500 total extraperitoneal approach laparoscopic herniorrhaphies: a single-institution review

At Georgia Baptist Medical Center, a community-based, university-affiliated hospital, we adopted the total extraperitoneal approach (TEPA) to laparoscopic herniorrhaphy due to potential complications in entering the abdominal cavity reported previously with the transabdominal preperitoneal technique (Am Surg 1996;62:69-72). We have also employed regional anesthesia (epidural) in 108 patients in whom the TEPA was utilized. In our institution, the TEPA has compared favorably to the transabdominal preperitoneal technique, with lower complication and recurrence rates. In patients with previous lower abdominal surgery, the TEPA is considered a relative contraindication due to the increased risk of complications (Am Surg 1997, in press). Since June 1993, we have performed 503 laparoscopic herniorrhaphies using the TEPA, with encouraging early results. To date, two recurrences have been reported, one with previous lower abdominal surgery and another whose recurrence was noted to be secondary to incomplete reapproximation of the mesh with staples around the cord structures. Four major complications include two bowel perforations and two cystotomies noted during balloon dissection of the preperitoneal space. Three of these patients had previous lower abdominal surgery. Epidural anesthesia was used in 108 patients, 4 of whom required conversion to general anesthesia due to peritoneal tears and pain associated with pneumoperitoneum. All four of these patients had previous lower abdominal surgery. In summary, the TEPA remains a viable technique for laparoscopic herniorrhaphy with acceptable complication and recurrence rates. Epidural anesthesia is well tolerated by the patients undergoing this particular repair. We feel that lower abdominal surgery may be a mitigating factor in selection of the TEPA. Continued re-evaluation of the procedure is warranted before definitive conclusions can be made.