AUS!. N.Z. J. Sue. 1993, 63, 823-824 823

ILIOINGUINAL NERVE ENTRAPMENT FROM LAPAROSCOPIC HERNIA REPAIR

SIMON WOODS AND ADRIAN POLGLASE Victorian Endosurgery Centre, Malvem, Wctoria, Awtralia

Key words: hernia, ilioinguinal nerve, laproscopy, s n r g e ~ ~ .

Introduction Entrapment of the ilioinguinal nerve during in- guinal hernia repair is a complication that has been recognized for many years. Most surgeons take pains to preserve the nerve although some divide it, accepting that the minor area of paras- thaesia is preferable to the potential pain if the nerve is inadvertently incorporated into a suture. It has been suggested that this problem would be avoided in laparoscopic hernia repair.' This paper reports that this complication can occur as a result of laparoscopic hernioplasty.

Case report Over the past 9 months a total of 149 laparo- scopic hernia repairs on 130 patients have been performed by the authors. A transperitoneal approach has been used in all cases, with dissec- tion of the peritoneum and extraperitoneal fat off the posterior wall of the inguinal canal and application of a polypropylene mesh patch over the entire posterior wall of the canal. The mesh is held in place with Endopath" (Ethicon, So- merville, NJ, USA) staples. Two of these patients (both of whom were thin), have subsequently complained of intense pain in the region of the inguinal canal. One patient had bilateral repairs and the pain was only reported on one side. No evidence of sepsis, hernia recurrence or other complication could be identified. Conservative treatment with analgesia was instituted. Neither patient improved with time and both were unable to return to work. In both patients a decision was made to re-explore the repairs 7 weeks after the initial surgery.

Correspondence: S. Woods, Suite 27, Cabrini Medical Centre,

Accepted for publication 13 August 1992.

Isabella St, Malvern, Vic. 3144, Australia.

At that time, a repeat laparoscopy was per- formed, but no problem could be seen with the repair. The mesh was in satisfactory position and evidence of reperitonealization could be seen. An inguinal incision was made and the inguinal canal explored. The findings were identical in both patients: three of the staples had passed through all muscle layers and had closed superfi- cial to the external oblique aponeurosis and one staple had entrapped the ilioinguinal nerve, which had to be divided to release the staple. In one patient a nylon dam was performed, to further reinforce the posterior wall of the canal. The patients' pain was immediately relieved. Both returned to work within 5 weeks of the second operation.

Discussisn Laparoscopic hernioplasty has recently attracted much attention, not all of it favourable." Various techniques have been described including trans- peritoneaP and extraperitoneal approaches! The majority employ a mesh such as a polypropylene, although expanded polytetrafluoroethylene has also been used.' Initially sutures were used to secure the mesh, but this is tedious. Most sur- geons now use stapling devices to secure the prosthetic material. At fust the present authors were concerned that the staples may not have been adequate to secure the mesh and in six of the initial cases supplementary percutaneous su- turing was employed as an adjunct. Subsequent experience has made the authors confident that the staples are indeed effective. The two cases presented here demonstrate just how deeply they can penetrate. The depth of penetration is deter- mined in part by the pressure applied to the stapler when firing and by any counter pressure being employed from outside. This experience suggests that excessive pressure should be avoided. The amount of force that should be exerted will remain a matter for clinical judgement and

824 WOODS AND POLGLASE

will also depend on the musculature of the pa- tient involved. Orientation of the stapler head along the axis of the ilioinguinal nerve may re- duce the possibility of entrapment.

The authors believe that laparoscopic hernia repair has a future in the management of selected patients. The rapid rehabilitation and early re- turn to work make it an attractive option for many. Patients must be informed of the possibil- ity of complications and the current lack of long- term data relating to the procedure before consenting.

2. MCKESSAR J. H. (1992) Laparoscopic repair of inguinal hernia (letter). Med. J. Aust. 156,508.

3. HUGH T. B. (1992) Laparoscopic repair of inguinal hernia (letter). Med. J. Aust. 156,223.

4. ARREGUI J. E., DAVIS C. J., YUCEL 0. & NAGAN R. F. (1992) Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: A prelimi- nary report. Sue. Laparosc. Endosc. 2,53-8.

5 . SEID A. S., DEWCH M. D. & JACOBSON A. (1992) Laparoscopic herniorrhaphy. Sue. Laparosc. En-

6. BLAMEY S. L. & WALE R. J. (1992) Laparoscopic repair of inguinal hernia (letter). Med. J. Ausr. 155, 718.

dose. 2,59-60.

1

7. TOY F. K. & SUOOT R. T. (1991) Toy-Srnoot la- paroscopic hemioplasty. Sue. Laparosc. Endosc. 1, References 151-5. PAGET G. W. (1992) Laparoscopic repair of inguin-

al hernia (letter). Med. 1. Ausf. 156,508.

Aus~. N.Z. J. Sue. 1993, 63, 824-826

PRIMARY TORSION OF THE GREATER OMENTUM

A. W. PICK AND B. T COLLOPY St Vincent's Hospital, Melbourne, victoria, Australia

Key words: abdominal pain, greater omentum, torsion.

Introduction Primary torsion of the greater omentum is an uncommon cause of abdominal pain and local- ized peritonitis that often mimics acute appendi- citis. A case is presented and the literature reviewed, with discussion of theories on the pathogenesis of this unusual entity. Emphasis is placed on the need to thoroughly examine the omentum during abdominal exploration for the so called negative acute abdomen.

Case report An 85 year old man presented with a 3 day history of constant, sharp, non-radiating pain in the right lower quadrant. The pain was exacerbated by coughing and moving, associated with nausea,

Correspondence: MI A. W. Pick, St Vincent's Hospital, Mel-

Accepted for publication 26 August 1992.

bourne, Vic. 3065, Australia.

but not vomiting, and there was no urinary or bowel dysfunction. He denied any history of preceding abdominal pain and his past medical history was unremarkable. On physical examina- tion he was pyrexial with localized tenderness and guarding in the right lower quadrant. A vage 6 X 9 cm mass was palpable 2 cm supralateral to McBurney's point. Rectal examination was non- contributory.

The white cell count was 11 500 with a normal differential. Urinalysis was normal and abdomi- nal X-rays were non-diagnostic.

A pre-operative diagnosis of acute appendicitis was made and operation performed via an oblique muscle-splitting incision centralized over the palpable mass. A small amount of serosanguin- ous fluid was encountered and immediately ap- porent in the wound was a 5 x 8cm mass adherent to the anterior peritoneum which con- tained infarcted omentum, clearly demarcated from the body of the greater omentum by a narrow pedicle that had undergone 720" clock- wise torsion. The mass was dissected free from