Volume 04 Issue 09-2024
46
American Journal Of Biomedical Science & Pharmaceutical Innovation
(ISSN
–
2771-2753)
VOLUME
04
ISSUE
09
P
AGES
:
46-53
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
Analysis of the results of treatment of inguinal hernias using endovideosurgical hernioplasty: TAPP, TEP and e-TEP in
216 patients was carried out. Total extraperitoneal hernioplasty (TER) is preferable for patients who have undergone
operations on the abdominal cavity and pelvic organs due to the adhesion process. TARR is recommended when it is
necessary to perform simultaneous operations and in case of bilateral localization of hernias. It made it possible to
reduce the number of hematomas (in the TARR groups from 8.6% to 3.7%, in the TER-e-TER groups from 7.6% to 5.7%)
and seromas (in the TARR groups from 8.6% to 7.4%, in the TER-e-TER groups from 13.5% to 5.7%) with dissection in the
preperitoneal space.
KEYWORDS
Inguinal hernia, endovideosurgical hernioplasty.
INTRODUCTION
A significant number of existing methods of hernia
repair has become the basis for a huge number of
studies comparing the effectiveness of various
techniques. At the moment, however, there is no
irreproachable way to perform surgery to remove an
inguinal hernia. Tension methods of hernioplasty are
losing ground today, and among the non-tension
methods using a mesh allograft, endosurgical
Research Article
RESULTS OF ENDOVIDEOSURGERY FOR INGUINAL HERNIA
Submission Date:
Sep 20, 2024,
Accepted Date:
Sep 25, 2024,
Published Date:
Sep 30, 2024
Crossref doi:
https://doi.org/10.37547/ajbspi/Volume04Issue09-04
Kamalov N.A.
Samarkand State Medical University, Uzbekistan
Babazhanov A.S.
Samarkand State Medical University, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ajbspi
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 04 Issue 09-2024
47
American Journal Of Biomedical Science & Pharmaceutical Innovation
(ISSN
–
2771-2753)
VOLUME
04
ISSUE
09
P
AGES
:
46-53
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
techniques are gaining the palm, among which TAPP
(transabdominal preperitoneal hernia repair) and TEP
(totally extraperitoneal hernia repair) surgical
interventions stand out favorably [1,3]. Their
advantage, in addition to low invasiveness, is that the
implant is placed extraperitoneally and, accordingly,
does not have contact with the abdominal organs. This
sharply reduces the likelihood of the formation of
postoperative adhesions and peritoneal adhesions. In
the case of the use of TARR, which involves the use of
transabdominal access, there is a risk of injury to the
abdominal organs during surgery, especially in the case
of previous laparotomy. TER is devoid of this
drawback, since during the surgical intervention there
is no entrance to the abdominal cavity, and all
manipulations take place in the preperitoneal space.
However, this type of surgical intervention is
characterized by a small surgical space, which requires
a higher qualification of the operating surgeon[2,6].
Along with this, additional problems during TER may
occur in the case of previous prostate surgeries due to
the scarring process in the preperitoneal tissue [4,5].
Also, TER is not considered as a surgical treatment of
bilateral inguinal hernias. Improvement of the TER
technique by J. Daes (2010) was implemented in e-TER
(extended totally extraperitoneal hernia repair), which
made it possible to perform effective surgical
interventions for bilateral, strangulated and inguinal
hernias of large sizes.
Thus, the variety of endovideosurgical methods of
hernioplasty determines the need for their further
study in order to form the most favorable surgical
method of surgical intervention.
Objective
. To analyze the results of TARR and TER
endovideosurgical hernioplasty to determine the
indications and conditions for their implementation
and to identify shortcomings.
METHODS
The basis of this study is the analysis of the results of
treatment of inguinal hernias using endovideosurgical
hernioplasty: TARR, TER and e-TER in 216 patients
operated in the Department of Endoscopic Surgery of
Samarkand GMO No1 for 8 years (2017-2024).
