The American Journal of Surgery (2010) 199, 730 –735

Clinical Surgery-International

Clinically diagnosed groin hernias without a peritoneal sac at laparoscopy—what to do? Christian Hollinsky, M.D.*, Simone Sandberg, M.D. Department of Surgery, Hospital of Floridsdorf, Vienna, Austria KEYWORDS: Overlooked hernia; Laparoscopic herniorrhaphy; Femoral hernia; Sac-less hernia; Preperitoneal pathology

Abstract BACKGROUND: Groin or femoral hernias may be concealed behind intact peritonea when the laparoscopic transabdominal preperitoneal (TAPP) mesh technique is used. The aim of this study was to determine the causes, frequency, and surgical procedures in cases of clinically diagnosed hernias without peritoneal defects. METHODS: A prospective controlled study comprising 1795 consecutive patients undergoing 2190 laparoscopic TAPP herniorraphies was conducted. All hernias were first subjected to clinical investigations by the surgeons. Intraoperatively, all suspicious hernias were examined with regard to the presence of peritoneal hernial sacs. RESULTS: Of 2190 hernias, no hernia was seen transperitoneally in the laparoscopic procedures in 136 cases (6.2%). Forty-one femoral hernias (30.1%) were concealed behind intact peritonea. Forty-six lateral (33.8%) and 31 medial (22.8%) defects were sacless sliding fatty inguinal hernias. CONCLUSIONS: When using the TAPP technique, in addition to femoral hernias, especially sacless sliding fatty inguinal hernias may be overlooked because of intact peritonea. Therefore, in cases of clinically diagnosed inguinal hernias, the preperitoneal space should be inspected intraoperatively to avoid unsatisfactory results. © 2010 Elsevier Inc. All rights reserved.

When using the laparoscopic transabdominal preperitoneal (TAPP) technique, an inguinal or femoral hernia can be overlooked in the presence of an intact peritoneum. A hernia is defined as a “protrusion of the parietal peritoneum trough a pre-formed or secondary gap.”1 This definition is pertinent especially if one assumes that a hernia is caused by an increase in intraperitoneal pressure. However, the definition could be fateful for laparoscopic surgeons because, in rare cases, inguinal or femoral hernias may be filled with cord lipomas or preperitoneal fat. Thus, peritoneal protrusion does not occur.2– 4 Especially in the early days of the laparoscopic TAPP technique, this led to incorrect evaluations * Corresponding author. Tel.: 43-1-275-22-4141; fax: 43-1-275-22-4109. E-mail address: [email protected] Manuscript received February 8, 2009; revised manuscript March 17, 2009

0002-9610/$ - see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2009.03.007

of the pathology in the groin, because some surgeons were misled by intraperitoneal findings on laparoscopy. The peritoneum was not incised because no gap was seen, and the operation was concluded as a diagnostic laparoscopy.5,6 Because we had to deal with “recurrences” of this type shortly after the introduction of the TAPP technique, we started to investigate this phenomenon more closely. The specific aims of the present study were to determine (1) the frequency of intact peritonea in groin hernias and (2) what pathologies of the groin this phenomenon might cause. We investigated the association between the anatomy of the preperitoneal space, the different types of hernias, and, in cases of recurrent hernias, the impact of the initial operation on hernias without protrusion of the peritoneum. For laparoscopic surgeons, intact groin anatomy gives rise to the decisive question as to whether the operation

C. Hollinsky and S. Sandberg

Groin hernias without a peritoneal sac

should be concluded by performing a diagnostic laparoscopy or whether the peritoneum should be incised and a groin hernia operation performed. Because the published literature in this regard is inconclusive because of the small numbers of patients studied, we specifically addressed this issue in the present investigation.2–10

