Historical changes in recurrence forms and their mechanisms after laparoscopic transabdominal preperitoneal inguinal hernioplasty, as assessed by video review
Technical factors leading to hernia recurrence after transabdominal preperitoneal (TAPP) repair include insufficient dissection, inadequate prosthetic overlap and prosthetic size, improper fixation and folding or crinkling of the prosthesis. However, which of these can intraoperatively determine if a case will go on to develop recurrent hernias remains unclear. Methods: We reviewed operation videos for 27 control cases and primary laparoscopic hernioplasty of 13 lesions where the patient
... the patient suffered recurrence after TAPP repair. Five surgeons blindly reviewed the videos to assess surgical techniques such as adequate dissection, mesh coverage, and folding or crinkling of the mesh. We explored the association of the technique with development of recurrence across our policy change, and hernia type before and after recurrence. Results: After implementing a TAPP repair policy of covering myopectineal orifice (MPO) with sufficiently overlapped mesh, 79% of the rating were satisfactory, whereas 34% were satisfactory prior to the policy. The recurrence rate decreased to 0.7% (5/678) compared with 6.2% (10/161) before the policy ( p <0.001). Although various types of recurrences were noted in the earlier period, only primary indirect and recurrent indirect hernias were observed in the later period ( p =0.006). With univariate analysis, the scores of posterior prosthesis overlap to the MPO in the recurrent cases were significantly lower than controls in the later period ( p =0.019). Conclusions: Fully covering the MPO with mesh is essential for preventing direct type recurrence. Prosthesis overlap posterior to the MPO in a large indirect hernia is important for preventing recurrence.