the goals of laparoscopic repair versus open repair include decreased pain , faster recovery , less time lost from work , and lower recurrence and complication rates .
the enthusiasm for laparoscopic procedures has led to their rapid acceptance with adequate investigations of some , but not all , of the possible perioperative complications .
some of the complications are well known , including trocar injuries , port - site herniation , and neuropathy from improperly placed staples .
a less well - recognized complication after laparoscopic inguinal hernia repair is small bowel obstruction .
this may be due to adhesions to , or entrapment under , the mesh as seen with the intraperitoneal on - lay mesh technique , which has been reported .
several reports in the literature discuss obstruction after transabdominal preperitoneal repair ( tapp ) due to small bowel herniation through , or adherence at , the site of the peritoneal closure .
the complication rate after totally extraperitoneal repair ( tep ) is reported to be lower than that after tapp .
the abdominal cavity is not entered in tep ; the risk of bowel obstruction after tep was thought to be essentially zero .
the patient noted the hernias while doing some heavy lifting at work . over the next week , he had the intermittent appearance of a bulge in the groin , especially with straining or coughing .
bilateral laparoscopic total extraabdominal preperitoneal hernia repairs were performed with the patient under general anesthesia .
the posterior sheath was not violated . a balloon dissector ( preperitoneal distension balloon and inflation bulb ;
tyco healthcare , norwalk , ct , usa ) was placed posterior to the rectus muscle fibers and anterior to the posterior rectus sheath .
this was followed by insertion of a 10-mm 0 laparoscope into the lumen of the dissecting balloon .
the balloon dissector was next replaced with a 10-mm structural trocar ( structural balloon trocar and inflation bulb ; tyco healthcare , norwalk , ct , usa ) .
three additional 5-mm ports were placed in the preperitoneal space , one midway between the umbilicus and pubic symphysis and one each medial to the right and left anterior superior iliac spines .
the hernia sacs were dissected off the cord structures to the level of the peritoneum .
the sacs were not entered during dissection nor were they amputated . a piece of 15x11-cm prolene mesh was used to cover the defects on either side .
the mesh was placed such that 2/3 of it covered the anterior abdominal wall and 1/3 covered the posterior surface .
the mesh was secured to the pubic tubercle on either side , using protacks ( protack , tyco healthcare , norwalk , ct , usa ) .
no protacks were used to anchor the mesh to the lateral abdominal wall and inferior to the ileopubic tract .
the inferior and lateral edges of the mesh were held in place with graspers while the preperitoneal space was deflated .
he returned 3 times , once on postoperative day 1 , again on postoperative day 3 , and a third time on postoperative day 7 , each time with abdominal distention , nausea , and vomiting .
each time , his symptoms resolved in less than 24 hours . on his second readmission , computed tomography ( ct ) scans of the abdomen and pelvis and a small bowel follow - through series were obtained .
the ct scan did not show evidence of mechanical small bowel obstruction and was interpreted as being consistent with postoperative ileus .
the small bowel follow - through showed delayed transit through the small bowel at 3 hours with contrast reaching the distal colon and rectum .
this was also consistent with ileus . due to the recurrent nature of his symptoms ,
when he returned on postoperative day 7 with recurrent symptoms , laparoscopy was again recommended , and this time he consented . at laparoscopy
, a veress needle was inserted into the left upper quadrant , away from the prior trocar sites .
inspection of the peritoneal cavity showed that approximately 18 inches of small bowel had herniated through a defect in the peritoneum in the right lower quadrant ( figure 1 ) .
the loops of bowel were incarcerated in the preperitoneal space adjacent to , but not adherent to , the mesh .
the defect in the peritoneum ( figure 2 ) was repaired with a running 2 - 0 silk suture with intracorporeal suturing on an endostitch device ( endostitch , tyco healthcare norwalk , ct , usa ) ( figure 3 ) .
the patient was discharged home the following day after tolerating a regular diet and demonstrating normal bowel function .
as experience with laparoscopic procedures continues to grow , vigilance for recognizing new complications should be maintained . the peritoneal defect described in our case likely occurred when
lodha et al report a similar case of bowel entrapment in a peritoneal defect after a tep hernia repair .
when the preperitoneal space is rapidly deflated at the end of the procedure , the force of the intraabdominal gas may push bowel through the defect .
rodda et al have also suggested the equalization of pressures between the 2 compartments as a mechanism of bowel entrapment after tapp .
first , a vigilant search for and repair of any peritoneal defects should be part of any tep procedure .
petersen et al describe a case of obstruction after tapp due to a peritoneal defect .
the best choice of repair for peritoneal defects appears to be a suture repair , as was done in our patient .
secondly , evaluation of the abdominal cavity for possible pneumoperitoneum should be done after a tep repair .
evacuation of the abdominal pneumoperitoneum prior to deflating the preperitoneal space would decrease the force that drives the bowel through a small peritoneal defect .
this could be done with a veress needle just prior to evacuating the preperitoneal space .
one of the advantages of laparoscopy is that it avoids the morbidity of a long abdominal incision .
small bowel obstruction after laparoscopic hernia repair as reported in the literature has been treated both laparoscopically and with laparotomy .
one caveat is that pneumoperitoneum should be established at a site remote from the original port sites .
presented here , the veress needle was placed in the left upper quadrant to avoid the site of suspected obstruction and avoid injury from the veress needle .
another option would be to use the hasson technique , but the veress needle provides a better seal and can be placed without complications in most cases .
trocars 2 and 3 can be placed in the midline hypogastrium or medial to the iliac crests on either side of trocar 1 . both positions for trocar placement
midline trocar placement might decrease the likelihood of an unnoticed peritoneal defect ; however , in patients with a short distance between the umbilicus and pubic tubercle , not enough room exists to place 2 trocars in the midline .
increased awareness of bowel herniation through peritoneal defects will allow more rapid diagnosis and treatment .
most reports in the literature describe a 3- to 10-day delay in diagnosis prior to definitive treatment . as with our patient
, it is easy to attribute their symptoms to postoperative ileus , possibly aggravated by narcotics .
expensive diagnostic tests like ct scans and small bowel follow - through could be avoided with a heightened index of suspicion for this complication .
technical considerations that should be observed with tep include a search for peritoneal defects , adequate repair of such defects , and evacuation of intraabdominal pneumoperitoneum prior to evacuation of the preperitoneal space .
attention to these technical details along with increased awareness of the possibility of bowel entrapment should reduce their incidence .
small bowel obstruction after tep and other laparoscopic procedures can be managed laparoscopically to maintain the benefits of this approach .
knowledge of the presentation of small bowel entrapment in peritoneal defects could result in less costly and more timely intervention .
 laparoscopic hernia repair is a frequently performed operation . 
 although it has many advantages over open inguinal hernia repair , laparoscopic surgery is not without complications . 
 small bowel obstruction is a complication unique to laparoscopic repair of inguinal hernias . 
 it is reported following transabdominal preperitoneal repairs . 
 we present a case of small bowel incarceration through a peritoneal defect after a totally extraperitoneal inguinal hernia repair . 
 techniques to avoid this complication are presented . 
 the literature is reviewed . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION