500 TOTAL EXTRAPERITONEAL APPROACH LAPAROSCOPIC HERNIORRHAPHIES - A SINGLE-INSTITUTION REVIEW

At Georgia Baptist Medical Center, a community-based, university-affil iated hospital, we adopted the total extraperitoneal approach (TEPA) t o laparoscopic herniorrhaphy due to potential complications in enterin g the abdominal cavity reported previously with the transabdominal pre peritoneal technique (Am Surg 1996;62:69-72). We have also employed re gional anesthesia (epidural) in 108 patients in whom the TEPA was util ized. In our institution, the TEPA has compared favorably to the trans abdominal preperitoneal technique, with lower complication and recurre nce rates. In patients with previous lower abdominal surgery, the TEPA is considered a relative contraindication due to the increased risk o f complications (Am Surg 1997, in press). Since June 1993, we have per formed 503 laparoscopic herniorrhaphies using the TEPA, with encouragi ng early results. To date, two recurrences have been reported, one wit h previous lower abdominal surgery and another whose recurrence was no ted to be secondary to incomplete reapproximation of the mesh with sta ples around the cord structures. Four major complications include two bowel perforations and two cystotomies noted during balloon dissection of the preperitoneal space. Three of these patients had previous lowe r abdominal surgery. Epidural anesthesia was used in 108 patients, 4 o f whom required conversion to general anesthesia due to peritoneal tea rs and pain associated with pneumoperitoneum. All four of these patien ts had previous lower abdominal surgery. In summary, the TEPA remains a viable technique for laparoscopic herniorrhaphy with acceptable comp lication and recurrence rates. Epidural anesthesia is well tolerated b y the patients undergoing this particular repair. We feel that lower a bdominal surgery may be a mitigating factor in selection of the TEPA. Continued re-evaluation of the procedure is warranted before definitiv e conclusions can be made.