Single incision laparoscopic TAPP with standard laparoscopic instruments and suturing of flaps: A continuing study.

BACKGROUND: Single incision laparoscopic surgery, especially transumbilical, should be the closest to replicate the minimal access results achieved by natural orifice endoscopic surgery (NOTES). This study of single incision transabdominal preperitoneal (SITAPP) inguinal hernia repair is a continuing study exploring the peroperative variables and short and long term complications of this procedure. PATIENTS AND METHODS: All the 183 patients were operated by the same surgeon through a horizontal transumbilical incision positioned across the lower third of the umbilicus. Port access was through three separate transfacial punctures. Routine rigid instruments were used and the peritoneal flaps were either tacked or sutured into place. Patients with irreducible hernia and obstructed hernia were included, while those with strangulated hernia were excluded.
RESULTS: All the patients were male with an average age of 41.4 years. Twenty four patients had bilateral hernia, 15 patients had irreducible and 6 patients had obstructed hernia. The mean operating time was 38.3 mins for unilateral hernias completed with tackers and 42.8 mins in those with intracorporeal suturing. The corresponding operating time for bilateral hernias was 53.2 and 62.7 minutes. There was minimal serous discharge from the umbilicus in 8 patients, port site infection in 1 patient and recurrence in 2 patients over a 36 months period.
CONCLUSIONS: SITAPP for groin hernias, performed with conventional instruments is feasible, easy to learn, has a very high patient acceptance and is cosmetically superior to conventional TAPP. The use of tackers reduces the operating time significantly.

INTRODUCTION

Application of single incision laparoscopic approach to TAPP (SITAPP) for hernia repair is feasible and safe.[1] Cosmetic advantage, inherent to a transumbilical approach, notwithstanding, level 1 evidence regarding its superiority over the standard multiport transabdominal preperitoneal (STAPP) repair is still lacking. Subsequent to our reported initial experience of SITAPP, done through a transumbilical incision, using only conventional ports, rigid 10 mm telescope and rigid instruments,[1] this continuing study attempts to standardize the steps, compare the use of tackers with intracorporeal suturing of peritoneal flaps and looks at long term complications of SITAPP especially as regards recurrences.

MATERIALS AND METHODS

All the patients presenting with operable inguinal hernias in our unit, from October 2009 onwards, have been offered SITAPP as the first option, and an informed consent obtained. The prerequisite preoperative investigations and preparations are then carried out.

SITAPP was performed, under spinal anesthesia with sensorcaine, through a single 2.5-3.5 cms transverse transumbilical skin incision, positioned across the lower third of the umbilicus and the lower flap is dissected and undermined. Multiport transfacial access using one 10 mm camera and two 5 mm working ports was then gained. All the ports and instruments were those used in routine laparoscopic surgery. The telescope used was 30 degree 10 mm and the camera system was High definition by Storzl. The 5 mm ports were selected as simple tubes without a valve to prevent external clashing [Figure 1]. The peritoneal incision for accessing the preperitoneal space was kept short and extended medially from the medial umbilical ligament to about 5 cms laterally and not up to the anterior superior iliac spine as described for STAPP. The incision is positioned about 4-5 cms above the upper border of the deep inguinal ring. The preperitoneal space is created medially beyond the midline, laterally up to the anterior superior iliac spine, and caudally into the retropubic space. The hernia sac is separated from the cord structures and dissected either completely or if it is long then transected after ligation proximally. A 10 × 15 cm2 polypropylene mesh was spread out to cover the Fruchaud's orifice and tacked at 2 places (to the pubic bone and the upper lateral corner to the abdominal wall). The peritoneal flaps were then either tacked (Covidien Protack Autosuture USA) or stitched together using continuous sutures with 2-0 vicryl on, 40 mm ½ circle taper cut needle [Figures 2–4]. The umbilical transfacial punctures were closed individually and the umbilicus was then reconstructed with the same 2-0 vickryl suture [Figure 5]. The detailed steps have been described earlier.[1]

Figure 1

SITAPP ports and placement

Figure 2

Suturing of peritoneal flaps-lower leaf

Figure 4

Suturing of peritoneal flaps-completed

Figure 5

Umblicus reconstructed

Suturing of peritoneal flaps-upper leaf

The patients were administered the same analgesic drugs until discharge. For the alleviation of immediate post-operative pain, 100 mg Tramadol inj +25 mg Phenargan was administered in the intravenous fluid when the patient was wheeled out of the operation theater. Subsequent doses were on demand. Once oral intake was initiated 12 h after surgery, the patient was offered an alternative oral combination of diclofenac and paracetamol, when required.

Monitored parameters included operating time, per- and postoperative complications, numbers of injectable doses of analgesic, total duration of requirement of oral analgesics, post-operative ileus and umbilical site infection. Long term recurrence was assessed at 1 month and 6 months and up to 42 months post surgery. Significance of the data was based on the student “t” test, and a P-value of 0 was considered insignificant.

RESULTS

A total of 207 SITAPP procedures were performed on 183 patients between October 2009 and May 2013. All the patients were males with an average age of 41.4 years. Hernia demographics are available in Table 1. The average operating time for unilateral hernia was 42.8 mins (32-70 mins) in the suturing group and 38.3 in the tacker groupIn bilateral hernia, the corresponding time was 62.7 mins and 53.2 mins [Table 2]. The operating time was significantly different in the suturing and the tacker group [Table 2]. However, the time difference was not significant in the recurrent hernia group and was probably because of the very small sample size. Complete sac retraction and dissection were not possible in 39 patients, and was transected after it was dragged in for about 4-6 cms and proximal end ligated. There were no per-operative complications or conversions. Post-operative additional dose of injectible analgesic (more than one) was required in 66 patients (31.9%). Oral analgesics on day 2 were required in 96 (46.4%) patients. Day 2, VAS pain score of less than 5 was recorded in 133 patients (64.3%) [Table 3]. Discharge time was 1.6 days (1-3days). Serosangunious port site discharge persisted in 8 patients for 5-7 days, and there was wound site infection in 1 patient. There were two recurrences in 42 months of follow up (range 1 month to 42 months). The majority of patients had a 36 months follow up. The two recurrences seen were after 6 months and 7 months, respectively.

