© Springer International Publishing Switzerland 2016
Cavit Avci and José M. Schiappa (eds.)Complications in Laparoscopic Surgery10.1007/978-3-319-19623-7_66. Complications After Total Endoscopic Preperitoneal (TEP) Repair
(1)
Unit of Innovation in Minimally Invasive Surgery, Department of Surgery, University Hospital “Virgen del Rocío”, Sevilla, Spain
Electronic supplementary material
The online version of this chapter (doi:10.1007/978-3-319-19623-7_6) contains supplementary material, which is available to authorized users.
6.1 Introduction
Complications of laparoscopic surgery are different from those of conventional surgery. Laparoscopy seems to repair inguinal hernias with a lower rate of postoperative complications, especially to those related to surgical wound morbidity, infections or bleeding events, and postoperative surgical pain, but always these complications depend on the surgeon’s experience. Furthermore, the type and size of the hernia along with the patient’s conditions will also influence the presence of complications. On the other hand, most of intraoperative complications associated with this technique include complications due to the laparoscopic access, such as trocar injuries, although many specific complications related to the dissection of the area, mesh placement and fixation have also been described.
Laparoscopic surgery in inguinal hernia is associated to a complete change of the vision of the anatomy vs. conventional approach that adds technical difficulty, especially in the TEP (total extraperitoneal), where working space is limited and manoeuvres dissections are more complex.
In laparoscopic repair of inguinal hernias, there are two techniques well differentiated: total extraperitoneal approach (TEP) and transabdominal preperitoneal approach (TAPP), the intraoperative complications of each of them are differents. For this reason, it is important to describe complications specifically related to each technique.
6.2 Intraoperative Complications Related to TEP
6.2.1 Complications Related to the Access to the Preperitoneal Space
These complications are frequent during the learning curve and may force conversion to an open surgical technique. One of the main steps of this technique includes the access to the preperitoneal space. Inadequate access may lead to conversion to TAPP or to open surgery.
Access to this space may be carried out by blunt dissection, assisted by the tip of the optic followed by dissection with one instrument after introduction of the first trocar, or using a balloon. A randomised, prospective, multicentre study showed that a dissection balloon made the dissection of the preperitoneal space easier and safer, thus reducing operative time, conversion rate and number of complications.
Complications related to access to the preperitoneal space include:
1.
Problems related to epigastric vessels:
(a)
Blunt dissection with the finger before introduction of the trocar could lead to a tear of the epigastric vessels, resulting in intense bleeding. To avoid bleeding, it is important to introduce the finger below the rectus muscle without doing any lateral movement.
(b)
Another problem related to epigastric vessels includes dissection of the vessels from the anterior wall during dissection of the preperitoneal space, which makes surgery more difficult. It is important to perform a proper blunt dissection with the finger and to visualise the epigastric vessel through the balloon during insufflation, by introducing the optic inside of it, in order to guarantee that epigastric vessels are maintained attached to the anterior wall.
2.
Problems related to balloon dissection: Besides the problems previously mentioned, bleeding of the epigastric vessels, peritoneal tears could also be related to balloon dissection. Smooth insufflation of the balloon is one of the main steps to avoid this problem. On the other hand, proper indications for access and for the technique itself are other factors to avoid peritoneal tears. Patients with previous infraumbilical surgery could present fibrous tissue in this space with a difficult distension of the preperitoneal area. In this case, it is even more important to have slow and little dissection of the space with the balloon, continuing the dissection using scissors through the 5-mm trocar. In case of midline infraumbilical surgery, the incision for introduction of the balloon should be performed laterally to the incision, through the rectus muscle. In case of previous surgery in the preperitoneal space, such us prostatectomy, TAPP could be a better indication, although different authors, such as Dulucq et al., have shown that it is feasible. The last advice to avoid complications during balloon dissection include the recommendation of not to insufflate the balloon more than it is accepted, since it could blow up and make a massive tear of the peritoneum with the subsequent need to collect the different plastic parts of the balloon.
3.
Visceral and vascular injuries: These complications could happen during insertion of trocars to perform surgery. Since there is no access to the abdominal cavity, visceral injuries due to introduction of trocars are very rare in this approach.
4.
Bladder injuries: The most common visceral injury during TEP is related to injury of the bladder, while bowel injuries are uncommon, as trocars are inserted when the preperitoneal space is already created and under direct vision. Injury to the bladder has been reported in 8 of 3868 patients who underwent surgery during a 7.5-year period, the majority of whom had previously undergone suprapubic catheterisation. Laparoscopic peritoneal access or secondary suprapubic trocar placement can result in a bladder perforation, usually as result of failure to decompress a distended bladder. Less commonly, the injury is associated with a congenital bladder abnormality. Aspects to be considered to prevent or to treat this complication are:
(a)
A proper indication of the hernia to be repaired is an important factor to avoid this complication. Those cases with previous surgery in the preperitoneal space, such as prostatectomy, could increase adhesions of the bladder in this space, increasing the possibility of having an injury, especially during the manoeuvres of dissection of the preperitoneal space. Bladder is especially prone to injury during laparoscopic inguinal hernia repair when the preperitoneal space has previously been dissected, e.g. previous preperitoneal hernia repair or prostatectomy. Incarcerated hernias could also be related to these injuries, since the hernia sac is not yet reduced when the preperitoneal space is being created and a trocar may be inserted into the bladder. Based on this, correct indications for surgery are the best way to avoid this complication. Even though some authors have demonstrated good results with this approach in patients with previous prostatectomy, these hernias should be performed by TAPP approach, especially if surgeons are not experienced with this other technique.
