Clinical Application of the Modified Neck-Shoulder Technique Based on Membrane Autopsy in Laparoscopic Totally Extraperitoneal Prosthesis for Indirect Inguinal Hernia

doi:10.21203/rs.3.rs-3336874/v1

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Clinical Application of the Modified Neck-Shoulder Technique Based on Membrane Autopsy in Laparoscopic Totally Extraperitoneal Prosthesis for Indirect Inguinal Hernia

https://doi.org/10.21203/rs.3.rs-3336874/v1

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Objective: To investigate the anatomical basis and clinical application value of the modified neck-shoulder technique based on membrane autopsy in laparoscopic totally extraperitoneal prosthesis (TEP) for tension-free repairs of indirect inguinal hernia.

Methods:In this retrospective cohort study, we analyzed the clinical data of 136 patients with indirect inguinal hernia who underwent laparoscopic TEP for tension-free repairs in Department of gastroenterological surgery Unit 1, the First Hospital of Putian City, Fujian Province from June 2017 to June 2020. The patients were divided into the modified neck-shoulder technique group (68 cases) and the traditional surgery group (68 cases) according to the different surgical methods. The intraoperative and postoperative conditions of the two groups were compared.

Results:Both the modified neck-shoulder technique group and the traditional surgery group completed the herniorrhaphy. Compared with the traditional surgery group, the modified neck-shoulder technique group had a shorter operation time [(37.15±5.320) min vs. (54.04±5.202) min, t=18.472, p<0.001], less intraoperative blood loss [(5.53±1.634) ml vs. (16.21±3.375) ml, t=23.544, p<0.001], lower incidence of intraoperative peritoneal injury [3 cases (4.41%) vs. 9 cases (13.26%), χ²=3.29, p=0.07], lower intraoperative conversion rate [1 case (1.47%) vs. 8 cases (11.76%), χ²=5.83, p=0.016], and lower incidence of postoperative chronic pain [1 case (1.47%) vs. 12 cases (17.65%), χ²=10.291, p=0.001], all of which were statistically significant (p<0.05). Both groups were followed up for 12 months after surgery. Relapse was not observed in any case.

Conclusion: Based on the surgical principles of the open neck-shoulder technique and the understanding of the membrane autopsy in the inguinal region, our center has summarized a set of operation procedures called the “modified neck-shoulder technique” for laparoscopic TEP for tension-free repairs of indirect inguinal hernia. This new surgical technique could quickly and accurately separate and cross the interlayer gap in the preperitoneal space under the enlarged view of the laparoscope, allow the high ligation and detachment or return of the hernia sac, and make the placement of the patch more reliable, reduce collateral damage, reduce postoperative complications, and save operation time.

indirect inguinal hernia

herniorrhaphy

modified neck-shoulder technique

laparoscopy

The emergence of laparoscopic totally extraperitoneal prosthesis (TEP) for inguinal hernia¹, which covers and repairs the entire myopectineal orifice², has rapidly developed and become popular due to its effective prevention of hernia relapse and reduction of postoperative complications. Similar to the surgical concept of open preperitoneal tension-free repair using the “neck-shoulder technique”, the TEP approach does not enter the abdominal cavity and directly operates in the preperitoneal space. In 2001, Gilbert et al.³ proposed the “neck-shoulder technique”, which accurately identifies the “true hernia sac neck” (the junction of the hernia sac and transverse fascia) and gains quick entrance into the preperitoneal space through a correct incision in the transverse fascia for tension-free repair. This technique improves surgical safety and shortens operation time. Drawing on this surgical principle and combining it with the unique magnification view and changing perspective of laparoscopy, our center summarized a set of operation procedures called the “modified neck-shoulder technique” for laparoscopic TEP for tension-free repairs of indirect inguinal hernia, which utilized an understanding of membrane autopsy for tissue dissection and entry into the avascular planes and layers of the preperitoneal space to complete hernia sac handling and patch placement. This study retrospectively analyzed the clinical data of 136 patients with indirect inguinal hernia who underwent surgery in the Department of gastroenterological surgery Unit 1, the First Hospital of Putian City, Fujian Province, between June 2017 and June 2020, and investigated the clinical value of the modified neck-shoulder technique based on membrane autopsy in laparoscopic TEP for tension-free repairs of indirect inguinal hernia. The aim was to overcome the problems faced by traditional TEP surgery, such as unclear understanding of the complex fascial layers in the preperitoneal space, high surgical difficulty, and long learning period, and to promote and popularize TEP as an ideal herniorrhaphy technique.

