Implementation of the trans-abdominal partial extra-peritoneal (TAPE) technique in laparoscopic lumbar hernia repair

Fourteen patients diagnosed as lumbar hernia were enrolled from May 2009 until January 2014 in this retrospective study. The study was approved by clinical ethics committee of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. The written informed consents were obtained from all patients involved prior to data collection. Patients were recruited after TAPE was performed and the data was collected from retrospective chart review and postoperative follow-ups. All procedures were performed by the same surgical team. Exclusion criteria were: emergency presentation, American Society of Anesthesiologists (ASA) classification IV-V.

The patient was placed in a lateral decubitus position with the table flexed, opening the space between the rib cage and the iliac crest. Repair was performed under general anesthesia and pneumoperitoneum was created with a Veress technique. The abdominal pressure was maintained at 15 mmHg during the procedure. Three ports (two 5 mm and one 12 mm) were built along the middle line, with the 12 mm port located transumbilically and other two 5 mm ports located 5–6 cm away from the 12 mm port to reach both sides. Sometimes the location of trocars was different depending on the location and the size of the hernia. When the hernia is too large towards the middle line, the 12 mm port was located transrectusly on the opposite side of hernia at the umbilical level, and with other two 5 mm ports located 5–6 cm distance away from the 12 mm port to reach both sides along the vertical axis. After an overview (Fig. 1a), the colon was mobilized by opening the peritoneal reflection above the white line of Toldt (Fig. 1b). Because of gravity, the colon can be retracted so that the extra-peritoneal space can be dissected and exposed. Continuing with the mobilization posteriorly until the psoas muscle (Fig. 1c). Beware of the extra-peritoneal structure, e.g. ureter, vessels and nerves, etc. The borders of the defect were recognized before dissection was extended (Fig. 1c). Usually, the dissection was extend to the iliac bone inferiorly and 4–5 cm over the border of the defect superiorly. An expanded polytetrafluoroethylene mesh (COMPOSIX^™ E/X, BARD DAVOL Inc., Warwick, RI, USA; PROCEED™, Ethicon Inc., Somerville, NJ, USA) large enough to overlap onto the normal fascia was inserted via the 12 mm trocar and extended close to the defect. The “partial-double-crown” technique [7] was enrolled: by 5 mm helical tack (ProTack, Tyco, Covidien, Norwalk, CT, USA), the mesh were fixed anteriorly to the musculus transverses abdominis, superiorly to subcostal ventral wall, inferiorly to iliac bone; another row of tacks was applied over the mesh around the margins of the hernia defect (Fig. 1d). After overlapped with the psoas muscle, the posterior edge of the mesh was extra-peritoneally fixed to the psoas muscle by interrupted sutures (Fig. 1e) and/or synthetic cyanoacrylic glue (COMPONT, Beijing Compont Medical Devices CO.,LTD., Beijing, P.R. China). In case the inferior margin of the defect was beyond the iliac crest, the dissection was extended and the mesh was fixed to the Cooper’s ligament (Fig. 1f). On the other hand, if the superior margin of the defect was close to subcostal margin, the mesh was implanted with at least 5 cm overlap to the diaphragm, avoiding fixation to the diaphragm to prevent associated cardiovascular and pulmonary complications. When fixation was finished, the mesh can be anatomically considered as the peritoneum. Therefore, the colon can be restored to natural anatomical position through interrupted sutures to the mesh, making use of the reserved peritoneum above the white line of Toldt (Fig. 1g). The gravity effect from the colon can stabilize the mesh in the early postoperative stage. When finishing the repair, the mesh was implanted posteriorly into extra-peritoneal space and anteriorly into peritoneal cavity, i.e., partial extra-peritoneal position (Fig. 1g). Finally, the cavity was reviewed (Fig. 1h), all trocars were removed and the abdomen was deflated.

Demographic and operative data were obtained regarding age, gender, BMI (Body Mass Index, kg/m²), ASA score, concomitant disorders, history of previous abdominal surgery and/or trauma, hernia defect size, mesh size, operative time (defined as skin-to-skin time), blood loss, intra-operative intra-abdominal structure injury (including spleen, ureter, bowel, vessel and nerve injuries) and conversion. Perioperative data including analgesia usage, Visual Analog Scales (VAS) score on POD1 (postoperative day 1) and POD3 (postoperative day 3), transient paraesthesia, postoperative duration of hospital stay were recorded.

All patients were followed-up after being discharged, according to a pre-established protocol. This included recording of medical history as well as physical examination, which were assessed 1, 3, 6 months after surgery and every 1 year thereafter. CT scan of the abdomen was performed 1 year after surgery or when necessary. Time of returning to unrestricted movement was also recorded. Postoperative complications were evaluated as follows: seroma, hematoma, wound infection, abscess in surgical region, chronic pain, bulge, mesh displacement and recurrence. The last date for follow-ups was 31th, July 2015.

Data are expressed as mean ± standard deviation. All calculations were performed with the SPSS software package version 12.0 (SPSS Inc., Chicago, IL, USA).

Fourteen patients were enrolled in this study (Table 1). The mean age of the patients was 68 ± 8 years. Twelve patients enrolled were male while two enrolled were female, with the average BMI 25.5 ± 2.1 kg/m². All patients were diagnosed as unilateral lumbar hernia, within 10 locating on left side and four on right side. The etiology study showed that 13 lumbar hernia occurred after surgical operations and one case after trauma.

As the results showed in Table 2, intra-operative investigation concluded that the average size of the hernia defect was 86.8 ± 46.4 cm², while the mean size of the mesh implanted was 275 ± 61.2 cm². The mean operative time was 59.2 ± 8.2 min. There was no intra-operative visceral injury in this serial of cases. There was no conversion case and all patients accepted the TAPE technique successfully. No patients accepted postoperative analgesia and the average VAS score on POD1 and POD3 was 3.8 ± 1.9 and 2.2 ± 1.6, respectively. The mean postoperative hospital stay was 4.0 ± 1.3 days.

No patient lost to follow-up during the investigation. The median follow-up time was 33 months. During the follow-ups, no complications as seroma, hematoma, wound infection, abscess in surgical area and chronic pain were observed. The follow-ups showed that all the patients returned to unrestricted movement within 2 weeks after surgery. There was no recurrence occurred according to postoperative physical examinations and/or CT scan during follow-ups.