|Year : 2018 | Volume
| Issue : 3 | Page : 235-240
Transabdominal preperitoneal hernioplasty for inguinal hernia and male fertility
Ayman M Elwan1, Ahmed F Aldek2, Tarek M Emran3
1 Department of General Surgery, Al-Azhar Faculty of Medicine, New Damietta, Egypt
2 Department of Radiology, Al-Azhar Faculty of Medicine, New Damietta, Egypt
3 Department of Clinical Pathology, Al-Azhar Faculty of Medicine, Cairo, Egypt
|Date of Submission||16-Apr-2018|
|Date of Acceptance||27-Jan-2019|
|Date of Web Publication||15-Apr-2019|
Ayman M Elwan
General Surgery Department, Al- Azhar University (Damietta), 34517, New Damita City
Source of Support: None, Conflict of Interest: None
Objective Inguinal hernia is a common surgical problem. Spermatic cord structures may be injured during open hernia repair, but it is uncommon after laparoscopic repair.
Aim The aim was to study transabdominal preperitoneal (TAPP) inguinal hernioplasty and its effect on fertility in male patients.
Patients and methods From July 2015 to November 2017, 30 male patients underwent laparoscopic TAPP inguinal hernioplasty and were included in this study. Testicular duplex and semen analysis were done preoperatively and 3 and 6 months postoperatively.
Results Preoperative sperm count and motility were within normal ranges. Three months postoperatively, there was a decrease in sperm count in five (16.7%) patients and decreased sperm motility in three (10%) patients. Further three months later, sperm count returned to normal ranges in all patients, and sperm motility returned to normal ranges in two (6.7%) patients but still decreased in one (3.3%) patient. Regarding testicular duplex, arterial flow was normal in all patients preoperatively; 3 months later, there was a decreased arterial flow in two (6.7%) patients; and 6 months postoperatively, testicular arterial flow returned to normal.
Conclusion Laparoscopic TAPP hernioplasty is feasible, is easy to learn, and has good results. Postoperatively, there was no significant affection of testicular perfusion or sperm characteristics.
Keywords: fertility, inguinal hernia, transabdominal preperitoneal
|How to cite this article:|
Elwan AM, Aldek AF, Emran TM. Transabdominal preperitoneal hernioplasty for inguinal hernia and male fertility. Al-Azhar Assiut Med J 2018;16:235-40
|How to cite this URL:|
Elwan AM, Aldek AF, Emran TM. Transabdominal preperitoneal hernioplasty for inguinal hernia and male fertility. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Jul 6];16:235-40. Available from: http://www.azmj.eg.net/text.asp?2018/16/3/235/255854
| Introduction|| |
Inguinal hernia is known to be one of the commonest surgical problems, as it occurs in 5–10% of the male population. Moreover, inguinal hernioplasty is the commonest performed surgical operation .
Surgeries for groin hernias were practiced at the end of the 16th century. At the 19th century, surgeons started to perform repairs that involved reduction and resection of the hernial sac and reinforcement of the posterior wall of the inguinal canal by various techniques. The use of prosthetic mesh was started in the 1960s, primarily in elderly with recurrent hernias .
Laparoscopic and conventional surgical approaches are available for inguinal hernioplasty. Recommendations for inguinal hernioplasty mostly include prosthetic mesh for lower recurrence .
Very good long-term results of these mesh repairs permitted acceptance of mesh repair in a larger group of patients. In the early 1980s, laparoscopic methods for groin hernioplasty were introduced, adding another technique for management of these hernias. Transperitoneal and totally extraperitoneal laparoscopic techniques have been developed .
Orientation of the spermatic cord anatomy has critical importance as it reflected on testicular physiology and function. The spermatic cord structures, such as vas deferens, testicular vessels, nerves, lymphatic, and fascia, are vulnerable to injury . There are different factors that lead to interruption of testicular perfusion .
Inguinal hernia itself may impair testicular perfusion; this was presented in some studies which may be owing to mechanical compression on the spermatic cord in the inguinal canal .
Akbulut et al.  documented that testicular volume is considered as an important outcome measure in patients with inguinal hernioplasty. Lima et al.  reported no changes in the volume of the testes or blood flow over 6 months postoperatively in participants under hernioplasty for their inguinal hernias.
| Patients and methods|| |
From July 2015 to November 2017, 30 male patients with inguinal hernia were included in the study. They underwent laparoscopic transabdominal preperitoneal (TAPP) hernioplasty in the Department of Surgery, New Damietta University Hospital.
The study was conducted according to Ethical Committee standards, and informed written consent was obtained from every patients before surgery.
Inclusion criteria were male, 20–40 years old, with reducible primary unilateral inguinal hernia. Exclusion criteria were past history of trauma of the testes, previous testicular surgery, and clinically proven testicular disease.
Cardiopulmonary and urological assessment plus routine investigations were done. Testicular duplex and semen analyses were done preoperatively and 3 and 6 months postoperatively.