1.1 Study subjects

A retrospective cohort study was conducted. Inclusion criteria were as follows: (1) adult patients with inguinal hernia, and (2) patients with recurrent hernia. Exclusion criteria were as follows: (1) patients with a history of laparoscopic inguinal herniorrhaphy, (2) patients with severe internal medical conditions such as cardiopulmonary disease who could not tolerate general anesthesia, (3) patients with severe coagulation disorders, and (4) patients with difficult-to-reduce hernias.

Based on the above inclusion criteria, clinical data were retrospectively collected from 136 male patients with indirect inguinal hernia who were treated in the Department of gastroenterological surgery Unit 1, the First Hospital of Putian City, Fujian Province, between June 2017 and June 2020. Among them, 68 cases were treated with the modified neck-shoulder technique and 68 cases were treated with the traditional method. This study complied with the Declaration of Helsinki and all patients provided informed consent and signed the consent form for the surgical procedures.

1.2 Surgical methods

General anesthesia was administered to all patients. Patients were placed in a 10°-15° supine position with the head lower than the feet and their arms tightly against their body. The surgeon stood on the opposite side of the hernia, with the assistant on either the affected side or the cephalic side. The monitor was placed at the foot end of the operating table. All patients had one observation trocar and two operation trocars inserted using a midline approach. The open technique was usually employed, with a small incision of approximately 1.0 cm made below the umbilicus. The anterior rectus sheath was incised, and the rectus abdominis was retracted bilaterally with a hook to create a gap, into which an observation trocar (diameter of 12 mm) was inserted between the rectus abdominis and posterior rectus sheath. Under direct vision, the surgeon introduced the laparoscope through the umbilical port and passed it through the transverse fascia to access the fascial plane between the transverse fascia and the extraperitoneal fascia. Two operation trocars (diameter of 6 mm) were inserted under direct vision at the upper one-third and lower one-third of the distance between the umbilical region and pubic symphysis lines.

Modified Neck-Shoulder Technique Group: (1) Retzius space separation: Under the guidance of the indicative anatomy of the posterior rectus sheath, the transverse fascia was passed through to enter the fascial space formed by the transverse fascia and the superficial layer of extraperitoneal fascia. At this time, it was necessary to reveal the pubic symphysis in order to find the pectineal ligament, which was an important anatomical landmark. Identifying the pectineal ligament could help confirm the depth of the first fascial space (Fig. 1A) and could be used to expand this space. If the first fascial space was expanded accurately, the inferior epigastric vessels appeared naturally. The indirect hernia sac neck could then be confirmed outside of the vascular root, which was the position of the “neck-shoulder” incision. At the same time, the region where the direct inguinal hernia and femoral hernia were located could be explored, and the hernia sac could be directly confirmed and restored. (2) Treatment of the indirect inguinal hernia sac: The “point” of the neck-shoulder junction was cut, and the outside and covering of the hernia sac were separated close to the peritoneum, ensuring that the peritoneum was not deliberately exposed in order to avoid breaking. Because it was an oriented separation, the scope of the extension should be small (Fig. 1B) and gauze should be used as a guide (Fig. 1C). Then, the surgeon entered the separation paths inside and below the hernia sac at the position of the neck-shoulder incision before extending downward and outward to expose the ductus deferens. The spermatic vessels were exposed outside of the ductus deferens, with complete exposure of the spermatic cord (Fig. 1D). The surgeon crossed the path between the first fascial space and the safe zone, and separated the layers outward, close to the hernia sac wall. The gauze that was fixed on the outside and within the hernia sac was located and met with the previous path of the hernia covering (Fig. 1E). Here, we did not distinguish the spermatic cord, peritoneum, and the deep layer of the extraperitoneal fascia. The hernia sac was completely transected and stripped (Fig. 1F). (3) Bogros’ space separation: The complete separation of the spermatic cord from the peritoneum ensured subsequent separation in the safe zone. Furthermore, this ensured the rapid expansion of the non-vascular layer, which included the peritonealization of the spermatic cord and separation of the Bogros’ space. During this process, we diluted the exposure of the peritoneum. To avoid injury to the peritoneum and challenges in subsequent operations, we expanded the space closest to the peritoneum (Fig. 1G). Finally, a patch was placed to cover the entire myopectineal orifice (Fig. 1H).

