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Transabdominal preperitoneal repair for a recurrent inguinal hernia after Kugel procedure using the medial umbilical ligament: A case report


 Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China

Date of Submission02-Sep-2021
Date of Acceptance21-Dec-2021
Date of Web Publication06-Jul-2022

Correspondence Address:
Heguang Huang,
Department of General Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou 350001, Fujian Province
China
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_283_21

PMID: 35915518

  Abstract 


The Kugel procedure resulted in extensive adhesion in the preperitoneal space. Performing a transabdominal preperitoneal repair (TAPP) for recurrent hernia after Kugel procedure is extremely difficult. In this case report, we present the case of a 81-year-old male who presented with recurrent inguinal hernia after Kugel procedure 8 years ago. Transabdominal laparoscopy was performed first. Indirect hernia formed inferior to the lateral edge of the previous mesh was diagnosed under laparoscopy. The patient's medial umbilical ligament (MUL) was big enough and could be completely released by separating the Retzius space. Finally, TAPP was successfully performed by using the MUL to create and close the preperitoneal space. No perioperative complications or hernia recurrence was observed 1 year after the surgery. Using the MUL to deal with preperitoneal problems was practical and feasible.


Keywords: Kugel procedure, medial umbilical ligament, recurrent inguinal hernia, transabdominal preperitoneal repair



How to cite this URL:
Wang C, Lin R, Lin X, Lu F, Chen Y, Huang H. Transabdominal preperitoneal repair for a recurrent inguinal hernia after Kugel procedure using the medial umbilical ligament: A case report. J Min Access Surg [Epub ahead of print] [cited 2022 Aug 17]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=350044





  Introduction Top


Transabdominal preperitoneal repair (TAPP) has been widely used for inguinal hernias because of its minimal invasiveness. More and more attention has been paid in recurrent inguinal hernias. However, TAPP needs a large preperitoneal space, which makes it a challenge to be applied for recurrent hernias after preperitoneal repair, such as Kugel procedure. In this case report, TAPP was performed in a recurrent inguinal hernia after Kugel procedure using the medial umbilical ligament (MUL) to create and close the preperitoneal space.


  Case Report Top


An 81-year-old male patient who had a right inguinal hernia repair 8 years ago presented with a 2-month history of a new reducible right inguinal swelling. Details of the previous operation were not clear. Physical examination and preoperative ultrasound examination indicated a recurrent right inguinal hernia.

The standard three-trocar technique for TAPP was adopted after the induction of pneumoperitoneum. By laparoscopic exploration, a recurrent right inguinal hernia was confirmed. The new hernia sac protruded through the internal ring at the outer side of a Kugel patch (0010101, Bard, USA) [Figure 1]a. The Retzius space could be separated on the ventral side of the Kugel patch. During the procedure, the spermatic cord vessels were accidentally cutoff and clipped using a hem-o-lok [Figure 1]b. The upper thin peritoneum could not be separated from the patch due to extensive adhesion, and the separation was limited to the outside of the patch [Figure 1]c. A right 3Dmax patch (10.8 cm × 16.0 cm, Bard, USA) was cut open on 12 o'clock to be inserted in the preperitoneal space, covering the Kugel patch. Then, the mesh was sutured for fixation [Figure 1]d. The MUL was pulled laterally and sutured to the peritoneum by Y-shaped continuous suture. The preperitoneal space was completely closed to avoid contact between the patch and the intra-abdominal organs [Figure 2].
Figure 1: Creating the preperitoneal space and placing the patch. (a) A recurrent right indirect inguinal hernia was confirmed with the hernia sac protruding through the internal ring at the outer side of a Kugel patch. (b) Creation of the preperitoneal space. (c) The dashed area indicates the separation area of superior peritoneum. (d) A right Bard 3Dmax patch was cut open on 12 o'clock to be inserted in the preperitoneal space, covering the Kugel patch

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Figure 2: The medial umbilical fold was pulled laterally and sutured to the peritoneum by a Y-shaped continuous suture. The preperitoneal space was completely closed to avoid contact between the patch and the intra-abdominal organs

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The patient had an uneventful post-operative course, and no post-operative complications were observed during the 1-year follow-up period, including scrotal pain, seroma or recurrence.


