure. Acceptable operating time and hospital stay, as well as lack of influence on the length of convalescence, may present an interesting alternative to two separate procedures Key words: TAPP, transabdominal pre-peritoneal technique, laparoscopic cholecystectomy, simultaneous

Simultaneous TAPP (transabdominal preperitoneal technique) for inguinal hernia and cholecystectomy – a feasible and safe procedure Inguinal hernia repairs and cholecystectomies are the most common surgical procedures performed worldwide. In the recent decades, early disease detection has notably increased due to easily accessible ultrasound. Today laparoscopic cholecystectomy is the gold standardtreatment globally (1). The prevalence of cholecystectomy varies widely

across Europe, ranging from about 80-250 per 100 000 population (2). It is estimated that 20 million hernia repairs are performed every year worldwide. The number of the procedures varies, depending on the region, and the estimates range from 100-300 per 100 000 people annually (3). The possibility of a simultaneous hernia repair and cholecystectomy using the laparoscopic approach became the topic of much debate during the 2012 meeting of the Polish Hernia Society. We observed that reports in

Unauthenticated Download Date | 8/22/15 9:24 PM

74

A. Lehmann et al.

the currently available literature on the safety of performing the two procedures simultaneously are inconclusive (4). Since we are of the opinion that both procedures may be undertaken simultaneously, a retrospective analysis of the patients who underwent the surgeries was carried out to assess the safety of the procedure. Material and methods A. Patients Eight surgeries in patients with diagnosed inguinal hernia and gallstones were performed at the Department of General Surgery, Wejherowo Hospital for Specialized Surgery, and the Department of General Surgery, Toruń County Hospital, between October 2007 and November 2012. Simultaneous cholecystectomy and inguinal hernia repair was performed with the use of the TAPP (transabdominal pre-peritoneal) technique. Patients’ characteristics together with hernia classification according to the European Hernia Society (EHS) are presented in tab. 1 (5). All patients were male, aged from 47 to 70 years. Three patients werediagnosed with bilateral hernia, four cases with direct (medial) inguinal hernia (M2) and four cases with indirect (lateral) inguinal hernia (one case L1, three cases L2). B. Surgical technique The procedures were performed under general anesthesia, in supine position. The patients were placed in the Trendelenburg or the reverse Trendelenburg positions, depending

on the operated area. All patients were administered a single intravenous dose of antibiotics preoperatively. Typically, hernia repair was performed first, followed by a cholecystectomy. According to the standard procedure, three trocars were inserted at the umbilical level (10 mm – the optical trocar, 5 mm – two working trocars): first the safe, umbilical trocar, next the following trocars, under visual control. In most cases the basic anatomic landmarks (medial umbilical ligament, lateral umbilical ligaments, deep inguinal ring, anterior superior iliac spine, superficial abdominal veins, structures of the spermatic cord) were identified. Other important structures such as Cooper’s ligament, pubic bone, femoral ringbecame visible only after the pre-peritoneal space was revealed. The surgical technique was in accordance with the recommendations of the International Endohernia Society (IEHS) (6). The pre-peritoneal space was closed with stapling. Table 2 presents types of meshes, their size and fixations used during the procedure. Next, the patients were placed in the reverse Trendelenburg position and, depending on the operating conditions and technical problems, an additional working trocar was introduced. Table 3 demonstrates the number and size of the trocars used during the entire procedure, together with the additional port of entry. In each case the standard surgical technique was used and Calot’s triangle was exposed. The cystic duct and the cystic artery were identified and clipped with titanium clips. The gall-bladder was then dissected from the liver bed and removed. In the event of the gall-bladder perforation, copious amounts of saline solution were used

Table 1. Patients’ characteristics (1 – symptomatic cholelithiasis, 2 – asymptomatic cholelithiasis) Patient no

EHS classification

1 2 3 4 5 6 7 8

M2 L2 M2 M2 L2 L1 M2 L2

Side bilateral right right left bilateral bilateral right left

Age (years)

Gender (male)

Gall-stones

67 70 51 47 58 61 72 68

M M M M M M M M

1 2 1 1 1 1 1 2

Unauthenticated Download Date | 8/22/15 9:24 PM

Simultaneous TAPP (transabdominal pre-peritoneal technique) for inguinal hernia and cholecystectomy

75

Table 2. Characteristics of meshes Patient no

Type of mesh

1 2 3 4 5 6 7 8

UltraPro Bard3D Mesh UltraPro UltraPro UltraPro UltraPro UltraPro Prolene

Mesh size (cm x cm) 9 x 14 10,3 x 15,7 13 x 10 10 x 15 10 x 14 9 x 13 10 x 15 10 x 14

Table 3. The number, size and location of the trocars Number of trocars 4 3 4 3 4 4 4 4

10 mm 1 – 1 – 1 1 1 1

5 mm – – – – 3 3 3 3

Location epigastrium – epigastrium – epigastrium epigastrium epigastrium epigastrium

for the irrigation of the peritoneal cavity. A Redon drain was always left in the gall-bladder bed. On postoperative day 7, patient mobility and level of satisfaction were evaluated. The patients were assessed for the presence of postoperative complications (infection, swelling, hematoma) and pain. Due to the fact that it was an observational study, no statistical analysis was performed. The arithmetic mean was used to summarize the results (Microsoft Excel software). Results Mean operating time was 55 minutes (30-60 minutes), with average length of stay of 3.625 days (2-7 days). No intra-operative complications and/or on postoperative day 7 were noted in 6 out of 8 patients. In 1 patient a small hematoma was found in the right groin and evacuated through a single puncture incision (10 ml of bloody fluid was evacuated) on postoperative day 7. The second patient developed fever postoperatively, not connected to surgical site complication, treated conservatively withantibiotics, and was released home in good overall condition after 7-day hospital stay.