All of them were hospitalized for planned surgical
treatment. In accordance with the tasks, the patients
were divided into 2 groups. Retrospective groups
included 110 patients who underwent the following
patients: - TARR hernioplasty
–
58 patients; - TER
hernioplasty
–
52 patients.
Prospective groups included 106 patients who
underwent the following patients: - TARR hernioplasty
–
54 patients; - e-TER hernioplasty
–
52 patients.
Among the patients, men of middle and older age
groups prevailed, which is characteristic of inguinal
hernias. All hospitalized patients were diagnosed with
primary uni- or bilateral inguinal hernias of I, II or III (A
or B) types (according to Nyhus). In the retrospective
groups, inguinal hernias were most often found in Type
II (oblique with an expanded ring) and Type IIIA
Volume 04 Issue 09-2024
48
American Journal Of Biomedical Science & Pharmaceutical Innovation
(ISSN
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2771-2753)
VOLUME
04
ISSUE
09
P
AGES
:
46-53
OCLC
–
1121105677
Publisher:
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Servi
(straight). At the same time, among those operated
using the TARR techniques, there were more patients
with complex types of hernias (Type IIIA and Type IIIB).
Bilateral hernias (Type IIIA) were observed in 4 (3.6%)
patients, and all of them were operated using the TARR
technique.
This study involved patients who had previously
undergone surgical treatment. In the TARR group,
these were 10 (17.2%) patients, and in the TER group
–
11 (21.2%). The most common is an open-access
appendectomy in the right iliac region.
In the prospective groups, inguinal hernias of types II
and IIIA were most common in 77 (72.6%) patients.
From these, more patients with direct hernias (Type
IIIA) were operated using the e-TER technique: 40.4%
compared to 33.3% among those, who were operated
using the TARR technique. At the same time, the group
of patients operated using the TARR technique
included 3 (4.6%) patients with concomitant
cholelithiasis, chronic calculous cholecystitis, who
underwent simultaneous surgical interventions:
hernioplasty + cholecystectomy. Patients with type IIIB
hernias, which included sliding and inguinal-scrotal
hernias, were more often operated on by the e-TER
method: 17.3% versus 5.6% in the TARR group. Patients
hospitalized with bilateral direct hernias (Type IIIA)
were also more likely to be operated on by extended
full extraperitoneal hernioplasty (5 (9.6%) patients.
Patients with an operative history were much more
likely operated using the e-TER technique. Thus,
among all patients in whom e-TER was used (n=52), 15
(28.8%) had previously undergone abdominal surgery.
In the TARR group (n=54), there were 6 such patients
(10.1%), and all previous surgical interventions were
performed by endovideosurgery.
Ultrasound scanning has found its wide use in
instrumental diagnostics of PG. The thickness of the
oblique abdominal muscles in patients with PG was
significantly less in comparison with healthy
individuals.
Figure 1. Criteria for the width of the
oblique abdominal muscles (rectus and
internal) in patients with inguinal hernia
Figure 2. Ultrasound picture of the muscles
of the inguinal region in a patient with
inguinal hernia
Volume 04 Issue 09-2024
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American Journal Of Biomedical Science & Pharmaceutical Innovation
(ISSN
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2771-2753)
VOLUME
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ISSUE
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OCLC
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1121105677
Publisher:
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Muscle thickness indicators during tension in patients
with PG changed by 0.192±0.101 cm on average, while
in the group of healthy individuals the change in this
indicator was more significant
–
by 1.186±0.109.
Consequently, in patients with PH, in contrast to
healthy people, a decrease in the width of the oblique
abdominal muscles is impaired by muscle tension,
which, in fact, is considered a predisposing factor for
destructive changes in the tissues of the aponeurosis
of the abdominal muscles and an increase in the size of
the hernial defect that has arisen.