(b)
Special mention should be made to large direct or medial hernias, since the bladder can be a frequent content of this type of hernias and usually the sac is attached to the transversalis fascia when the space is created. On the other hand, caution must be taken when reducing this sac, as improper traction can result in injury.
(c)
Another aspect to be considered is when hernia repair is performed in a patient with the bladder filled with urine. In this case, the bladder can decrease the preperitoneal space and trocars become more prone to injure the bladder. For this reason, it is recommended to have the patient emptying the bladder before going to operating room.
(d)
This lesion shall be suspected if urine is withdrawn into a syringe after Veress needle insertion or if blood and gas are noticed in the urine drainage bag if the patient is catheterised. In questionable cases, methylene blue dye may be instilled into the bladder to look for leakage. Bladder injury recognised during laparoscopy shall be repaired laparoscopically, providing the experience of the surgeon is sufficient. This should be followed by bladder drainage for 7–10 days.
(e)
Bladder injury may present in a delayed fashion with haematuria and lower abdominal discomfort. Contrast-enhanced computerised tomography, cystography, or cystoscopy are the primary imaging techniques used to evaluate patients for suspected injury. Small defects may be managed with postoperative decompression via an indwelling catheter for urinary drainage, whereas larger defects need repair.
5.
Trocar site hernias: Hernias at trocar site are very rare after TEP for different reasons: first reason is because assisting trocars are usually 5-mm trocars, and the second reason is that the 10–12-mm trocars just open the anterior fascia, maintaining the posterior fascia of the rectus muscle preserved.
6.
Hypercapnia: This complication occurs during CO2 insufflation. The absorption of CO2 in the preperitoneal space is higher than intraperitoneally, being a factor to be considered when insufflation of CO2 happens in a virtual space, especially preperitoneally. This complication is related in most cases to the learning curve, since longer intraoperative time can increase the absorption of CO2 by blood vessels of the preperitoneal space. Expert surgeons with short surgical time rarely see this complication, as it can be prevented by decreasing surgical time. On the other hand, the role of the anaesthesiologist is very important in order to monitor this situation.
7.
Subcutaneous emphysema: This complication is common, but does not require any treatment, since CO2 is rapidly absorbed right after surgery.
6.2.2 Complications Related to the Dissection of the Hernia
1.
Bowel injury: Studies on TEP and TAPP report intraoperative intestinal injury in 0–0.3 % of cases, with rates of 0–0.06 % in larger investigations involving over 1000 patients. Problems can arise if patients are not correctly placed in the Trendelenburg position. When this happens, the intestines can remain in the hernia sac, increasing the risk of thermal damage. Extraperitoneal laparoscopic surgery is performed under general anaesthesia with good muscle relaxation, otherwise the working space is too small and the bowel would be pushing the preperitoneal space, increasing the risk of injury. On the other hand, in case there is any gas leak, the preperitoneal space also becomes too small. For this reason, we use the balloon trocar to make the incision airtight.
2.
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Vascular injuries: In large investigations, involving over 1000 patients, the rates of injuries to great vessels are of 0–0.11 %. These vascular injuries may arise from injury to major vessels, to epigastric vessels, to vessels from the cord or to vessels surrounding Cooper’s ligament. During dissection, the surgeon must visualise an aspect of “spider’s web”, to indicate that he/she is in the right direction. Dissection must be blunt in order to decrease the possibility of an injury to the vessels of this space. During this dissection, the surgeon uses diathermy to control possible bleeding from small vessels. The bipolar method seems to be safer than the monopolar. Different situations, besides bleeding of epigastric vessels which have been previously described, are:
(a)
At the high end of the dissection, there is always a small vessel, collateral of the inferior epigastric vessels. This vessel has to be coagulated with diathermy to prevent bleeding.
(b)
The vas deferens is seen lying separately on the medial side, and the gonadal vessels are seen laterally, forming a triangle. This triangle, known as the “triangle of doom”, is bounded medially by the vans deferens, laterally by the gonadal vessels, with its apex at the internal inguinal ring, and the base is formed by the peritoneum. Dissection should be clear in this region, to avoid injury to the cord structures or iliac vessels.
(c)
Bleeding from the vessels surrounding the area of the Cooper’s ligament might be difficult to control, being most of the time controlled with precise coagulation. In case of difficulty to control bleeding, the best methods to achieve a good haemostasis are to introduce gauze and to compress or to use some haemostatic agents.
(d)
Injury to the major vessels can be fatal and usually requires urgent laparotomy and vascular repair.
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