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Take Down of Peritoneum – Q&A
Docs,
Good afternoon, and Happy Memorial Day weekend.
I have read in a variety of posts here that it is important to take down the peritoneum in order to fully investigate when doing a laparoscopic exploration.
I have also read that this ‘adds’ significantly to the procedure – although I am not sure what is meant by that expression. Does it add to the duration of the surgery, or does it require a special skill set?
Pondering what I’ve read, I’m left with a few questions that, perhaps, some of the doctors could answer.
1) What are the drawbacks to taking down the peritoneum? Does it considerably lengthen the procedure? GIven its benefits, why isn’t it done during a “standard” exploration?
2) Does it create a weak spot that could be problematic going forward?
3) Does it put the patient at risk to adhesions?
4) Is it possible to take down the peritoneum on a male patient with a prior TEP repair?
5) Is there a high likelihood of identifying the problem when doing a laparoscopic exploration vs open exploration (I have bilateral pain so I believe I am more suited to the scope).I am very likely going to have an exploration done in the coming months. I want to make sure that I am well informed going forward. Once again, thank you to whomever can assist.
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3 Replies
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Thank you for your reply. It was very insightful, and I appreciate it. I am glad you had a good doctor who was able to get to the bottom of things.
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When I had my exploration and mesh removal, the surgeon, Dr. Billing, noted that both sides looked normal, from inside, using TAPP. This was noted in my notes from surgery. I had the mesh implanted via TEP. It wasn’t until he peeled the peritoneum back that he could see that one side was folded. He did the most painful side first, and the other side a month later. The other side did not have any folds, it had moved downward but otherwise was flat and well-placed. But both sides had looked the same on the first examination, from inside. That might be what you’re reading about, the fact that you can’t see mesh problems from inside like you can see a hernia. Apparently, a hernia will cause a depression that can be seen from inside.
On the second removal he tried to take a look at the first removal site but reported that he couldn’t because there was an adhesion. I got the impression that it’s not uncommon. But I’ve been fine with the adhesion, no complications. He also noted the second side, which was placed properly and had not folded, was edematous. It was inflamed and surrounded by fluid. That apparently did not show from the other side of the peritoneum either.
The peritoneum is an interesting thing. Apparently it can react almost as a whole to try and reform and protect the intestines. It seems like it’s a race between the peritoneum and the other healing response that causes adhesion. I think that adhesions are also possible with open surgery if the peritoneum is breached during removal. One advantage of TAPP, I think, is that the surgeon can see the work that’s been done before allowing the intestines to make contact with the peritoneum again. With open surgery maybe not so easy. But I am no expert.
Good luck.
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This primarily applies to inguinal hernias, but also true of other abdominals as well. it is recommended during laparoscopy in a virgin space, ie, no mesh repair.
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