Berney C R
Bankstown-Lidcombe Hospital, University of New South Wales, Bankstown, NSW, 2200, Australia.
Hernia. 2017 Oct;21(5):737-743. doi: 10.1007/s10029-017-1632-9. Epub 2017 Jul 11.
Indirect inguinal hernia related to the presence of a patent processus vaginalis (PPV) in adult is estimated to be around 15%. Most surgeons would favor a standard anterior hernioplasty to minimize the potential risk of damaging the spermatic cord structures that are always intimately fused to the congenital peritoneal sac. This also means overlooking the potential benefit of alternative posterior techniques such as endoscopic totally extraperitoneal (TEP) repair that is known to offer faster recovery with reduced risk of developing chronic groin pain. The aim of this study was to evaluate the safety of TEP approach for repair of adult inguinoscrotal hernias associated with completely PPV and to compare those results with a corresponding group of male patients undergoing an identical procedure, but with no demonstrated PPV.
This is a prospective study of consecutive male patients diagnosed with inguinal hernia during a 10-year period and eligible for endoscopic TEP repair. Every recognized completely PPV were systematically divided taking care not to damage the attached cord structures and the proximal end closed with a pre-tied Endoloop of PDS. In both groups, all meshes were secured with fibrin sealant only. Patients were reviewed in clinic 2 and 6 weeks after the operation. Further follow-up was scheduled if deemed necessary. The primary post-operative outcome parameter was spermatic cord injury; secondary outcome parameters included groin pain, surgical complications, and recurrence.
Nine hundred and thirty-nine hernia repairs were prospectively recorded during this period. All procedures were carried out endoscopically. A total of 41 patients with a median age of 27 years presented with 43 inguinoscrotal hernias (two bilateral) related to the presence of a congenital completely PPV. 72% of them were right-sided. No injury to the cord structures was recorded and only one complication (2.4%) occurred at 1 week post-operatively that was unrelated to the PPV. There was no report of chronic groin or testicular pain, symptomatic seroma formation, or hernia recurrence. By comparison, out of the 608 patients representing the no PPV group, there were 35 complications out of 33 patients (5.4%), one of those requiring subsequent laparoscopic revision. Only one early post-operative recurrence was recorded in this group (0.15%).
In the presence of a completely PPV, the recognized benefit of a posterior approach, such as endoscopic TEP inguinal hernia repair, outweighs the theoretical risk of damaging the spermatic cord structures when dissecting and dividing the congenital hernia sac. This technique should be the preferred option among expert laparoscopic surgeons.
成人中与开放的鞘突管（PPV）相关的间接腹股沟疝估计约为15%。大多数外科医生倾向于采用标准的前路疝修补术，以尽量减少损伤总是与先天性腹膜囊紧密融合的精索结构的潜在风险。这也意味着忽视了替代后路技术（如内镜完全腹膜外（TEP）修补术）的潜在益处，已知该技术能使患者恢复更快，且慢性腹股沟疼痛的发生风险降低。本研究的目的是评估TEP方法修复与完全PPV相关的成人腹股沟阴囊疝的安全性，并将这些结果与一组接受相同手术但未证实存在PPV的男性患者进行比较。
这是一项对连续10年期间被诊断为腹股沟疝且适合内镜TEP修补术的男性患者进行的前瞻性研究。每一个确认的完全PPV都被系统地分开，注意不要损伤附着的精索结构，近端用预先系好的PDS Endoloop封闭。在两组中，所有补片仅用纤维蛋白密封剂固定。术后2周和6周对患者进行门诊复查。如有必要，安排进一步随访。主要术后结局参数是精索损伤；次要结局参数包括腹股沟疼痛、手术并发症和复发。
在此期间前瞻性记录了939例疝修补术。所有手术均通过内镜进行。共有41例中位年龄为27岁的患者出现43例与先天性完全PPV相关的腹股沟阴囊疝（2例双侧）。其中72%为右侧。未记录到对精索结构的损伤，术后1周仅发生1例并发症（2.4%），与PPV无关。没有慢性腹股沟或睾丸疼痛、有症状的血清肿形成或疝复发的报告。相比之下，在代表无PPV组的608例患者中，33例患者中有35例并发症（5.4%），其中1例需要随后进行腹腔镜翻修。该组仅记录到1例早期术后复发（0.15%）。
在存在完全PPV的情况下，后路手术（如内镜TEP腹股沟疝修补术）公认的益处超过了在解剖和分离先天性疝囊时损伤精索结构的理论风险。对于专业腹腔镜外科医生来说，这种技术应该是首选。