As part of the exclusion of complications (seroma,
hematoma) and possible migration of the mesh during
the first few days after surgery, all patients underwent
ultrasound scanning. Small hematomas and seromas
(volume up to 20 ml) were subjected to conservative
treatment, large ones (volume more than 20 ml) were
punctured under ultrasound control.
RESULTS AND DISCUSSION
Analysis of the treatment of patients in retrospective
groups showed the following results. The average
duration of surgical interventions was 82.3±15.2
minutes with the TARR method, and 79.1±13.4 minutes
with the TER method (p>0.05).
The total number of complications registered in both
groups was 12 (10.9%) cases. Intraoperative
complications were more common in the TER group
(13.4% versus 8.6% in the TARR group). In the group of
patients operated using the TARR technique, in 5.2% of
cases, damage to internal organs occurred at the stage
of the first trocar placement. All of these patients had
previously undergone abdominal surgery. Such a
complication was not noted in the TER group, since the
technique did not imply entry into the abdominal
cavity. The most common intraoperative complication
of TER surgery was damage to the parietal peritoneum
during dissection in the preperitoneal space. The
developed pneumoperitoneum did not allow
continuing the operation by the TEP method.
Conversion was carried out - the transition to TARR.
This option has also been classified as an intraoperative
complication. Damage to the epigastric vessels was
slightly more common with the TARR technique (3.4%
versus 1.9% with TEP).
The incidence of postoperative complications did not
differ statistically significantly in the TARR and TER
groups, amounting to 31.0% and 30.8%, respectively
(p>0.05). At the same time, most of the complications
did not have significant consequences. Seromas and
hematomas
in
both
groups
were
treated
conservatively with a positive effect. In 3 cases, their
evacuation by puncture method under ultrasound
guidance was required. Mesh migration, which was
observed in 2 (3.4%) cases in the TARR group and in 1
(1.9%) case in the TEP group.
Long-term results of ECH hernioplasty were traced in
84 (76.4%) patients of retrospective groups. 43 (74.1%)
patients after TARR hernioplasty and 41 (78.8%)
patients operated on by TER answered the
questionnaire. The duration of postoperative follow-
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VOLUME
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OCLC
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Publisher:
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up averaged 19.4±3.9 months. Recurrent inguinal
hernia was detected in 1 (2.3%) patient from the TARR
group and in 1 (2.4%) patient from the TER group.
The prospective study is based on treatment outcomes
from 106 patients. Of these, 54 patients were operated
on using the TARR technique, and 52 using the e-TER
technique.
The TARR
operation
was
performed
under
endotracheal anesthesia with mechanical ventilation.
The technique of transabdominal preperitoneal
hernioplasty pursues the main task of eliminating a
hernial defect on the abdominal side, which is achieved
by placing a mesh implant on the posterior wall of the
inguinal canal, due to which it is strengthened (Fig. 3,
4).
Figure 3. - Fixation of the mesh endoprosthesis
Figure 4. - Final stage. Peritonization of the
endoprosthesis
A feature of full extraperitoneal e-TER hernioplasty is
that the entrance to the abdominal cavity is not
performed, and all manipulations take place in the
space created outside it (Fig. 5, 6).
Figure 5 - Dissection in the
extraperitoneal space
Drawing. 6. The mesh implant is placed
in the preperitoneal space
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The mean duration of e-TER hernioplasty was
significantly shorter than that of TARP (59.7±12.1 versus
65.2±13.5 minutes (p<0.05).
The total number of intraoperative complications was
significantly lower (p<0.05) with e-TER surgery (3.8%
versus 5.5% with TARD). At the same time, most
complications from the e-TER group relate to damage
to the parietal peritoneum, which is less significant
than damage to the abdominal cavity organs or
epigastric vessels that occurred in TARR. In the group
of patients operated on using the TARR technique,
compared to the retrospective group of TARR, the
number of abdominal organ injuries decreased from
5.2% to 3.7%. This decrease is explained by the fact that
similar injuries occurred in patients who had previously
undergone abdominal surgery. There was also a
decrease in the incidence of epigastric vascular injury
in the prospective groups compared to retrospective
groups. At the same time, the difference in the TARR
groups was not statistically significant (p>0.05), in
contrast to the TER and e-TER groups, where the
reduction in the incidence of this intraoperative
complication is statistically significant (p<0.05).
