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Diagnostic laparoscopy as the definitive means of hernia detection?
Wes
In the event that I take the peritoneum down and there is a cord lipoma (prepetitoneal fat) that I reduce then IMO it is necessary to either close down the internal ring with a stitch (most commonly robotically) or place a mesh. I personally place a mesh but as Dr. Towfigh said, on experimental protocol using the robot there are folks closing the internal ring without mesh placement. We will have to see how this pans out over the coming years. A straight forward diagnostic lap without taking the peritoneum down I would not put an intraperitoneal piece of mesh and yes this is different than taking down the peritoneum. A missed prepetitoneal fat piece referred to as a cord lipoma could be missed as it would have been in my case today and was likely missed in the original open repair. If you take down the peritoneum and no hernia or cord lipoma then I would say you could consider not placing mesh. I will say that most often when I go back for recurrence or persisten pain laparoscopically after anterior repair I often find a cord lipoma that was not previously reduced. Hope that makes sense. If I can get a minute I will put a short video of my case together from today that we can maybe get some stills or video showing the difference. What you see in this case is clear reduction of the sac with residual cord lipoma that was not evident as part of the initial indirect hernia which is clearly visualized. Hope that helps. Dr. Szotek.