From May 2020 to July 2021, patients who underwent transumbilical SIL-TEP repair of bilateral inguinal hernia with a single mesh through the posterior sheath posterior were retrospectively analyzed.
Inclusion criteria: (1) age > 18 years old, (2) bilateral inguinal hernia diagnosed preoperatively, and lesions confirmed by medical history, symptoms, physical examination and auxiliary examination (conventional color Doppler ultrasound or CT) before surgery, (3) patients able to tolerate general anesthesia.
Exclusion criteria: (1) incarcerated hernia,ascites hernia; (2) patients with severe heart, lung or liver dysfunction who could not tolerate general anesthesia; (3) patients with previous history of lower abdominal surgery.
Data collection and analysis: Basic information of patients: gender, age, body mass index (BMI), comorbidities such as hypertension, type 2 diabetes, etc. Intraoperative data: operation (endoscopic) time, estimated blood loss and intraoperative complications. Postoperative data: visual analogue scale (VAS) 24h after surgery, comfort score 3 months after surgery, length of stay, follow-up time and complications. Early follow-up was conducted by outpatient department and telephone at 2 weeks, 3 months and 1 year after surgery, respectively, and the follow-up content included infection, chronic pain, recurrence, seroma and foreign body sensation.
Statistical treatment: SPSS 22.0 software was used for statistical analysis of the obtained data. The measurement data were expressed as mean ± standard deviation (’ x ± s), and the counting data were expressed as frequency (%).
A total of 33 patients with bilateral inguinal hernia who underwent this operation met the inclusion criteria, including 31 males and 2 females, aged 63.27 ± 10.94 years (34–82 years), body mass index (BMI) 22.81 ± 2.43kg/m2, hypertension accounted for 21.21%, diabetes 9.09%.
Surgical methods
Before surgery, we need to measure and mark the distance from umbilicus to anterior superior iliac spine, umbilicus to pubic symphysis, bilateral anterior superior iliac spine, and anterior superior iliac spine to pubic symphysis, so as to tailor the mesh according to the patient's situation(FIG 1).
Combined intravenous and inhalational general anesthesia was used for surgery, and an indwelling catheter was inserted before surgery. The skin and the subcutaneous tissue were incised with an arc-shaped dermoid-incision of 2-2.2 cm through the lower edge of the umbilicus (Fig. 2), and the abdominal linea alba was transected about 5–10 mm below the periumbilical fascia (Fig. 3). For patients with narrow linea alba, we incised the bilateral rectus abdominis sheath, with a total length of about 2 cm. We then bluntly and sharply separated a preperitoneal space under direct vision at the level behind the posterior sheath posterior and inserted a single-port (Fig. 4). After the installation of the single-port device, we separated the surgical channel between the posterior rectus sheath and the preperitoneum under direct vision with an electric hook and noninvasive forceps (Fig. 5), where we entered the Retzius space from the level in front of the transversalis fascia (Fig. 6). It then expanded to both sides into the Bogros space. After we initially established the Bogros space and separated the lateral peritoneal return line, we treated the hernia sac on one side first. We completely stripped the hernia sac of direct hernia and minor indirect hernia, as far as possible. For large scrotal hernia and recurrent indirect hernia, we mostly used active incision of the hernia sac and transection of the distal inner ring of the hernia, and then pulled the needle straight with 3 − 0 barbed suture and sutured continuously. We then treated the contralateral hernia. The methods were as described previously. We inserted the pre-cut single mesh after we completed the separation. We used Bard 30*26 cm common mesh in the first operation of our team, and Johnson & Johnson 30*30 cm UMI large-lightweight mesh in the remaining 32 cases. We designed the mesh according to the size of the hernia ring using a specific mesh cutting method (Fig. 7). The diameter of the direct hernia ring was greater than 3 cm, and the height was 12 cm. For cases less than 2.5 cm, the height was 10.5 cm. The width of the mesh was the distance between the patient’s anterior superior iliac spine and the pubic symphysis. The measured data from each case are shown in Table I, and the distance was between 25 and 30 cm. In practice, we used 26 to 30 cm. We flattened and deflated the mesh and sutured the incision. Detailed surgical procedures are shown (Fig. 8, 9, 10, 11, 12, 13). Photos of postoperative effects are shown (Fig. 14).