Traditional Surgery Group: After entering the preperitoneal space, the first step was to separate the Retzius space between the pubis and bladder. Once the preperitoneal space was successfully established, the Retzius space was naturally formed, and simple separation was sufficient to expose the pubic symphysis and pectineal ligament. During this process, exploration and treatment of direct and femoral hernias should be completed. After completing the separation of the Retzius space, do not rush to search for the indirect inguinal hernia sac, but first separate the Bogros’ space. This space was located between the inferior epigastric vessels and the anterior superior iliac spine. The adhesions between the transversus fascia covering the conjoint tendon and the posterior rectus sheath and peritoneum were gently pushed away on the lateral aspect of the inferior epigastric vessels to fully visualize the Bogros’ space, and the outer edge of the indirect hernia sac was naturally revealed. At this point, the indirect hernia sac was found, and it was located on the outer side of the inferior epigastric vessels. The hernia sac was pulled back from the inguinal canal and return to high in the abdominal cavity. The spermatic vessels and ductus deferens were separated from the internal ring horizontally and behind, completing the “spermatic cord abdominalization.” Finally, a patch was placed to cover the myopectineal orifice.

1.3 Observation indicators

Operation time, intraoperative blood loss, intraoperative peritoneal injury rate, intraoperative conversion rate, incidence of postoperative chronic pain, postoperative recurrence rate, etc.

1.4 Statistical methods

SPSS 25.0 statistical software was used for statistical analysis. Normally distributed measurement data were expressed as ‾x ± s, and the independent sample t-test was used for comparison between groups. Categorical variables were expressed as frequency (%), and the chi-square (χ²) test was used for comparison between groups. P < 0.05 indicated statistical significance.

Both groups successfully completed the repair of indirect inguinal hernia. Compared with the traditional surgery group, the modified neck-shoulder technique group had shorter operation time, less intraoperative blood loss (Table 1, p < 0.05), lower intraoperative peritoneal injury rate (Table 2, p < 0.05), lower intraoperative conversion rate (Table 3, p < 0.05), and lower incidence of postoperative chronic pain (Table 4, p < 0.05). The patients in both groups were followed up for 12 months postoperatively. No recurrence cases were observed.

Table 1

Comparison of the operation time and intraoperative blood loss between the two groups (‾x ± s)
Items	Modified neck-shoulder technique group (n = 68)	Traditional surgery group (n = 68)	t value	p value
Intraoperative blood loss (ml)	5.53 ± 1.634	16.21 ± 3.375	t = 23.544	p < 0.001
Operation time (min)	37.15 ± 5.320	54.04 ± 5.202	t = 18.472	p < 0.001

Table 2

Comparison of the intraoperative peritoneal injury between the two groups (χ²)
Items	Modified neck-shoulder technique group (n = 68)	Traditional surgery group (n = 68)	χ² value	p value
Intraoperative peritoneal injury (n)	3 (4.41%)	9 (13.26%)	χ²=3.29	p = 0.07
Non-intraoperative peritoneal injury (n)	65	59	χ²=3.29	p = 0.07

Table 3

Comparison of the intraoperative conversion rate between the two groups (χ²)
Items	Modified neck-shoulder technique group (n = 68)	Traditional surgery group (n = 68)	χ² value	p value
Intraoperative conversion (n)	1 (1.47%)	8 (11.76%)	χ²=5.83	p = 0.016
Non-intraoperative conversion (n)	67	60	χ²=5.83	p = 0.016