  Discussion Top


Compared with anterior approach repair, the Kugel procedure proposed in 1999[1] can repair the entire inguinal region to strengthen the potential weakness of the myopectineal orifice, with the lower incidence of chronic pain and recurrence.[2] As our hospital performs the largest number of Kugel procedure in China and perhaps the world, we developed a modified Kugel procedure[3] through the internal ring approach on the basis of predecessors' and our experience and successfully promoted it to primary hospitals. However, the learning level of each hospital is uneven. Post-operative recurrence frequently occurs due to incorrect patch placement. Kugel surgery can cause extensive adhesion in the preperitoneal space, so the second surgery is usually performed through an anterior approach, such as Rutkow or Lichtenstein.

TAPP and totally extraperitoneal repair has been widely used in the repair of various inguinal hernias.[4] For recurrent cases, especially those with unknown previous surgical details, transabdominal laparoscopy can explore the operative area more better to formulate appropriate treatment strategies, which has great significance for reducing surgical risks and complications.[5] Thus, in the case reported in this paper, we performed transabdominal laparoscopy first. If the previous operation was Lichtenstein or other procedures did not involve the preperitoneal space, a standard TAPP would be performed easily. However, we could see a preperitoneal mesh, indicating that the patient's previous operation was Kugel procedure. Moreover, the patient's MUL was big enough and could be completely released by separating the Retzius space, which provided an opportunity to close the preperitoneal space. The results showed that using MUL to deal with preperitoneal problems was practical and feasible. We believe that most patients can achieve tension-free peritoneal closure by separating the Retzius space. If patients do not have enough tissue, the surgical strategy should be changed. The surgeon needs to make an accurate judgment before opening the peritoneum.

The greatest challenges for recurrent inguinal hernia repair are scar adhesions and abnormal anatomy caused by previous surgery. Separating the adhesions to create a surgical area and avoiding damage to normal tissues are the important requirements for high-quality surgery. In this case, we severed the spermatic veins completely because it was difficult to recognize the organization on the internal ring area. The surgeon must be sufficiently aware of the scar adhesions and abnormal anatomy to avoid damaging important tissues. Individualized treatment for patients is extremely important, and complex cases such as this case need to be carried out in centres with more experience.

Acknowledgements

This study was supported by Natural Science Foundation of Fujian Province, China, (No. 2018J05134), Medical Minimally Invasive Centre Programme of Fujian Province, China (No. 2017-171) and Key Clinical Speciality Discipline Construction Program of Fujian Province, China (No. 2012-649).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kugel RD. Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless, inguinal herniorrhaphy. Am J Surg 1999;178:298-302.  Back to cited text no. 1
    
2.
Kugel RD. The Kugel repair for groin hernias. Surg Clin North Am 2003;83:1119-39.  Back to cited text no. 2
    
3.
Lin R, Lin X, Lu F, Fang H, Yang Y, Wang C, et al. A 12-year experience of using the Kugel procedure for adult inguinal hernias via the internal ring approach. Hernia 2018;22:863-70.  Back to cited text no. 3
    
4.
Chen LS, Chen WC, Kang YN, Wu CC, Tsai LW, Liu MZ. Effects of transabdominal preperitoneal and totally extraperitoneal inguinal hernia repair: An update systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2019;33:418-28.  Back to cited text no. 4
    
5.
Köckerling F, Schug-Pass C. Diagnostic laparoscopy as decision tool for re-recurrent inguinal hernia treatment following open anterior and laparo-endoscopic posterior repair. Front Surg 2017;4:22.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04