Methods In a prospective controlled study, 2190 consecutive laparoscopic inguinal hernia repairs were performed in 1795 patients using the TAPP technique. The operations were either conducted personally by the first author or under his supervision between January 1993 and December 2007. Of the patients, 1567 (87.3%) were men and 228 (12.7%) were women, their ages ranging between 16 and 93 years (mean age, 54.3 years). The patients were sent to us by the general practitioner on grounds of a more or less painful protrusion in the inguinal region. All patients underwent clinical examinations by the surgeon at a special outpatient department for hernias and were investigated in both groins. Given a clear diagnosis of an inguinal hernia, the patient was scheduled to undergo groin hernia operation. In the event of contraindications for general anesthesia or the laparoscopic procedure (eg, an adherent abdomen, or the patient had undergone radical resection of the prostate gland) or if the patient expressed a preference for open surgery, the latter was performed; these patients were excluded from the present study. If no explicit findings were obtained despite pain in the groin (eg, a soft groin, an open inguinal ring, incipient hernia), an ultrasound investigation of the groin was additionally performed. In rare cases, supplementary nuclear magnetic resonance investigations were conducted. If these investigations also showed no explicit sign of inguinal hernias, the patients were examined by other specialists (eg, orthopedists, urologists, gynecologists) to exclude other pathologies associated with pain in the groin. In patients who had persistent pain in the groin and no pathologies on the investigations, conservative treatment (analgesics, local lidocaine infiltrations, antiphlogistic agents) was administered. If these measures failed, sportsman’s hernias were diagnosed, and the indication for TAPP was established in 8 professional athletes or active amateur athletes. Preoperatively, the groin with the hernia was marked with a pen. Intraoperatively, the TAPP technique was performed in the typical manner. The peritoneum on the marked side was always incised, regardless of whether a peritoneal defect was present or not. The peritoneal space was then carefully and accurately dissected and the following anatomic structures were inspected: the inferior epigastric vein, the superior ramus of the pubic bone, the symphysis, the deferent duct, and the spermatic cord. Occasionally, the femoral branch of the genitofemoral nerve and the lateral femoral cutaneous nerve were also inspected.

731

The hernias were localized and the hernial gap measured with an instrument. Cord lipomas, herniated preperitoneal fat, and other pathological structures (eg, pathological lymph nodes, cysts) were separated from the hernia, resected, and sent for histologic examination. A mesh (initially a heavy polypropylene mesh; thereafter, we increasingly used polypropylene or polyester meshes with large pores) measuring 15 ⫻ 10 cm, with rounded edges, was placed and fixed with a stapler. Finally, the peritoneum was closed using a hernia stapler or continuous sutures. If a hernia that had not been identified on clinical examination was found on the contralateral side, it was treated in the usual manner using the TAPP technique. These additional groin hernias were not included in the study. All operations were fully recorded on video. Each patient was examined postoperatively after 1 week. When patients had protrusions in the groin (eg, a hematoma or seroma) at this control investigation, they were controlled a further 1 or 2 times until the protrusion had completely disappeared. Patients with sportsman’s hernia were routinely called for follow-up examinations after 6 and 12 months. Multivariate associations between risk factors and hernias without peritoneal defects were evaluated using multiple linear regression analysis (XLSTAT; Addinsoft USA, New York, NY). The level of significance level was set at P ⬍ .05.

Results Of 1795 patients, 395 had clinically diagnosed bilateral hernias. Thus, we counted 2190 hernias in all. In 136 cases (6.2%), we found normal groins with no sign of peritoneal defects or hernial sacs. The reason a hernia was not identified transperitoneally was the presence of femoral hernias in 41 cases (30.1%; Figs. 1 and 2, Table 1). In the reference group consisting of hernias with peritoneal protrusions, femoral hernias were present in only 3.4% of cases (P ⬍ .0001; Table 2). Lipomas of the spermatic cord or round ligament were a frequent cause (46 cases [33.8%]) of hernias without peritoneal defects (Table 1). Thirty-one medial hernias could not be seen by the transperitoneal approach because of herniated preperitoneal fat (Figs. 3 and 4). Rarely diagnosed preperitoneal pathologies (such as enlarged lymph nodes in the hernia or atypical cicatrized hernias) are summarized in Table 1. On linear regression analysis, particularly femoral hernias were associated with a highly significant risk for being overlooked because of intact peritonea (P ⬍ .0001). Likewise, hernias with intact peritonea were found significantly more often in younger patients (P ⬍ .02) and in the presence of smaller defects (P ⬍ .01) than in the reference group. This was proved by the direct association between age and hernia size, because the sizes of the hernias were markedly increased with advancing age. This facilitated the identifi-

732

The American Journal of Surgery, Vol 199, No 6, June 2010 Table 1 Causes of hernias without a peritoneal defect (n ⫽ 136 [6.2%]) Pathology

Number of hernias %

Lipoma of the cord or round ligament 46 Preperitoneal fatty tissue in medial hernia 31 Femoral hernia 41 Sliding sigma 4 Sliding caecum 1 Enlarged lymph nodes in hernia 2 Atypical cicatricial hernia 1 Open deep inguinal ring 2 Deficiency of the posterior inguinal wall 8

Figure 1 Intraperitoneal view of a normal groin on the right side. No sign of a hernia.

