Full text of DOI:10.1007/s004640090073

Surg Endosc (2001) 15: 1179–1183
DOI: 10.1007/s004640090073
©
Springer-Verlag New York Inc. 2001
Laparoscopic transperitoneal hernia repair of incarcerated hernias:
Is it feasible?
Results of a prospective study
B. J. Leibl, C. G. Schmedt, K. Kraft, B. Kraft, R. Bittner
Department of General and Visceral Surgery, Marienhospital, B o¨ heimstr. B o¨ heimstrasse 37, 70199 Stuttgart, Germany
Received: 28 September 2000/Accepted in final form: 21 December 2000/Online publication: 16 August 2001
Abstract
nique (TAPP) used for incarcerated inguinal hernias, differ-
entiating between acutely incarcerated hernias, which re-
quired emergency surgery, and chronically incarcerated her-
nias. This study sought to answer two questions: (a) Can the
situation of an incarcerated hernia be solved endoscopi-
cally? (b) Does the laparoscopic approach have any ben-
efits?
Background: Laparoscopic transperitoneal hernia repair
(
TAPP) has proved its efficiency in elective surgery. How-
ever, TAPP results with incarcerated hernias still are un-
known.
Methods: Data from a prospective study were evaluated
with regard to TAPP repair for both chronically and acutely
incarcerated hernias.
Results: During a 6-year period, 220 incarcerated hernias
were repaired (194 via TAPP). The median operation time
for TAPP was 55 min. An accompanying resection therapy
became necessary for only four of the emergency cases
Material and methods
After the introduction of TAPP, a prospective data bank was established at
the authors’ institution with the help of a special documentation team to
enable a close follow-up evaluation of patients.
Reports on the TAPP repair technique have been published by the
authors in several previous papers [2, 12, 13], so that there is no need for
another detailed presentation. Special features connected to irreducible
inguinal hernias, however, need to be specified. Because extensive paral-
lels exist in the endoscopic technical handling of acutely and chronically
incarcerated inguinal hernias, both situations receive a common discussion
in this report.
The reduction of the hernia contents must be given utmost priority in
the therapy of these hernias. If reduction by external manual pressure
should become possible with the patient under anesthesia, the familiar
standardized TAPP repair of the inguinal region could then be performed.
If manual reduction fails, the inguinal region will need to be dissected first
in the preperitoneal plane to present the so-called hernia ring. By applying
manual pressure to the inguinal region from outside while starting to dis-
sect the hernia sac, a reduction of the hernia contents becomes feasible in
some cases. In all the remaining cases, a reduction obstacle exists because
of a strong discrepancy between the size of the hernia defect and the hernia
contents.
After a precise dissection of the hernia ring in the preperitoneal plane,
the ring can be enlarged by an electrocauter incision in a ventral direction
The incision must be made in a ventromedial direction for medial hernias
and in a ventrolateral direction for lateral hernias, so injury to the femoral
and epigastric blood vessels can be avoided safely. After irrigation with
saline solution, the hernia contents are placed in the lower abdomen, and
the hernia repair typically is completed.
(
(
11.1%) and two of the chronically incarcerated cases
1.3%) in the TAPP group. Postoperative morbidity was
2
.8% in the emergency group and 3.8% in the chronically
incarcerated group, which does not differ from the rate for
TAPP used on reducible hernias. One recurrence was found
2
6 months after TAPP reconstruction (0.5%).
Conclusion: Laparoscopic inguinal hernia repair (TAPP)
represents an efficient therapeutic concept in the treatment
of both chronically and acutely incarcerated inguinal her-
nias.
Key words: Incarcerated inguinal hernia — TAPP repair
Epidemiologic data [23] on the prevalence and course of
inguinal hernia disease are scarce. Additional data on the
probability of an incarceration vary considerably (0.29–
2
.9%) in the literature [1, 5, 7, 15]. Except for case reports,
references to possible endoscopic therapy in the case of an
incarceration are unknown so far.