Table 4

Comparison of the incidence of postoperative chronic pain between the two groups (χ²)
Items	Modified neck-shoulder technique group (n = 68)	Traditional surgery group (n = 68)	χ² value	p value
Postoperative chronic pain (n)	1 (1.47%)	12 (17.65%)	χ²=10.291	p = 0.001
Non-postoperative chronic pain (n)	67	56	χ²=10.291	p = 0.001

TEP surgery is performed in the preperitoneal space between the transverse fascia and the peritoneum. This space is traversed by structures such as the inferior epigastric vessels, genital vessels, and ductus deferens, and is covered by different layers of fascia that interweave and overlap with each other, making the anatomy complex and the operative space narrow, which can easily lead to complications such as peritoneal injury and vascular injury^{4, 5}. Therefore, identifying and operating in the correct fascial space is the key to the success of TEP surgery, and can avoid the occurrence of complications. Understanding the anatomy of the inguinal region under laparoscopy is the basis for ensuring the success of TEP surgery. The abdominal wall layers in the inguinal region are, from the inside out, the peritoneum, extraperitoneal fascia, transverse fascia, abdominal muscle, transitional sheath, subcutaneous tissue, and skin. However, there is currently controversy over the concept and understanding of the transverse fascia and extraperitoneal fascia. Some scholars believe that the transverse fascia is divided into two layers⁶. Others believe that the deep membranous structure of the transverse fascia is not the transverse fascia itself, but the preperitoneal fascia (PPF), which was explicitly proposed by Fowler⁷ in 1975. Ansari⁸ confirmed that the double-layer membranous structure of the transverse fascia belongs to two different systems of fascia with independent blood supply sources. Arregui⁹ pointed out in a study of laparoscopic surgery that the deep layer of the transverse fascia, that is, the fascia on the deep side of the inferior epigastric vessels, should be called the PPF. Therefore, it is now generally agreed that the PPF and the deep layer of the transverse fascia belong to the same structure. Similarly, there are different views among scholars at home and abroad regarding the morphology of the PPF. European and American scholars, represented by Fowler, believed that the PPF is divided into a superficial layer comprised of fatty structures and a deep layer of dense membranous structures. Japanese scholars believed that PPF contains fat and other tissues between two membranous structures, forming a surrounding abdominopelvic cavity, called the “preperitoneal space”¹⁰. The urogenital system and its associated blood vessels are within the “preperitoneal space” formed by the deep and superficial layers of the extraperitoneal fascia. The author believed that from the perspective of embryonic development, there is support for the existence of the “preperitoneal space” structure. Within a gastrula, which is a triploblastic embryo comprised of ectoderm, endoderm, and mesoderm, tubular structures develop during early embryogenesis via rolling up of the epithelium¹¹. Based on this phenomenon of tissue embryonic development, Japanese scholars such as Sato¹² proposed that the abdominal trunk is comprised of multiple ring layers, which is similar to the structure of an onion skin, and the preperitoneal space develops from interpenetration and surrounds the abdominopelvic cavity. During right hemicolectomy with complete mesocolic excision and retroperitoneal urogenital surgery, two layers of fascia were found behind the Toldt fusion fascia formed by the wall layer of the peritoneum, namely the Gerota fascia and the Zuckerkandl fascia. Corresponding to this should be the deep and superficial membranous structures of the PPF.

Figure 2 was a schematic diagram of the three-dimensional structure observed under the laparoscope during TEP surgery in a male patient with a right indirect inguinal hernia, combined with the situation of the fascia layer of the inguinal canal. The diagram showed a cross-sectional view of the distal hernial sac and proximal internal inguinal ring. The structure of the outer layer of the rectus sheath, such as the abdominal wall muscles, is omitted. The testes, epididymis, ductus deferens, and their vessels in the anterior peritoneal cavity descend to the scrotum during embryonic development. At the same time, cystic protrusions of the peritoneum drop to form the vaginal process outside the inferior vessels of the abdominal wall, which surrounds the testicles from both sides or from the front¹³. The peritoneal cavity of the vaginal process is fused and occluded after birth, forming a single dense vestige of vaginal process. If it fails to occlude, it forms a communicating hydrocele. The protrusion of the indirect inguinal hernia sac is the same as the peritoneal vaginal process during the embryonic period, during which the hernia sac is located above the vaginal process (Fig. 3).