cation of hernias in elderly persons. In contrast, gender, the presence of a recurrence, the type of inguinal hernia, and the side of the hernia showed no significant difference in relation to whether the hernia was accompanied by an intact peritoneum or not (Table 2). In 276 hernias (12.6%), recurrences were treated by surgery at time points 0.3 to 59 years (mean, 10.2 years) after the initial operations. Recurrences after the use of suture techniques or Lichtenstein operations were frequently femoral hernias. After open surgery, multiple hernias occurred on average in 17% of patients. After TAPP techniques, lipomas of the spermatic cord that had escaped detection at the primary operation were a frequent reason for reoperation (Table 3). The first postoperative control after 1 week revealed painful swelling (hematomas or seromas) in the groin in 74 patients (4.1%), who were fol-

Figure 2 Dissection of the peritoneum and preperitoneal fat reveals a femoral hernia measuring about 8 mm in diameter (white arrow). *Cooper’s ligament. **Superior ramus of the pubic bone.

33.8 22.8 30.1 2.9 0.7 1.5 0.7 1.5 5.9

lowed up until the hematomas (or seromas) had disappeared. After this time, they had no further symptoms. All other patients were devoid of any symptoms in the groin at the first control investigation. Just a few patients reported complaints at the trocar site.

Comments Visualization of the groin has been greatly improved by the laparoscopic technique compared with open surgery.11,12 During the first few years after the introduction of laparoscopic hernia surgery, it was assumed that viewing the groin intraperitoneally was sufficient to confirm the diagnosis of hernia. A groin hernia was considered present only when a peritoneal defect or a peritoneal hernia sac was identifiable.13 Only after investigation of recurrent hernias following the use of TAPP technique was it found that hernias may be present even in patients with intact peritonea.14 In the meantime, a few published case reports of “recurrent hernias” have shown that during the initial laparoscopic operation, the groin was deemed to be free of hernia because no gap was seen in the peritoneum.2,5,15,16 Because of these scarce data, it has not been possible to decide how laparoscopic surgeons should proceed in cases of clinically diagnosed hernias and intact peritonea. Gersin et al3 and Hainsworth5 are clearly in favor of opening the preperitoneal space and performing a TAPP operation in the groin. In contrast, some surgeons rate a herniorrhaphy as “overtreatment” in the absence of a hernial sac.6 – 8 In a prospective controlled study, we evaluated our TAPP operations: hernias were found concealed within normal peritonea in 6.2% of cases. In these patients, femoral hernias were found in 41 cases (30.1%). Femoral hernias are difficult to diagnose, especially by open surgical techniques. According to Koch et al17 and Mikkelsen et al,18 the primary reason for the 15-fold more frequent occurrence of femoral hernias during reoperations for recurrence was the overlooked femoral hernia at the primary operation. By contrast, laparoscopic techniques permit the surgeon to view all hernias above and below the iliopubic tract. Small

C. Hollinsky and S. Sandberg Table 2

Groin hernias without a peritoneal sac

733

Hernias without peritoneal defects in relation to various patient-related and hernia-related factors

Factors exerting a potential influence Mean age (y) Female Recurrent hernia Side of hernia Left Right Hernia location Medial Lateral Combined Femoral Defect size (mm)

Visible hernial ring (n ⫽ 2054)

% (93.8)

Intact peritoneum (n ⫽ 136)

% (6.2)

t

11.7 12.5

49.1 31 19

25.2 14.0

⫺2.34 ⫺0.99 1.20

.02 .33 .23

914 1140

44.5 55.5

63 73

46.3 53.7

⫺0.67 ⫺1.39

.51 .16

700 1146 139 69 27

34.1 55.8 6.8 3.3

30 56 9 41 17

22.2 41.1 6.6 30.1

⫺1.03 ⫺0.79 ⫺0.04 5.55 ⫺2.67

.31 .43 .97 ⬍.0001 ⬍.01

54.8 197 257

P value

Patients: n ⫽ 1795; hernias: n ⫽ 2190. Significance was determined by linear regression analysis.

femoral hernias are frequently diagnosed only after dissection of preperitoneal fat. Therefore, this step of the operation should be performed carefully and thoroughly. Lipomas of the spermatic cord or the round ligament escaped detection by the transperitoneal approach in 46 cases (33.8%). Lilly et al2 found cord lipomas in 22.5% of all hernias; nearly one third of these were devoid of any peritoneal defects. Of these, the authors were able to identify every second cord lipoma preoperatively by exact clinical investigation and ultrasound as well as nuclear resonance imaging of the groin. Studies conducted by Gersin et al,3 Nasr et al,4 and Lau15 also demonstrated the difficulty of identifying cord lipomas without peritoneal defects. Just as lipomas of the spermatic cord and the round ligament may be found in cases of lateral hernias, preperitoneal fat may be found within hernias in the absence of peritoneal defects in cases of medial hernias. In the present study, the latter phenomenon was established as the cause in