To evaluate this therapeutic alternative, we analyzed
prospective data on the transperitoneal endoscopic tech-
When the peritoneum has been closed again, the decision on a neces-
sary resection therapy can be made, depending on the vitality of the pre-
viously incarcerated organs. A resection is either performed intraperito-
neally or prepared endoscopically according to the guidelines for endo-
scopically assisted intestinal surgery. Adhesions, existing mostly in cases
Correspondence to: B. J. Leibl

1
180
Table 1. Treatment groups
TAPP
TAPP
AI (n ס 36)
n (%)
CR
CI (n ס 9)
n (%)
CR
AI (n ס 17)
n (%)
a
CI (n ס 158)
Nyhus type
n (%)
Female gender
39 (25)
8 (5)
38 (24)
50 (32)
26 (16)
43 (27)
13 (36)
4 (11)
11 (31)
11 (31)
7 (19)
3 (8)
2 (22)
4 (44)
1 (11)
1 (11)
3 (34)
0
7 (41)
5 (31)
4 (23)
0
4 (23)
4 (23)
II
IIIa
IIIb
IIIc
IV
a
Seven multiple counts because of multiple hernia defects
TAPP, laparoscopic transperitoneal hernia repair; CR, conventional repair; CI, chronically incarcerated
hernia; AI, acutely incarcerated hernia
Nyhus II, indirect hernia; NyhusIIIa, defect of dorsal wall of inguinal canal; Nyhus IIIb, indirect hernia
with defect of dorsal wall of inguinal canal; Nyhus IIIc, femoral hernia; Nyhus IV, recurrent hernia
of chronically incarcerated hernias, usually are not taken down. The hernia
contents instead of this, should be reduced en bloc.
indirect hernias, which was not statistically different from
the incidence of these defects in incarcerated hernias (Table
As with elective procedures, an antibiotic prophylaxis is applied for
incarcerated hernias. Obvious signs of intestinal gangrene with severe in-
guinal wall infection were seen as a contraindication for laparoscopic sur-
gery. The same contraindication also applied to patients unfit for an en-
doscopic procedure because of cardiologic or pulmonary problems. Data
from patients treated conventionally for these reasons (11.8%) also were
documented, but no comparison between endoscopic and conventional
repairs was performed. Statistically relevant results were calculated with
the help of the SPSS program for MS Windows Release 5.0, assuming a
significance p values less than 0.05.
1
). For incarcerated hernias, the patients’ preoperative his-
tory of hernia disease was 9 months (range, 0.1–600
months), whereas for elective surgery, it was found to be 6
months (range, 0.1–720 months).
Operation timing and procedure
The median operating time was 55 min (range, 20–270 min)
for each laparoscopic treatment group of incarcerated her-
nias, as compared with 53 min (range, 35–80 min) for
chronically incarcerated and 55 min (range, 30–129 min) for
acutely incarcerated hernias managed with conventional
treatment. On the other hand, the median time required for
TAPP repair in the elective surgery group of reducible her-
nias was 45 min, which was significantly shorter (p < 0.001)
than the duration of TAPP for incarcerated hernias. In the
TAPP groups there were 17 (9%) patients in whom an ad-
ditional procedure was performed (e.g., contralateral hernia,
incisional hernia, cholecystectomy). The kinds of hernia
content are presented in Table 2, and the techniques for its
reduction are presented in Table 3. Preperitoneal fat as her-
nia content was found significantly less frequently in the
emergency TAPP group than in the incarcerated hernia
TAPP group (p < 0.05), whereas the opposite was true for
the ileum (p < 0.001). The decision whether the hernia
contents needed to be resected was reached after inguinal
reconstruction in the TAPP groups. A resection became
necessary in four cases (2 omentum majus, 1 ileum, and 1
vermiform appendix: Table 4) of acute incarceration and
two cases of the chronic incarceration. The difference was
significant between TAPP in chronic incarceration and
TAPP in acute incarceration for frequency of ileum (p <
0.05) and “others” resection (p < 0.05). The indication for
resection therapy in the acutely incarcerated cases was
documented necrosis of the stricken organs. In the chroni-
cally incarcerated situation, the indication for resecting a
part of the omentum majus was malperfusion after difficult
reduction maneuvers.
Results
Within 6 years, 220 incarcerated inguinal hernias were sub-
jected to surgery, 53 (24.1%) of which required emergency
surgery. A TAPP repair was performed for 158 chronically
incarcerated hernias and 36 acute incarcerations. None of
these situations necessitated conversion to an alternative
surgical procedure. In 26 patients, a conventional anterior
repair was performed for logistical reasons or because there
were signs of bowel gangrene with severe inflammation of
the abdominal wall.
During the same period, 5487 additionally, cases of re-
ducible hernias were repaired by elective TAPP surgery.
The total prevalence of incarcerated hernias during this
6
-year observation period varied between 2% and 5% of all
inguinal hernias each year.