One gram of prophylactic intravenous third-generation cephalosporin at induction was used routinely. Laparoscopic TAPP inguinal hernioplasty was carried out with general anesthesia. Foley’s catheter was placed before surgery. The supine position was ruled with both arms tucked by the patient side, and the head end of the table was tilted down 30° to enable production of pneumoperitoneum and transfer of the bowel away from the surgical field. Veress needle was used to create pneumoperitoneum. After achievement of satisfactory pneumoperitoneum, it was discarded, and a 10-mm port was placed through the supraumbilical incision. Two 5-mm ports were introduced as functioning ports for both hands of the operator, at the umbilicus level in the midclavicular lines.
The hernia defect was examined and the type (direct or indirect) was established by the relative location of defect to the inferior epigastric vessels and cord structures. The spermatic vessels arise laterally, and the vas deferens comes medially to meet at the internal ring; this forms an inverted V. The inferior epigastric vessels can be seen running upward from this point ([Figure 1]).
|Figure 1 Relations between inferior epigastric vessels, internal ring, direct hernia, vas difference, and spermatic vessels.|
Click here to view
Contents of the sac, if present, were reduced by the help of atraumatic bowel forceps; the structures in the groin area were recognized after reduction of the sac contents, namely, the external iliac artery and vein in the triangle of doom.
The peritoneal incision was begun at a point midway between the groin crease and the umbilicus, generally approximately 5 cm above the internal ring; it extended from above the anterior superior iliac spine to medial umbilical ligament. The flap was elevated by blunt and sharp dissection in cephalocaudal direction. Dissection continued medially to the symphysis pubis to show the Cave of Retzius.
In a direct hernia, the sac composed of peritoneal out pouching and a different quantity of fat (extraperitoneal), which may be very bulky. After the lateral dissection starting near the anterior superior iliac spine, the flap was raised medial to the internal ring till the midline. The hernial sac is anterior and lateral to the components of the cord.
Dissection of the sac was performed with care for hemostasis; a polypropylene mesh of 12 cm (transverse)×10 cm (vertical) was used for repair and then introduced into the surgical field by the 10-mm supraumbilical port after removal of the telescope. The mesh was applied directly over the spermatic cord covering the myopectineal orifice.
Transfascial sutures or tackers were applied over the medial and upper border of the mesh to anchor it to the underlying muscles. Generally, three sutures or staplers were enough: one on the medial border and two on the upper border ([Figure 2]). After placement of the mesh, the peritoneal flap was closed over the mesh to prevent bowel and omental adhesions, and this was done with absorbable sutures or tacker ([Figure 3]).
All carbon dioxide gas was removed from the peritoneal cavity. Ports were removed after raising up the anterior abdominal wall, and closure of the wounds was done.
Postoperative pain was measured using the visual analog scale, which consists of a line, usually 100-mm long, whose ends are labeled as the extremes (‘no pain’ and ‘worst pain as could be’). A patient was asked to put a mark on the line, indicating his pain intensity . Patients were followed up for a minimum of 6 months.
Statistical analysis was conducted using PC with the statistical package for the social sciences (SPSS) version 16.0 for Windows (SPSS Inc., Chicago, Illinois, USA).
| Results|| |
A total of 30 male patients were included in our study, and their age ranged from 20 to 40 years (mean: 32.03 years). Follow-up period ranged from 6 to 28 months (mean: 14.7 months).
Regarding the type of hernia, there were 22 (73.3%) patients with indirect hernia, three (10%) patients with direct hernia, and five (16.7%) patients with pantaloon hernia. The mean operative time was 70 min.
Postoperative pain was mild for 23 (76.7%) patients, moderate for six (20%) patients, and severe for one (3.3%) patient.
Preoperative sperm count and motility were within the normal ranges; 3 months postoperatively, there was a decrease of sperm count for five (16.7%) patients and reduced sperm motility for three (10%) patients; and 6 months postoperatively, sperm count came back to normal ranges for all patients and sperm motility returned to normal ranges for two (6.7%) patients and continued for one (3.3%) patient.
Regarding testicular duplex, arterial flow was normal for all patients preoperatively; 3 months postoperatively, there was a decreased testicular arterial flow for two (6.7%) patients; and 6 months postoperatively, the testicular arterial flow returned to normal. There was postoperative seroma in four (13.3%) patients, which resolved individually within 1 month. There was no recorded recurrence or mortality in the follow-up period.
Demographic data are presented in [Table 1].
| Discussion|| |
Inguinal hernia is a common clinical problem in males. The lifetime rate of inguinal hernia is 27% in males and 3% in female. The inguinal hernia risk grows with age . Pollack and Nyhus  reported that more than 500 000 hernioplasty are carried out each year. Laparoscopic repair also provides very good results when surgeons are experts in the technique. It results in decreased postoperative pain, less wound infection, and rapid return to daily activity and working .
It is rare but important that vascular complications of inguinal hernia repair range from decrease testicular perfusion to testicular ischemia. Moreover, perimesh reaction may lead to fibrosis, which can affect testicular blood flow. These complications may cause infertility .
