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CHALLENGES TO THE 10 GOLDEN RULES FOR A SAFE MINIMALLY INVASIVE SURGERY (MIS) INGUINAL HERNIA REPAIR: CAN WE IMPROVE?
Christiano Claus1, Leandro Totti Cavazolla2, Marcelo Furtado3
1Minimally Invasive Surgery Department, Jacques Perissat Institute, Positivo University, Curitiba, Brazil.
Background:
Since publication of our paper "Ten Golden Rules for a Safe MIS Inguinal Hernia Repair" we have received many questions. As the authors, we feel it is important to address these topics as a follow-up to our paper.
Aim:
To discuss in more details the main points of controversy, review the rules and update de recommendations.
Method:
The questions and discussions came mainly over five rules, numbered 3, 5, 6, 7, 10. We analyzed all the comments about recommendations and update some technical principles.
Results:
Rule 3 - Removing normal fat plugs from the obturator canal is unnecessary and therefore is not recommended; Rule 5 - transection of the uterine round ligament (1 cm proximal to the deep ring) facilitates adequate dissection. When performed in this way it does not appear to be associated with complications; Rule 6 - transection of huge sacs are safer than over-dissection of the cord structures. Whether dissecting completely the sac or abandon the distal part it results in less postoperative seromas is an ongoing debate; Rule 7 - any retroperitoneal structure traversing the internal ring is or play a role like a hernia. Failing to identify and remove the lipoma will ultimately result in the patient experiencing a recurrence; Rule 10 - in TAPP peritoneum should preferably be closed with suture than tackes.
Conclusion:
10 Golden Rules emphasize the most important surgical tips and technical steps that allow the safe performance of MIS repairs of inguinal hernias, regardless the technique.