Operative findings and demographic data
Table 1 presents the distribution for the different types of
hernias, differentiating between the TAPP repair and the
Shouldice procedure on the one hand and chronically and
acutely incarcerated hernias on the other. In 16% to 33%
(
Table 1) of the cases, a femoral hernia was found with the
incarcerated hernia, whereby in 0.9%, the same was true for
reducible hernias (p ס 0.001). A scrotal hernia was seen in
6
7 (31%) incarcerated cases, as compared with 6% in the
elective surgery group (p ס 0,001). The rate of female
patients varied between 22% and 41% throughout the dif-
ferent groups with incarcerated hernias. During the obser-
vation period, the rate of female inguinal hernias in the
elective surgery group of reducible hernias was 8% (p ס
Complications
Postoperative complications are listed in Table 5. In the
TAPP group, a reoperation became necessary in one case
0.03). In the elective group, there were 43% direct and 57%

1181
Table 2. Hernia contents
TAPP
CI (n ס 158)
n (%)
TAPP
AI (n ס 36)
n (%)
CR
CI (n ס 9)
n (%)
CR
AI (n ס 17)
n (%)
Hernia contents
Omentum majus
Preperitoneal fat
Colon
62 (39)
50 (32)
31 (20)
8 (5)
8 (22)
4 (11)
7 (19)
15 (42)
0
1 (3)
1 (3)
0
3 (33)
5 (29)
2 (22)
0
1 (11)
4 (44)
0
0
0
0
0
Ileum
13 (77)
Ovar
1 (1)
0
Urinary bladder
Appendix vermiforis
Others
3 (2)
0
1 (1)
0
2 (3)
1 (6)
Note: Multiple counts possible
TAPP, laparoscopic transperitoneal hernia repair; CR, conventional repair; CI, chronically incarcerated
hernia; AI, acutely incarcerated hernia
Table 3. Reduction maneuvers of hernia contents
TAPP
CI (n ס 158)
n (%)
TAPP
AI (n ס 36)
n (%)
CR
CI (n ס 9)
n (%)
CR
AI (n ס 17)
n (%)
Reduction maneuvers
Reduction during anesthesia
Incision of hernia ring
Dissection of hernia sac
Total
18 (11)
68 (43)
13 (36)
20 (56)
3 (8)
0
2 (12)
3 (18)
12 (70)
17 (100)
4 (44)
5 (56)
9 (100)
72 (46)
158 (100)
36 (100)
TAPP, laparoscopic transperitoneal hernia repair; CR, conventional repair; CI, chronically incarcerated
hernia; AI, acutely incarcerated hernia
Table 4. Resection treatment of hernia contents
of incarcerated hernias, whereas 42 recurrences (0.7%) were
found in the reducible group (median follow-up period, 34
months).
TAPP
TAPP
CR
CR
Resection
treatment
CI (n ס 158) AI (n ס 36) CI (n ס 9) AI (n ס 17)
n (%)
n (%)
n (%)
n (%)
Omentum
Small bowel
Colon
2 (1)
2 (5)
1 (3)
1 (11)
3 (18)
4 (23)
1 (6)
Discussion
0
0
0
0
0
0
0
Others
No
1 (3)
32 (89)
36 (100)
0
At this writing, several prospective and randomized studies
have shown endoscopic therapy of inguinal hernias to be an
effective procedure in elective situations [2, 10–13, 20].
Apart from case reports [19, 20], no data on the routine use
of this surgical method for incarcerated hernias are known
to date. The following questions must be answered concern-
ing use of the endoscopic technique in this situation:
156 (99)
158 (100)
8 (89)
9 (100)
9 (53)
17 (100)
Total
TAPP, laparoscopic transperitoneal hernia repair; CR, conventional repair;
CI, chronically incarcerated hernia; AI, acutely incarcerated hernia
because of a mesh infection. A sump drainage was im-
planted anteriorly with subsequent inguinal irrigation, with-
out removal of the mesh. In no case with additional resec-
tion therapy did a deep infection occur. The incidence of
mesh infection in the reducible TAPP group was 0.1% (dif-
ference not significant). In the conventional treatment
group, reoperation became necessary in two cases for in-
fection and in one case for intra-abdominal hemorrhage af-
ter resection of the omentum majus. In the laparoscopic
groups there was one case of accidental colon puncture with
the Veress needle, which was remedied without any further
consequences by direct suturing. The total morbidity of
TAPP used for incarcerated hernias (Table 5) was not sta-
tistically different from that of TAPP used for reducible
hernias (2%).
1
. Is an endoscopic procedure under the outlined circum-
stances, which often are aggravated by an accompanying
intestinal obstruction, technically feasible as a routine
method?
2
3
. Can an additional resection be performed without con-
siderably increasing the risk for an infection of the ap-
plied mesh?
. Are there benefits for the endoscopic procedure?