The preperitoneal space can be subdivided into three spaces: (1) the first space between the transverse fascia and the superficial layer of the extraperitoneal fascia, (2) the second space between the superficial and deep layers of the extraperitoneal fascia, and (3) the third space between the deep layer of the extraperitoneal fascia and the peritoneum (Fig. 4). Extraperitoneal fat fills the space between the spermatic cord and the peritoneum. Furthermore, it is a non-vascular space that can be safely separated. We call the space between the spermatic cord and peritoneum, which includes parts of the second and third peritoneal spaces, a “safe zone”. The space between the spermatic cord and the superficial layer of the preperitoneal fascia, including the “death triangle” and “pain triangle,” is considered a “danger zone” because subsidiary-injuries, such as massive hemorrhaging and chronic neuropathic pain, are common when operating in this space.

As shown in Fig. 4, the Retzius space is expanded in the first peritoneal space during TEP. Additionally, the treatment of the hernia sac and expansion of the Bogros’ gap should be performed in the third space, if possible, to at least ensure that it is completed in the “safe zone.” Although difficult to achieve, the keys to successfully completing TEP include spanning the first peritoneal space and the “safe zone”.

In addition, it is difficult to distinguish the fascial layer during the operation, even when using a laparoscope; this contributes to the long learning period associated with mastering TEP surgery. In particular, the peritoneum may be easily broken because the wall of the hernia sac cannot be accurately identified; this also affects surgical progress. Adjacent membranous structures may fuse and degenerate with organ development. For example, different types of hydroceles are caused by incomplete atresia of the vaginal process. It is difficult to separate the dense adhesions of uterine round ligaments, hernia sac walls, and the peritoneum in female patients. A loop-like structure, termed the preperitoneal loop, is caused by partial fusion of multiple layers of fascia surrounding the hernia sac, including the transverse fascia, superficial and deep layers of the extraperitoneal fascia, and a single layer of the peritoneum, which forms the hernia sac wall¹⁴. The special changes of the membranes during development have been previously described by Gong Jianping¹⁵.

It is important to address the difficulties associated with TEP and ensure that TEP is completed quickly, accurately, and at the highest quality. Gilbert proposed the application of the neck-shoulder technique in open inguinal hernia surgery. The surgery is comprised of two core components. First, the hernia ring is compared to the “neck”, while the transverse fascia is compared to the “shoulder”. The transverse fascia is cut at the “neck-shoulder” junction to ensure accurate entry into the anterior peritoneal space. Second, the spermatic cord and peritoneum are completely separated, which allows the surgeon to enter the “safe zone” below the exposed spermatic cord. There is no discrimination between the peritoneum and the deep layer of the extraperitoneal fascia, which allows easier identification of the fascial layers. Furthermore, this approach avoids the breaking of the peritoneum, ensures rapid separation of the non-vascular layer, reduces bleeding, and facilitates smooth placement of the hernia patch.

We further optimized and refined this approach after analyzing the principles of the neck-shoulder technique, which was applied to TEP surgery. We compared the superficial layer of the extraperitoneal fascia to the “shoulder”, which is termed the same as in open surgery. The superficial layer of the extraperitoneal fascia must be accurately identified in order to safely separate the Retzius space and ensure proficiency during the subsequent operation. We constructed the following: (1) a detailed description of the specific part of the “shoulder” incision (named the “point”), (2) a detailed path of the first space to the “safe zone” (named the “line”), and (3) a detailed description of the separation of the non-vascular layer (named the “side”). In our center, we named the specific method from the “point” to the “line” and then from the “line” to the “side” as the “modified neck-shoulder technique”.