Type of stapler SecureStrap Sorbafix SecureStrap EHS Endohernia Endohernia Endohernia Endohernia

Discussion Laparoscopic cholecystectomy has unquestionably become the method of choice in gallbladder surgery. Disease detection rates are very high due to easily accessible ultrasound. Also, inguinal hernias are more frequently detected owing to the ultrasound examinations. We noticed a significant number of patients with cholecystolithiasis and accompanying inguinal hernia or hernias. Simultaneous procedures remain to be relatively rare, thus the literature offers few reports and on small groups of patients. Sarli in his a prospective randomized study discribed thirty low-risk patients with symptomatic chronic calculous cholecystitis and synchronous primary unilateral inguinal hernia who undergo TAPP and LC (7). The results described did not differ from reported by us in our material.According to our findings and literature review we are of the opinion that a simultaneous technique is safe and beneficial for the patients. In the other authors studies we did not find advice on the prioritization exercise routines, but we think. notably, it is important to start with the hernia repair and follow with cholecystectomy as that particular order of events prevents contact between bile and mesh in case of gallbladder perforation. However, this is only our opinion, which is not confirmed in clinical research papers. Average length of hospital stay after laparoscopic cholecystectomy is 1 to 3 days (8, 9, 10) and 1-4 after TAPP (11, 12, 13). The simultaneous procedure does not prolong the convalescence and hospital stay when compared to two separate surgeries. Two separate treatments would require 2 separate admissions to the hospital, 2 operations, and twice the cost and potential morbidity and mortality.

Unauthenticated Download Date | 8/22/15 9:24 PM

76

A. Lehmann et al.

Conclusions The method is safe and offers a possibility to surgically fix two pathologies with the use of four trocars at the most. We also believe that

the combination of the two procedures is an interesting alterative to currently used algorithms and the obtained results further support our thesis, compelling us to make this technique more widespread.

References 1. Bittner R: The standard of laparoscopic cholecystectomy. Langenbecks Arch Surg 2004; 389: 15763. 2. Paat-Ahi G, Swiderek M, Sakowski P et al.: DRGs in Europe: a cross country analysis for cholecystectomy. Health Econ 2012; 21 Suppl 2: 66-76. 3. Kingsnorth AN, LeBlanc KA: Management of abdominal hernias. 3rd ed. London, New York: Edward Arnold, 2003: 40-47. 4. www.hernia.pl (streszczenia zjazdowe, Kongres PKP Maciejewo 2012) 5. Miserez M, Alexandre J H, Campanelli G et al.: The European hernia society groin hernia classification: simple and easy to remember. Hernia 2007; 11(2): 113-16. 6. Bittner R, Arregui ME, Bisgaard T et al.: Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (InternationalEndoherniaSociety (IEHS)).Surg Endosc 2011; 25(9): 2773-2843. 7. Sarli L, Villa F, Marchesi F: Hernioplasty and simultaneous laparoscopic cholecystectomy: a prospective randomized study of open tension-free versus laparoscopic inguinal hernia repair. Surgery 2001; 129(5): 530-36. 8. El-labban Gouda, Hokkam Emad,El-labban Mohamed et al.: Laparoscopic elective cholecystec-

tomy with and without drain: A controlled randomized trial. J Minim Access Surg 2012; 8(3): 9092. 9. Kurpiewski W, Pesta W, Kowalczyk M et al.: The outcomes of SILS cholecystectomy in comparison with classic four-trocar laparoscopic cholecystectomy. Wideochir Inne Tech Malo Inwazyjne 2012; 7(4): 286-93. 10. Shea JA, Healey MJ, Berlin JA et al.: Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis. Ann Surg 1996; 224: 609-20. 11. Sato H, Shimada M, Kurita N et al.: The safety and usefulness of the single incision, transabdominalpre-peritoneal (TAPP) laparoscopic technique for inguinal hernia. J Med Invest 2012; 59(3-4): 235-40. 12. McCormack K, Wake BL, Fraser C et al.: Transabdominalpre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review. Hernia 2005; 9(2): 109-14. 13. Wang MG, Tian ML, Zhao XF et al.: Effectiveness and safety of n-butyl-2-cyanoacrylate medical adhesive for noninvasive patch fixation in laparoscopic inguinal hernia repair. Surg Endosc 2013 10. (Epubahead of print).

Received: 26.11.2013 r. Adress correspondence: 84-200 Wejherowo, ul. Jagalskiego 10 e-mail: [email protected]

Unauthenticated Download Date | 8/22/15 9:24 PM