laparoscopic inguinal hernioplasty is being performed more frequently everywhere , now that several well - designed prospective and randomized studies have shown that it produces results that compare favorably to the open conventional approaches with the added and well - known advantages of this type of mini - invasive surgery . however , like any other surgical procedure , it has complications , some of which appear to be unique to this technical modality like intestinal obstruction related to tapp .
a 65-year - old white male was seen in our office with the main complaint of bilateral inguinal hernias diagnosed elsewhere . he had had an appendectomy 15 years before .
he recently complained of pain in the right side and was referred to our office by his brother , who had been operated with the same diagnosis using laparoscopy in 1993 .
the rest of the clinical examination was unremarkable , and a chest film and electrocardiogram and pre - operative laboratory workup were within normal limits .
accordingly , on january 22 , he was admitted to the spanish hospital in mxico city and , under general endotracheal anesthesia , a 2 cm lower umbilical incision was made . under direct vision
the anterior fascia of the rectus muscle was incised and its fibers retracted . the preperitoneal space was dissected and a balloon trocar was inserted and advanced to the level of the pubis . during the dissection of the preperitoneal space , it was observed that the peritoneum was torn at the site of the previous appendectomy incision , and the procedure was converted to a transperitoneal approach .
two 10 mm trocars were placed in each flank under direct vision and transillumination to avoid injury to the epigastric vessels .
the right peritoneal incision was extended and a large indirect hernia with an accompanying direct defect were seen .
a lipoma was excised , and the peritoneal sac was dissected free up to the level of the umbilicus .
a 15  7 cm polypropylene mesh was introduced , unrolled and properly placed and anchored using a 5 mm tacker ( origin medical systems , inc .
, menlo park , california ) in cooper 's ligament , the upper medial corner of the hesselbach 's triangle , and in the lateral upper aspect above the level of the anterior and superior iliac spine .
the peritoneal defect was closed with a running suture of 00 pds ( polydioxanone ethicon , ltd , u.k . ) , ( figure 1 ) .
a similar procedure was carried out in the left side for a smaller indirect hernia .
the patient was discharged eight hours later with normal and stable vital signs , tolerating well a liquid diet .
the next morning he requested pain medication at home and took the analgesic prescribed ( ketorolac p.o .
10 mg ) , and soon after that he presented nausea and several episodes of forceful vomiting .
he was seen and examined at the emergency room at which time he was found to have normal vital signs , mild dehydration and abdominal distention with hyperactive bowel sounds without rebound .
he was hospitalized , a nasogastric tube was inserted , intravenous fluids and a second generation cephalosporin was given iv .
he failed to improve overnight , having a large ng aspirate , and he developed inguino - scrotal swelling for which reason he was taken to the operating room and re - operated using general endotracheal anesthesia . upon introduction of the 10 mm laparoscope , it was obvious that 30 - 35 cm of small intestine loops were herniated through a right peritoneal suture defect ( figure 2 ) . with the aid of two 10 mm babcock - type of forceps ,
all the loops of small bowel were carefully extracted from the defect and none of them showed signs of severe ischemia nor perforation .
the preperitoneal defect was irrigated and 10 ml of normal saline containing 1 g of kanamycin were left in .
the peritoneal defect was closed using interrupted  figure of x  stitches of polydioxanone until a water - tight closure was achieved ( figure 3 ) .
the postoperative period was uneventful ; he passed flatus in the second postoperative day , tolerated a liquid diet and was discharged on the 3rd postoperative day on oral antibiotics for an additional 10 days . he has remained asymptomatic to this date , having assisted to the office several times and is satisfied with the result of the operation .
closure of the defect with interrupted  figure of x  stitches using 00 polydioxanone .
at least nine prospective studies have compared the frequency of complications between laparoscopic and open inguinal hernia repair .
overall , the complication index is higher for the open procedures ( 22% vs 18% ) , though there is not statistical significance .
, in their multicentric prospective and randomized study , also found a higher morbidity for the open techniques ( 20.3% vs 20.1% ) even though in this report the use of extra trocars , rupture of instruments , and conversion from tapp to tep techniques were considered complications .
fortunately , most of the complications following laparoscopic hernia repair are minor ( seromas , hematomas , pneumoscrotum , orchitis , etc . ) although there are some serious complications of the operation like nerve entrapment and intestinal obstruction .
the latter is rare and may be caused by herniation of an intestinal loop through a port incision ( usually bigger that 5 mm ) when the wound has not been closed correctly .
we found at least 15 cases reported in the literature of intestinal obstruction due to herniation of the intestines or adhesions at the site of peritoneal closure after a transabdominal preperitoneal inguinal repair ( tapp ) . in five of these patients reoperation
was done laparoscopically , whereas in three it was done by laparotomy and in seven cases the approach was not specified .
one patient with a staple peritoneal closure developed an internal herniation , was re - operated by laparoscopy and presented a second intestinal obstruction in the same place that had been closed again with the staples and had to be re - operated for the second time by laparotomy .
herein reported - the 420th consecutive laparoscopic inguinal repair in our group since 1992 - it is possible to speculate that the vomiting crisis that our patient suffered soon after the analgesic ingestion could have caused a sudden increase of the intra - abdominal pressure leading to herniation of intestinal loops through the peritoneal inguinal closure . in general , the authors agree that staple closure can be defective if a large gap is left between them and that this may lead to the  shower - curtain  effect , which also occurred in this patient who had a running stitch type of closure .
our group previously repaired peritoneal defects with a running - suture or  figure of x  interrupted stitches with 00 pds ( polydioxanone ) and , as shown in figure 1 , the closure seemed to be adequate , initially .
after the presentation of this complication , our current opinion is that when tapp is indicated , a safer closure should be done with interrupted  figure of x  stitches , leaving a space of not more than 0.5 cm between each .
the procedure of choice at the present time is to carry out a tep procedure whenever it is possible , in which this complication is avoided .
there are , though , indications for a tapp procedure with advantages , and a reduced number of tep procedures will be converted .
so , it is necessary to keep in mind the possible complications of the former method to prevent them and treat them correctly once they appear .
finally , we think that the approach of choice in a reoperation of this type of case is laparoscopy because the lysis of adhesions and the internal herniation can be solved readily with this method .
if needed , the umbilical trocar incision can be lengthened 3 or 4 cms to assist the procedure in order to exteriorize necrotic intestinal loops to perform the resection / anastomosis procedure and introduce them back into the abdominal cavity . alternatively ,
if deemed necessary , a formal laparotomy can be done once the diagnosis has been established .
even though laparoscopic inguinal repair has gained popularity due to its results and advantages , it should not be forgotten that , as in any other surgical procedure , complications may appear and some of them can be serious or even lethal .
a water - tight peritoneal closure in the tapp procedure , using interrupted stitches with an adequate closure of the rest of trocar wounds , should reduce the risk of postoperative intestinal obstruction , considerably .
 a case is presented of a male patient that presented with intestinal obstruction in the early postoperative period of a transabdominal preperitoneal inguinal repair ( tapp ) that was diagnosed and repaired successfully using laparoscopy . 
 whenever a total extraperitoneal procedure ( tep ) can not be performed , the peritoneal closure of the tapp should be done water - tight using interrupted stitches of absorbable monofilament sutures . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSIONS