Diagnostic laparoscopy as the definitive means of hernia detection?

[Chaunce123]

For the difficult to detect hernia cases that are harder to pin down, but could exist and could be problematic, is diagnostic laparoscopy the definitive method of determining whether a hernia exists or not?

To simplify it greatly, it is as obvious as sticking a camera in the belly and looking around for an obvious hole somewhere? Find something and fix it, find nothing and no harm done? Is there much risk to that approach? Are some patients better suited to this than others?

I have seen what sounds like variations of this discussed on this forum, it sounds logical but is it just too invasive to be a standard diagnostic method for hernias?

[sngoldstein]

Diagnostic laparoscopy as the definitive means of hernia detection?

It’s not that simple. First, even though laparoscopy is a fairly low risk procedure, it is not risk free and that risk goes up significantly in patients with prior surgery. Second, small fat containing hernias are not always seen in a standard laparoscopy. The peritoneum needs to be opened which adds significantly to the procedure. Third, a hernia may or may not be the cause of pain and sometimes the only way to know is to do a repair, which can actually make things worse. The bottom line is that there are no easy answers and the decision has to come after a detailed discussion between the patient and surgeon.

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I would agree with Dr. Goldstein. Often there is fat from the retroperitoneum that is contained in a small hernia or at least as a cord lipoma that can cause pain when a transabdominal lap approach is used. This often is not seen intra-abdominal and the peritoneum must be opened to see it. Dr. Szotek

[jgens99218]

Diagnostic laparoscopy as the definitive means of hernia detection?

Dr Goldstein

Rarely have a read a response that provides an answer so clearly and concisely.

Just wanted you to know.

JG

[Chaunce123]

Diagnostic laparoscopy as the definitive means of hernia detection?

These are great replies and very informative, thank you Dr. Goldstein and Dr. Szotek.

A follow up question — What happens if a peritoneum laparoscopy is performed and no hernia is found? Does that ever happen? Are other problems ever seen in that approach which warrant fixing?

[wes878]

Diagnostic laparoscopy as the definitive means of hernia detection?

quote :

These are great replies and very informative, thank you Dr. Goldstein and Dr. Szotek.

A follow up question — What happens if a peritoneum laparoscopy is performed and no hernia is found? Does that ever happen? Are other problems ever seen in that approach which warrant fixing?

I would like to know the answer to this as well. Is there always “something” that could be fixed, even if it looks semi-normal? i.e., just put some mesh in there and see if the pain is eventually reduced? Would you go that far in and then not end up doing anything, or would you always do something once you got to that point? Also, if you end up getting mesh put in, but the pain ends up getting worse eventually, is it fairly easy to remove? Thanks

[jgens99218]

Diagnostic laparoscopy as the definitive means of hernia detection?

Wes

Let’s be clear. Removing mesh is never fairly easy. In fact is is extremely difficult and must be done by an experienced mesh removal surgeon, even then there is a high probability of long term complications. Lap placed mesh requires the peritoneum to be removed with the removal of the mesh. As Dr. Goldstein said diagnostic lap surgery has it risks and would be determined by your surgeon based on your condition. Some surgeons will insert mesh as a preventive measure if they are already there inside you. Example while fixing an inguinal hernia on one side. Once the mesh is in it doesn’t like to come out so think twice about getting mesh unless absolutely necessary.

JG

[drtowfigh]

Diagnostic laparoscopy as the definitive means of hernia detection?

Wes,

It’s not uncommon to perform a laparoscopy and miss a hernia. If the hernia is plugged with extraperitoneal fat, then a typical intraperitoneal exploration will not show the hernia hole. A complete exploration in the right setting should include taking down the peritoneum and looking right at the muscle itself, without anything obstructing the view.

I do not recommend placing mesh if there is no hernia. That can cause mesh-related complications and treating that is complicated and frought with risks, as Jgens points out.

[wes878]

Diagnostic laparoscopy as the definitive means of hernia detection?

Thank you for the response Dr. Towfigh. Is it possible to take down the peritoneum but not end up putting mesh in if a hernia is not seen? Or is the mesh required once the peritoneum is taken down? Also, do you know of a good hernia surgeon in San Diego county I could visit?
Thank you

[Chaunce123]

Diagnostic laparoscopy as the definitive means of hernia detection?

I don’t know for sure, but I think if you have the TEP surgery you always get a mesh to support it?

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I do not know anyone performing TEPP without mesh placement although it would theoretically be possibly by simply suturing the defect closed from the TEPP space and not placing mesh. Most surgeons do not close the defect from behind and just place mesh. Closing increasing chances of pain form nerve entrapment also. Some folks are starting to close on the robot but that is a TAPP approach.

[Owen2016]

Diagnostic laparoscopy as the definitive means of hernia detection?

Is this the safest surgery to check for a hernia? Does it become obvious that a hernia was causing the pain?

[drtowfigh]

Diagnostic laparoscopy as the definitive means of hernia detection?

If a hernia is not noted laparoscopically, it is okay and I would say it is preferred, that mesh is not placed.