The most common postoperative complications were
the formation of seromas and hematomas in the area
of the mesh implant, and if the frequency of
hematomas in the groups did not have statistically
significant differences (p>0.05), then seromas were
more common in e-TER hernioplasty, which may be
due to a large volume of dissection in the preperitoneal
tissue. The rate of mesh migration in the immediate
postoperative period was slightly less common in the
e-TER group of 1.9% versus 3.7% in the TARP group,
although these differences were not statistically
significant (p>0.05).
At the same time, it should be emphasized that only
self-fixing mesh implants were used in e-TER
hernioplasty, and stapler mesh fixation was used in
TARR. The frequency of superficial suppuration also
did not have statistically significant differences
between the groups. The incidence of infection in the
mesh area did not differ significantly in the TARP and e-
TER groups.
Long-term results of ECC hernioplasty in prospective
groups were observed in 91 (85.8%) patients within 10
to 32 months (average 17.2±3.8 months) after surgery.
Of these, 47 (51.6%) patients were operated on using
the TARR technique, and 44 (48.4%) patients with the
e-TER method. Recurrence of hernia was detected in 1
(2.1%) patient from the TARR group, recurrence was
not detected in the e-TER group.
The main advantages of the e-TER method are its
greater effectiveness and safety compared to the
TARR technique in cases of previous surgical
interventions on the abdominal cavity and pelvic
organs. Along with this, the TARR method makes it
possible
to
perform
simultaneous
surgical
interventions, which was shown by the example of
patients with concomitant cholelithiasis, chronic
calculous cholecystitis. Bilateral hernias can be
Volume 04 Issue 09-2024
52
American Journal Of Biomedical Science & Pharmaceutical Innovation
(ISSN
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ISSUE
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OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
successfully operated by the usage of any techniques.
Also, much depends on the experience and
preferences of the operating surgeon. If there are
contraindications to general anesthesia, which is
necessary for TARR hernia repair, the e-TER technique,
which can be performed under regional anesthesia,
can be the operation of choice.
CONCLUSIONS
1. Endovideosurgical transabdominal preperitoneal
(TARR) inguinal hernioplasty was accompanied by
abdominal organ injuries in 5.2%, which was excluded
with total extraperitoneal (e-TER) plasty. However,
due to technical difficulties due to space constraints of
3.8%, the TER has been converted to TARR.
2. Total extraperitoneal hernioplasty (TER) is
preferable in patients who have undergone abdominal
and pelvic surgery due to adhesions. TARR is
recommended when it is necessary to perform
simultaneous operations and in case of bilateral
localization of hernias.
3. The algorithm for choosing the method of
endovideosurgical operations for inguinal hernias,
based on taking into account the advantages and
disadvantages of TARR and TER, made it possible to
achieve a higher level of quality of treatment, made it
possible to reduce the number of hematomas (in the
TARR groups from 8.6% to 3.7%, in the TER-e-TER
groups from 7.6% to 5.7%) and gray (in the TARR groups
from 8.6% to 7.4%, in the TER-e-TER groups from 13.5%
to 5.7%) in the dissection in the preperitoneal space.
4. The incidence of hernia recurrence in the TARR and
e-TER groups with a mean postoperative follow-up
period of 17.2±3.8 months in TARR was 2.1% with
recurrence leveling in e-TER. In the retrospective TARR
and TER groups, the incidence of hernia recurrence
also did not have significant differences (2.3% and 2.4%,
respectively), but it was higher than in the prospective
study, which proves the clinical efficacy of
endovideosurgical hernia repair of inguinal hernias
with a differentiated approach to the choice of surgical
method.
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VOLUME
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OCLC
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1121105677
Publisher:
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