Table 1

Inguinal hernia-demographics

Table 2

SITAPP operating time n = 207

Table 3

Complications SITAPP n = 207

DISCUSSION

SILS procedures require modification in technique as compared to the standard laparoscopic approach. This is because of the very close proximity of the fulcrums of the instruments to each other (1.5 to 2.0 cms apart), which naturally results in clashing of instruments both inside and outside the body. The problem of clashing of ports was partly offset by using two 5 mm simple tube trocars instead of the flap valve trocars flanking the 10 mm trocar [Figure 1]. The learning curve especially with conventional instruments is also not very long. However, the same cannot be said for the use of special instruments which require a long learning curve. It also needs to be stressed that a logical progression from a 4 port to 3 port standard laparoscopic approach is a must before starting on SITAPP. This ease in mastering SILS has been largely responsible for the inclusion, during the last 2-3 years, of more and more laparoscopic procedures under the SILS umbrella. Thus, SILS approach now includes almost all advanced laparoscopic surgeries including urological applications,[23] gynecological interventions,[4] colorectal[56] and bariatric surgeries.[78]

Performing SILS involves a choice between either using the standard instruments and ports or graduating to new innovative multiport systems, exorbitantly priced angulating scopes, longer scopes and bent or roticulating instruments. Having said that it must be acknowledged that the success of advanced SILS procedures is in large part because of the advent and availability of transumblical ports, like triport and airseal port, which have multiple entry points. The procedures have been further facilitated by the recent introduction of rotating instruments and curved instruments.[910]

Single incision repair of groin hernias, either as single incision totally extraperitoneal repair (SITEP) or SITAPP is now being, successfully, carried out more and more frequently.[1112] While SITEP is usually done through an extraumbilical incision SITAPP is also possible through a transumbilical approach giving it a cosmetic advantage. SITEP cannot be done through a transumbilical approach because accessing the preperitoneal space through an umbilical approach would be difficult and the skin incision would have to be infraumbilical and thus the cosmetic advantage would be lost. So to retain the cosmetic advantage of an umbilical incision, TAPP appears to be a better option.

The placement of the incision differs across various reports, being supra umbilical,[13] infraumbilical[1415] or transumbilical.[1617] The only approach in all our patients was the transumbilical approach with mobilization of the lower flap [Figure 1]. The incision size in all the reports varies between 2.0 cm-3.0 cms. Our incision size also varied between 2.5-3.0 cms. It is obvious that the transumbilical incision, rather than a supra or infraumbilical incision, will result in a more cosmetic scar and a nearly normal looking umbilicus. Routine ports suffice for the SILS approach[118] although most of the reports mention SITEP repairs with special ports.[1516]

Series reports for SITAPP repair for inguinal hernias, too, are very few and interspersed with case reports.[1112192021] Menenakos[13] reported on a patient with B/L inguinal hernia in whom they performed a SITAPP. The incision was supraumbilical and Triport access was used, however type of instruments has not been mentioned.[13] Pesta et al.[21] used the Coviden port for SITAPP, Ishikawa et al.[17] reported on a patient of inguinal hernia where SITAPP repair was done with the aid of Radius Surgical system for suturing. A series of 15 patients, in whom SITAPP had been carried out, has been reported recently.[22] Routine ports and rigid instruments have been used in this study. We too perform all our procedures with routine one 10 mm and two 5 mm tube ports and routine rigid instruments.

The peritoneal closure in SITAPP is routinely performed using tacks and very rarely by intracorporeal suturing. Norihiko Ishikawa et al.[17] closed the peritoneal flap with a suturing system. The other studies do not specifically mention the method of closure of the peritoneal flap and it probably means that it was with the conventional method of using tacks. Preference for tacks is because of the technical difficulty of performing intracorporeal suturing in SITAPP.[22] We have now sutured the flaps in 109 hernias, with intracorporeal continuous suturing with 2-0 polyglycholic sutures on 40 mm needle. The suturing in the initial stages was demanding but once we learned to do it right, we could accomplish it fairly easily. But the comparative time as compared to when tacks were being used was significantly more although the cost was significantly less. Our operative time of 38.3 min, for unilateral SITAPP with tacks is less than reports of 45.5 mins,[1] 51 +/− 17 mins,[19] 54.11 min,[22] 59.33 min,[12] 67 mins[19] and 120 mins[13] for the same procedure. Unfortunately, there are no reports on SITAPP completed with intracorporeal suturing of the peritoneal flaps.

Per-operative and post-operative complications were not encountered and - recurrence was seen in two patients (0.97%) which compares well with 2.9% mentioned by Sato.[11] Infection was not a problem and neither was port site hernia.

The final scar at 1 month post-operative was almost invisible and very cosmetic [Figure 5].

CONCLUSION

Level 1 evidence about the advantages of SITAPP is still awaited but we have amply demonstrated that SITAPP is safe, easily learnt and results in remarkable scar cosmesis. In fact scar cosmesis is responsible for the very high acceptance rate among patients.