Laparoscopic Dissection of the hernia area alone does not predispose it to hernia formation. It’s one of the perks of laparoscopy.

I offer robotic-assisted Inguinal hernia repair without mesh. I do it under a research protocol so that I can follow my outcomes prospectively. I am hopeful that it may be a valid non-mesh option that is also minimally invasive.

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

On this topic. I just did a case today that I completely reduced the hernia sac through TAPP approach and there was large prepetitoneal cord lipoma that was not evident intra-abdominally. This is the prime example of something that could possibly be missed with diagnostic lap alone and not taking the peritoneal reflection down. There was no evidence of this on intra-abdominal exam.

[drtowfigh]

Diagnostic laparoscopy as the definitive means of hernia detection?

Dr Garth Jacobsen in San Diego

[wes878]

Diagnostic laparoscopy as the definitive means of hernia detection?

quote :

On this topic. I just did a case today that I completely reduced the hernia sac through TAPP approach and there was large prepetitoneal cord lipoma that was not evident intra-abdominally. This is the prime example of something that could possibly be missed with diagnostic lap alone and not taking the peritoneal reflection down. There was no evidence of this on intra-abdominal exam.

I asked this somewhere earlier, but once you take the peritoneal down, does mesh need to be placed at that point? I understand it does not have to be placed during a diagnostic lap, but it sounds like these are two different things??

[pszotek]

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.

[wes878]

Diagnostic laparoscopy as the definitive means of hernia detection?

Thanks Dr. Szotek. I guess my question is, is the peritoneum vital to have intact? Once it is taken down, can it be placed back to where it was before, or does something else (mesh) have to be inserted in it’s place? This is assuming everything looks normal on close inspection, no hernia or lipoma. Also, is insurance covering this “experimental” robotic repair? Thank you

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I believe it is best to have intact and often do most of my inguinal hernias through a TEPP or total extraperitoneal approach. Could you theoretically take it down and not replace it yes. Here are some images from today. One shows me with grasper and scissors and this is what peritoneum looks like before you take it down. Next image shows the flap down and looking into the prepetitoneal space at the cord structures. The final image shown a how you close it. I use a suture. Hopefully Dr. Towfigh can answer your question about research protocol regarding the robot. Regardless of you have a hernia and I fix it whether I suture it plus mesh or just suture it then I fixed a hernia and it will be covered. I don’t have any other experience as like I said regardless I fixed the hernia. In fact for many years we fixed hernias without mesh.

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I believe it is best to have intact and often do most of my inguinal hernias through a TEPP or total extraperitoneal approach. Could you theoretically take it down and not replace it yes. Here are some images from today. One shows me with grasper and scissors and this is what peritoneum looks like before you take it down. Next image shows the flap down and looking into the prepetitoneal space at the cord structures. The final image shown a how you close it. I use a suture. Hopefully Dr. Towfigh can answer your question about research protocol regarding the robot. Regardless of you have a hernia and I fix it whether I suture it plus mesh or just suture it then I fixed a hernia and it will be covered. I don’t have any other experience as like I said regardless I fixed the hernia. In fact for many years we fixed hernias without mesh. Hope this

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I believe it is best to have intact and often do most of my inguinal hernias through a TEPP or total extraperitoneal approach. Could you theoretically take it down and not replace it yes. Here are some images from today. One shows me with grasper and scissors and this is what peritoneum looks like before you take it down. Next image shows the flap down and looking into the prepetitoneal space at the cord structures. The final image shown a how you close it. I use a suture. Hopefully Dr. Towfigh can answer your question about research protocol regarding the robot. Regardless of you have a hernia and I fix it whether I suture it plus mesh or just suture it then I fixed a hernia and it will be covered. I don’t have any other experience as like I said regardless I fixed the hernia. In fact for many years we fixed hernias without mesh. Hope this

[drtowfigh]

Diagnostic laparoscopy as the definitive means of hernia detection?

quote :

Thanks Dr. Szotek. I guess my question is, is the peritoneum vital to have intact? Once it is taken down, can it be placed back to where it was before, or does something else (mesh) have to be inserted in it’s place? This is assuming everything looks normal on close inspection, no hernia or lipoma. Also, is insurance covering this “experimental” robotic repair? Thank you

Yes, insurance covers robotic repair. It is not experimental. I choose to do it under research protocol so that I can prospectively follow my patient outcomes and report my results in a research paper.

Peritoneum does not provide strength to a hernia or muscle. No mesh is necessary if exploration shows no hernia.

[Chaunce123]

Diagnostic laparoscopy as the definitive means of hernia detection?

The idea of a laparoscopic repair without mesh sounds intriguing. Is there some cases where this is more suitable than others? Does this have a good outcome based on existing experience and data?

[drtowfigh]

Diagnostic laparoscopy as the definitive means of hernia detection?

I only apply it to small hernias for now, as a proof of concept. Will know more as more patients choose to have me perform this type. So far, results have been excellent, but it’s too early to claim.

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