Figure 3 Trapped fat (sacless sliding fatty inguinal hernia) in a right-sided medial recurrent hernia. The hernial gap is marked with a white arrow. *Lateral margin of the rectus abdominis muscle.

nearly every fourth unidentifiable hernia (n ⫽ 31 [22.8%]). Read and Schaefer19 drew attention to the problem of herniated preperitoneal fat and termed this phenomenon the sacless sliding fatty inguinal hernia.7 On the basis of our results, it should be mentioned that, like lipomas of the spermatic cord, herniated preperitoneal fat in the medial hernia may also be overlooked or inadequately removed from the hernia during surgery.12 Fawcett and Rooney20 also stated that fatty protrusions observed during the repair of inguinal herniation comprise extraperitoneal fat extruded either through the deep inguinal ring or the floor of the inguinal canal. At first glance, recurrent hernias appear not to be associated with a significantly higher risk for being overlooked because of intact peritonea (14% vs 12.5%; Table 2). However, a closer appraisal reveals the problem: the anatomy of the region is altered after a conventional primary operation, or a mesh renders assessment of the groin difficult after laparoscopic surgery. We observed a markedly increased

Figure 4 After removal of preperitoneal fat, the hernial gap is clearly seen. *Lateral margin of the rectus abdominis muscle.

734 Table 3

The American Journal of Surgery, Vol 199, No 6, June 2010 Operations for recurrent hernia

Initial operation

n

Recurrence time in years, range (mean)

Bassini Shouldice Other suture techniques Lichtenstein TAPP Total

153 31 40 28 24 276

0.5–59 0.5–40 3–59 0.1–4 0.3–3 0.3–59

(12.4) (8.2) (13.8) (2.1) (1.5) (10.2)

Multiple hernial gaps (%) 36.6 29.8 17.5 3.6 — 17.4

Femoral hernia n

%

SSFIH

15 3 5 4 — 27

9.8 9.7 12.5 12.4 — 11.1

4 3 1 1 5 (2)* 14

SSFIH ⫽ sacless sliding fatty inguinal hernia. *SSFIH after TAPP total n ⫽ 5; in 3 cases, the peritoneum was not opened at the initial operation; in 2 operations, the lipoma was missed despite an opened peritoneum.

rate of multiple ipsilateral hernia gaps during reoperations for recurrence (17%; Table 3). This frequency is much higher than the 6% rate of multiple ipsilateral hernias at the primary operation, as reported by Ekberg et al.21 Therefore, during reoperation for recurrence, special attention should be given to any existing defects in the groin (possibly filled with preperitoneal fat) in addition to exposing the hernial gap. Recurrences after TAPP operations may occur because of missed cord lipomas. An overlooked cord lipoma is perceived as a hernia by the patient. However, even today, surgeons are occasionally deceived by an intact peritoneum and conclude the operation as a diagnostic laparoscopic procedure. One patient in our population had undergone 2 laparoscopic operations at a different hospital. In both operations, the patient’s intact peritoneum had convinced the surgeon of the absence of a groin hernia (Table 3). Recurrences of this type can probably be avoided by opening the preperitoneal space and carefully exposing the hernial gap.2,3,5,15 For intraoperative identification of cord lipomas, Lilly et al2 additionally recommended external compression over the inguinal canal and pushing the lipoma back through the deep inguinal ring. In our study, other pathologies, such as a sliding colon, enlarged lymph nodes, an open deep inguinal ring, or atypical incisional hernias in the groin, were rarely the cause of hernia in the presence of an intact peritoneum (Table 1). These and other rare pathologies (such as cysts or liposarcomas) reported by some authors may also fill an inguinal ring without being visible through an intact peritoneum.7,19 Sportsman’s hernias are borderline cases: the reason for chronic pain in competitive athletes or active amateur sportsmen is probably a deficiency of the posterior inguinal wall without demonstrable hernia.22–24 Because very few of our patients were genuine professional athletes, in cases of chronic pain and negative general investigations, operations were deemed appropriate for sportsman’s hernias in only 8 cases. Of these patients, who were followed up after 6 and 12 months, 6 had no pain, 1 was largely devoid of pain, and 1 had experienced no improvement after 1 year. In these patients, one nearly always finds a peritoneum without a hernia on surgery. Therefore, one should ask the

patient preoperatively whether he or she wishes to undergo mesh placement, with approximately 90% chances of success for elimination of the chronic pain.22–24