The major factors that impair testicular perfusion are testicular artery and vein injuries, thrombosis of spermatic veins plexuses, and testicular torsion. Moreover, the use of nonabsorbable mesh during hernioplasty leads to a persistent reaction to foreign body involving the adjacent tissues. In hernioplasty by different mesh maneuvers, the components of spermatic cord are possibly injured by this inflammatory reaction. However, other authors recognized that testes have more vascular supply than anticipated .
Spermatic cord dissection during hernioplasty is minimal with the laparoscopic approach; subsequently, there is a reduction of the risk of groin and testicular complications owing to injury to cord components and adjacent nerves .
It has been documented that the complication of ischemic orchitis and testicular atrophy occur in 2–3% of all hernia repairs .
Some authors comparing laparoscopic and open inguinal hernioplasty reported that the incidence appears to be lower in the laparoscopic group with transient cord/testicular pain in 0.9%, and persistent cord/testicular pain in 0.6%. Ischemic orchitis/epididymitis and hydrocele occurred in 0.9% ,.
Postoperative pain in our study was mild, and this could be explained by less tissue manipulation. Testicular ischemia leading to testicular atrophy occurs in 0.2–1.1% of all inguinal hernia repairs .
Singh et al.  performed randomized controlled trial including 120 patients to compare testicular function after laparoscopic (60 patients) and open (57 patients) inguinal hernioplasty; the results favored the laparoscopic approach. The laparoscopic group composed of TAPP (28 patients) and TEP (32 patients). Testicular function was estimated by the volume of the testes, blood flow, and the levels of hormones preoperatively and 3 months postoperatively. There was a reduction in testicular volume (3 cm) for both open and laparoscopic techniques, but this was significant in the open group. There was a significant reduction in serum testosterone only in the open group.
Color Doppler revealed that both centripetal and centrifugal vessels are viewed as short arteries or simple color points. There are transtesticular arteries that are present in approximately 50% of the participants as thicker and relatively long vessels that cross the testicular parenchyma; they may be nonsymmetrical and are shown, more often, in the upper half of the testis. Most of them accompany a vein. Flow in these vessels may be either centripetal or centrifugal . Typically, testicular ischemia is diagnosed clinically and confirmed by color or power Doppler examination when there is no detectable flow within the testicular parenchyma. Peritesticular hyperemia occurs in subacute or chronic phases owing to anastomoses with epididymal and deferential arteries .
Injury to the spermatic cord components are well-known complications of open hernia repair, although infrequent after laparoscopic hernioplasty. When these complications develop, they are quite troubling to the patient and the surgeon. Complications can usually be avoided by proper determination of the cord components before use of diathermy or division of any longitudinal structures and by gentle manipulation of the vas deferens and vessels of the testes with atraumatic tools. Scrotal pain owing to irritation of genital branch of genitofemoral nerve is seen in a small portion of patients after laparoscopic dissection of the posterior floor. It may occur later on as a delayed problem in some participants, probably owing to pressure or irritation of the nerve fibers secondary to fibrosis around the cord. For most of the patients, the scrotal discomfort vanishes with passage of time. There were 3–5% cases of ischemic orchitis reported with open hernia repair, which is extremely rare after laparoscopic approach .
In our study, there were no changes according to testicular volume either after 3 or 6 months. On the contrary, testicular arterial flow decreased for two patients. However, not significant statistically and returned to normal 6 months after operation. We refer this decrease of testicular arterial flow to handling and dissection of testicular vessels, which resolved later on and returned to normal after 6 months.Shin et al.  documented 14 patients with postoperative obstructive azoospermia after hernia repair with polypropylene meshes. Their report was soon followed by other case reports and studies focusing on this specific problem . Patients considered being at the highest risk are fertile males (18–60 years of age), subjected to bilateral mesh inguinal hernioplasty, and those who undergo unilateral repair with impairment of the contralateral testis .
In our study, 3 months postoperatively, there was a decrease of sperm count for five patients. However, it is not statistically significant and returned to normal ranges 6 months after operation. Moreover, there was a decreased sperm motility for three patients, however, not statistically significant. Six months postoperatively, sperm motility returned to normal ranges for two patients and persisted for one patient which is insignificant statistically. These results indicate that chronic inflammatory tissue reaction has no adverse effect on testicular perfusion and spermatogenic function over time.
Manjunath et al.  reported that TAPP is preferred to open Lichtenstein operation regarding postoperative complications. The incidence of vascular injuries and neuralgia can be circumvented by avoiding suturing or tackering in the triangle of doom and triangle of pain.
In our study, there was postoperative seroma seen in four patients, which resolved naturally within 1 month. There was no wound infection, hematoma, or hernia recurrence during the follow-up period.
| Conclusion|| |
Laparoscopic TAPP hernioplasty is feasible, is easy to learn, and has good results with less incidence of hernia recurrence. Postoperatively, no statistically significant affection of testicular perfusion or sperm motility was seen, so it has no significant effect on male fertility.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]