Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Lin-kou Medical Center, Tao-Yuan, 333, Taiwan
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Key words: canal of Nuck/inguinal hernia/laparoscopic surgery
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Materials and methods |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
As in standard procedure, the laparoscope was introduced through the umbilicus after establishing a pneumoperitoneal pressure of 15 mmHg. Two additional 5 mm accessory ports were placed through each lower quadrant. A standard laparoscopic enucleation of the ovarian cyst was then carried out, with appropriate haemostasis. Sutures were used to close the remaining ovarian tissue.
Identification of the inguinal hernia
A large opening was noted on the peritoneum at the ventral margin of the right round ligament, followed by the canal of Nuck passing into the pelvic wall (Figure 1). At the same time, a cystic bulge was noted above the right labia major, at about the location of the pubic tubercle (Figure 2
). This bulge could be enlarged or reduced by adjusting the pneumoperitoneal pressure from 0 mmHg to 20 mmHg, indicating that the canal of Nuck was patent.
|
|
The operating time to complete the two sutures was <8 min. Postoperative pain was minimal, and the patient was discharged from hospital in 20 h. After 2 years follow-up the patient was well and without any sequelae, the bulge above the labia major having never recurred.
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
An untreated reducible hernia has the potential to develop into an incarcerated hernia; therefore most surgeons suggest that the hernia is best repaired as soon as a reducible mass is noticed. With the conventional anterior herniorrhaphic method, not only is a larger skin incision required but the postoperative recovery is also lengthy and painful, owing to the delicacy of the tissues manipulated during surgery and the anatomic tension created by the repair. The current techniques of laparoscopic hernia repair are usually carried out with a mesh prosthesis in order to cover the defect in a tension-free manner, to prevent recurrence of tissue attenuation of the repair, and to reduce postoperative pain. The most popular laparoscopic herniorrhaphic procedures include an intraperitoneal onlay mesh (IPOM) technique, a transabdominal preperitoneal (TAPP) approach, and a totally extraperitoneal (TEP) approach (Fitzgibbons et al., 1995; Liem and van Vroonhoven, 1996
). A randomized, multicentre trial has been performed which concluded that patients who underwent the TEP technique recovered more rapidly and had fewer recurrences (Liem et al., 1997
). However, the mesh prosthesis is a material which evokes a marked tissue reaction and may induce severe pelvic adhesion; the mesh may also, on occasion, migrate across the peritoneum. Complications caused by mesh, including bowel obstruction (McDonald and Chung, 1997
), mesh infections (Avtan et al., 1997
) and mesh migration into bladder (Hume and Bour, 1996
) have been reported when using the TAPP approach. Bowel obstruction has also been reported in TEP (Eugene et al., 1998
).
In the past, these hernia repair procedures have been designed mainly for use in male patients, and earlier reports of female inguinal hernia have emphasized the different, albeit stronger, inguinal anatomy of females (Glassow, 1973; Spangen, 1995
). During development of the female fetus, the processus vaginalis has no testes through which to pass, and contains no spermatic cord except for the gubernaculum, which later becomes the round ligament of the uterus. Thus, most female inguinal canals have fewer weak points, and hence inguinal hernias are of a milder form than those found in males. It is doubtful whether it is necessary to use such complicated and invasive methods to repair a mild female indirect inguinal hernia, especially when the hernia (though symptomatic) has usually been neglected by the patient herself. However, concomitant simple closure of the inguinal canal is a quick and simple way to deal with the problem during the same laparoscopic operation, and disappearance of the bulging mass under pneumoperitoneal pressure offers a good test to confirm complete occlusion of the patent hernial canal. In comparison with traditional anterior herniorrhaphy, the laparoscopic simple closure method provides better results and less postoperative pain. This is because it offers the highest ligation of the hernia sac by using an intraperitoneal approach, as well as a less invasive access, since the surgeon has no need to section a thick layer of fat and muscle. Unlike the laparoscopic mesh hernioplastic method, the simple closure method reported here does not require dissection of the extraperitoneal space, and also eliminates the possibility of mesh infection and severe adhesion or bowel obstruction which may be caused by mesh migrating into the abdominal cavity.
In short, the previously neglected female indirect inguinal hernia with open canal of Nuck may be revealed unexpectedly during laparoscopy for diagnostic work-up of infertility or other gynaecological conditions. The hernia may be cured by simple closure of the internal inguinal ring during the same laparoscopic surgery. Disappearance of the vulvar bulging mass under pneumoperitoneal pressure confirms complete closure of the patent canal of Nuck. Overall, the technique involves straightforward surgery, a minimal degree of invasiveness, and virtually no postoperative discomfort. The outcome of this approach has been satisfactory over a 2-year follow-up period.
![]() |
Notes |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Eugene, J.R., Gashti, M., Curras, E.B. et al. (1998) Small bowel obstruction as a complication of laparoscopic extraperitoneal inguinal hernia repair. J. Am. Osteopath. Assoc., 98, 510111.[Abstract]
Fitzgibbons, R.J., Jr, Camps, J., Cornet, D.A. et al. (1995) Laparoscopic inguinal herniorrhaphy. Results of a multicenter trial. Ann. Surg., 221, 313.[ISI][Medline]
Glassow, F. (1973) An evaluation of the strength of the posterior wall of the inguinal canal in women. Br. J. Surg., 60, 342344.[ISI][Medline]
Hume, R.H. and Bour, J. (1996) Mesh migration following laparoscopic inguinal hernia repair. J. Laparoendosc. Surg., 6, 333335.[ISI][Medline]
Liem, M.S.L. and van Vroonhoven, T.J.M.V. (1996) Laparoscopic inguinal hernia repair. Br. J. Surg., 83, 11971204.[ISI][Medline]
Liem, M.S.L., van der Graaf, Y., van Steensel, C.J. et al. (1997) Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N. Engl. J. Med., 336, 15411547.
McDonald, D. and Chung, D. (1997) Large bowel obstruction: a postoperative complication after laparoscopic bilateral inguinal hernia repair. J. Laparoendosc. Adv. Surg. Tech. A., 7, 187189.[ISI][Medline]
Spangen, L. (1995) Nonpalpable inguinal hernia in women. In: Nyhus, L.M. and Condon, R.E. (eds), Hernia. J.B. Lippincott, Philadelphia, pp. 8790.
Submitted on July 29, 2000; accepted on October 6, 2000.