As we already know from various studies [5], a dispropor-
tionate share of females and femoral hernias as well as a
shift to a higher age in patients with incarcerated inguinal
hernias can be found. This also was confirmed by the cur-
rent study. It is not yet clear, though, how the risk for an
incarceration must be rated for the direct or indirect hernias
Postoperative outcome
After a median follow-up of 26 months and a follow-up rate
of 86%, one recurrence was found after TAPP repair (0.5%)
[
22], the medial type of hernia supposedly showing a lower
incidence of incarceration [6, 22]. Although not significant,
the current study found a slightly higher tendency for in-

1
182
Table 5. Complications
TAPP
CI (n ס 158)
n (%)
TAPP
AI (n ס 36)
n (%)
CR
CI (n ס 9)
n (%)
CR
AI (n ס 17)
n (%)
Complications
Bleeding
0
0
0
0
0
0
0
0
0
0
0
1 (5,9)
Infection
1 (0,6)
1 (0,6)
1 (0,6)
1 (0,6)
2 (1,3)
0
0
2 (11,8)
Lesion of d. deferens
Testicular atrophy
Reoperation
Others
Thrombosis
Mortality
Total
0
0
0
0
0
3 (17,6)
0
0
1 (2,8)
0
0
0
1 (5,9)
7 (41,2)
6 (3,7)
1 (2,8)
TAPP, laparoscopic transperitoneal hernia repair; CR, conventional repair; CI, chronically incarcerated
hernia; AI, acutely incarcerated hernia
carceration of indirect hernias. Additionally, the risk for
incarceration was found to be significantly higher for scrotal
hernias.
The first case reports on the successful laparoscopic
treatment of an incarcerated hernia in combination with a
laparoscopically assisted intestinal resection were published
in 1993 [19, 21]. In all cases, the repair was performed in a
transperitoneal laparoscopic way.
As a consequence of the authors’ data, special attention
must be turned to the different ways of reducing the hernia.
In about half of all laparoscopically treated cases (Table 3),
a successful incision of the hernia ring in the preperitoneal
plane was possible, leading to an easy reduction of the
hernia content. With adherence to the previously described
technique, this step of the procedure can be recommended
as standard treatment for incarcerated hernias.
tion in 8 of 17 patients) by a selection of patients. In a few
cases, the TAPP procedure also allows the discovery of
additional intra-abdominal problems and their possible si-
multaneous treatment, as occurred with 9% of the cases in
this study.
Any surgical procedure for incarcerated hernias how-
ever, must be judged for its efficiency in avoiding compli-
cations and recurrences as well as for its practicability. De-
spite a significantly longer operating time for incarcerated
hernias, data suggest that for incarcerated hernias, TAPP
should be considered for repair. However, because TAPP is
a technically demanding procedure, it should be reserved for
surgeons who are more experienced in this technique. The
current data demonstrate that the morbidity risk with this
difficult condition is not increased. The mortality rate of 0%
compares favorably with data from conventionally treated
patients with incarcerated hernias [3, 4, 8, 17, 18]. This fact
can be explained possibly by the already familiar advan-
tages of endoscopic techniques with respect to postoperative
recovery [10, 11].
As mentioned earlier, reduction of the hernia and the
familiar reconstruction of the inguinal region with a con-
cluding hermetic peritoneal closure should precede a pos-
sible resection therapy. With 1 in 194 patients (0.5%) the
rate of infection is insignificantly higher than with reducible
hernias (0.1%). This fact is congruent with reports on con-
ventional preperitoneal hernia therapy in case of an incar-
ceration [14, 16]. According to our experience, an antibiotic
prophylaxis and peritoneal irrigation after the hernia reduc-
tion are advisable. In agreement with other authors, a con-
traindication to the implantation of a mesh, and thus to the
aforementioned procedure, is seen when advanced intestinal
necrosis with inguinal abdominal wall infection is present
If the problem of recurrence after TAPP is considered,
similarly low rates can be found for repair of both reducible
and incarcerated hernias.
The aim of this prospective study was to evaluate the
data for use of the TAPP technique in treating incarcerated
hernias to document the feasibility of the endoscopic pro-
cedure. The trial was not designed to compare conventional
and laparoscopic repair. With increasing experience in
TAPP repair for incarcerated hernias, even in emergency
situations, this technique currently is applied routinely at the
authors’ institution. It must be noted, however, that in cases
of incarceration, only a transperitoneal procedure appears to
be qualified for assessing and treating hernia contents.
[
14].
The advantage of laparoscopic therapy first of all is the
gain it offers in diagnostic safety. Particularly, pseudoincar-
cerations can thus be clarified and unnecessary “hernia re-
pairs” avoided. On the other hand, after the reduction of the
hernia, a meticulous assessment of the previously incarcer-
ated organs with respect to their vitality becomes possible,
leading to a definite decision on an additional resection. The
time needed for the reconstruction of the hernia can further-
more provide a sufficient recovery period for the incarcer-
ated organs, so that an unnessessary resection might be
avoided. This issue, which also is addressed by Ishihara et
al., [9] is supported by the data from the current study. An
intestinal resection became necessary in only 4 of 36 emer-
gency laparoscopic procedures. This however, possibly in-
fluenced the disadvantage of the conventional group (resec-
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