Conclusions All surgeons would be well advised to investigate their patients’ groins preoperatively to obtain a clear idea of the pathology of the preperitoneal space in the event of an intact peritoneum. We recommend that the peritoneum be opened in cases of clinically diagnosed groins or femoral hernias, because pathologies in the preperitoneal space cannot be identified through the peritoneum in 6% of cases. By carefully inspecting all potential hernias and dissecting sacless sliding fatty inguinal hernias from the defects, one should be able to avoid unsatisfactory results.

References 1. Schumpelick V. Hernien. 2nd ed. Stuttgart, Germany: Ferdinand Enke Verlag; 1990. 2. Lilly M, Arregui M. Lipomas of the cord and round ligament. Ann Surg 2002;235:586 –90. 3. Gersin K, Heniford B, Garcia-Ruiz A, et al. Missed lipoma of the spermatic cord. A pitfall of transabdominal preperitoneal laparoscopic hernia repair. Surg Endosc 1999;13:585–7. 4. Nasr A, Tormey S, Walsh T. Lipoma of the cord and round ligament: an overlooked diagnosis? Hernia 2005;9:245–7. 5. Hainsworth P. A hernia sac cannot be found at operation. Br J Surg 2000;87:521. 6. Waters K. Clinical dilemma. A hernia sac cannot be found at operation. Br J Surg 1999;86:1107. 7. Dickson G. A hernia sac cannot be found at operation. Br J Surg 2000;87:521. 8. Jensen P, Bay-Nielsen M, Kehlet H. Planned inguinal herniorrhaphy but no hernia sac? Hernia 2004;8:193–5. 9. Novitsky Y, Czerniach D, Kercher K, et al. Advantages of laparoscopic transabdominal preperitoneal herniorrhaphy in the evaluation and management of inguinal hernias. Am J Surg 2007;193: 466 –70. 10. McDonnell C, Walsh T. A hernia sac cannot be found at operation. Br J Surg 2000;87:521–2.

C. Hollinsky and S. Sandberg

Groin hernias without a peritoneal sac

11. Fagan S, Awad S. Abdominal wall anatomy: the key to a successful inguinal hernia repair. Am J Surg 2004;188:3S– 8S. 12. Awad S, Fagan S. Current approaches to inguinal hernia repair. Am J Surg 2004;188:9S–16S. 13. Sailors D, Layman T, Burns R, et al. Laparoscopic hernia repair: a preliminary report. Am Surg 1993;59:85–9. 14. Lowham A, Filipi C, Fitzgibbons RJ, et al. Mechanisms of hernia recurrence after preperitoneal mesh repair. Traditional and laparoscopic. Ann Surg 1997;225:422–31. 15. Lau H. Sliding lipoma: an indirect inguinal hernia without a peritoneal sac. J Laparoendosc Adv Surg Tech A 2004;14:57–9. 16. Lau H. Recurrence following endoscopic extraperitoneal inguinal hernioplasty. Hernia 2007;11:415– 48. 17. Koch A, Edwards A, Haapaniemi S, et al. Prospective evaluation of 6895 groin hernia repairs in women. Br J Surg 2005;92:1553– 8.

735

18. Mikkelsen T, Bay-Nielsen M, Kehlet H. Risk of femoral hernia after inguinal herniorrhaphy. Br J Surg 2002;89:486 – 8. 19. Read R, Schaefer R. Lipoma of the spermatic cord, fatty herniation, liposarcoma. Hernia 2000;4:149 –54. 20. Fawcett A, Rooney P. Inguinal cord lipoma. Br J Surg 1997;84:1169. 21. Ekberg O, Lasson A, Kesek P, et al. Ipsilateral multiple groin hernias. Surgery 1994;115:557– 62. 22. Genitsaris M, Goulimaris I, Sikas N. Laparoscopic repair of groin pain in athletes. Am J Sports Med 2004;32:1238 – 42. 23. van Veen R, de Baat P, Heijboer M, et al. Successful endoscopic treatment of chronic groin pain in athletes. Surg Endosc 2007;21: 189 –93. 24. Ziprin P, Prabhudesai S, Abrahams S, et al. Transabdominal preperitoneal laparoscopic approach for the treatment of sportsman’s hernia. J Laparoendosc Adv Surg Tech A 2008;18:669 –72.