The steps of this technique can be outlined as follows. Step 1 includes completely separating the Retzius gap, revealing the “shoulder” (superficial layer of the extraperitoneal fascia), confirming the inferior vessels of the abdominal wall (Fig. 5) and the neck of the indirect hernia sac outside of the vascular root, which is the position of the “neck-shoulder” incision (i.e., the “point”) (Fig. 6). Step 2 includes opening the superficial layer of the extraperitoneal fascia from the “point” and into the inner and lower parts of the hernia sac neck. We found that constructing the “line” between the inner and lower parts of the hernia sac neck and spermatic cord (the ductus deferens and spermatic vessels) is a safe and reliable surgical approach. However, the vaginal process of the double peritoneum below the hernia sac is structurally different from that of the single peritoneum above the hernia sac. With the degeneration and atresia of the vaginal process, multiple peritonea fuse together and cause thickening of the layers under the hernia sac. It is difficult to break the peritoneum if the space below the hernia sac is separated. Furthermore, consistently using the spermatic cord as an anatomical marker and at a lower position ensures access to the “safe zone”. Step 3 emphasizes the importance of separating the outside and covering of the hernia sac first in order to orient the separation path and ensure that this path for the inner and lower hernia sac does not deviate from the “safe zone”. It requires a small and simple operation that is close to the peritoneum but does not deliberately expose the peritoneum in order to avoid breaking. Then, the separation path below the hernia sac is oriented. It is extended outward until it meets the first path; this allows complete transection or stripping of the hernia sac (Fig. 7). At this point, the spermatic cord is completely separated from the peritoneum, which ensures rapid expansion of the subsequent non-vascular layer. The spermatic cord is covered with peritoneum and the Bogros’ space is separated; this allows determination of the “side”.

Our operation procedures differ from those of the “Guidelines for Laparoscopic Inguinal Hernia Surgery” (2017 edition)¹⁶. They differ in the separation of the Retzius gap from the preperitoneal space, the treatment of the indirect hernia sac, and the separation of the Bogros' space. Therefore, we should ensure that we can safely enter the “safe zone” and rapidly expand the non-vascular layer. It should be noted that, given the characteristic of TEP as a layer surgery, the principle of layer-by-layer dissection and expansion is primarily based on separation. Except for the transverse cutting of the hernia sac and the incision of the “point” (i.e., the junction of the “neck-shoulder”), which requires the use of an electric scalpel for sharp dissection, the rest of the operation was performed using blunt dissection with non-injury grasping forceps as much as possible.

The modified neck-shoulder technique in TEP surgery is based on the concept of membrane autopsy. It overcomes the limitations of the limited magnification of laparoscopy and the insufficient understanding of the fine abdominal wall fascia layer formed during embryo development. Furthermore, it ensures that the operation is performed in the correct fascial space, avoids subsidiary-injuries, improves the quality of the operation, and shortens the learning time. However, more high-level clinical studies are warranted in order to demonstrate the effectiveness and safety of the technique in hernia repair. Additionally, more autopsies are needed to confirm the anatomical theories of the inguinal region. However, proposal of the surgical concept is the most important as it provides new insight into hernia surgeons in the hope that TEP surgery will enter the era of hernia surgery with more accurate fascial anatomy.

Conflicts of interest

The authors declare that they have no competing interests.

COI/Disclosures and acknowledgments

Dr. Goufeng Pan and Yanchang Xu equally contributed to this work. All authors have contributed significantly to this work, and all authors are in agreement with the content of the manuscript. There are no conflicting financial interests. The authors thank Editage (www.editage.cn) for English language editing. All the authors read and approved the final manuscript.

Ethics approval and consent to participate

An ethical approval has been obtained from the Institutional Ethical Committee of the First Hospital of Putian prior to initiation of the research work (2017-002). Informed consent has been obtained from each patient.

Funding

Not applicable

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No competing interests reported.

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Clinical Application of the Modified Neck-Shoulder Technique Based on Membrane Autopsy in Laparoscopic Totally Extraperitoneal Prosthesis for Indirect Inguinal Hernia

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Abstract

Figures

Introduction

1. Materials and methods

1.1 Study subjects

1.2 Surgical methods

1.3 Observation indicators

1.4 Statistical methods

2. Results

3. Discussion

4. Conclusion

Declarations

References

Additional Declarations

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