C. R. Berney: “The Endoloop technique for the primary closure of direct inguinal hernia defect during the endoscopic totally extraperitoneal approach”

Excerpt

We thank Christoph Berney for his interesting publication, in which he once again draws attention to the important problem of seroma formation in large direct or medial inguinal hernias following endoscopic totaly extraperitoneal patch plasty (TEP) [1]. It can cause patient discomfort and anxiety and often mimics an early hernia recurrence. Its volume is proportional to the size of the preperitoneal dead space after reduction of the hernia. For every direct (medial) defect found in the Hesselbach’s triangle and measuring more than 1.5 cm in diameter, Berney recommends systematic plication with a single (occasionally two) Endoloop^® Ligature of PDS^®II. From his results, Berney concluded that his technique is safe, efficient, and very reliable for the prevention of postoperative seroma formation [1]. In the “Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia” of the International Endohernia Society, it is pointed out on page 2,793 that for large or medial hernias, the extended transversalis fascia should be inverted and fixed to Cooper’s ligament [2]. However, to prevent chronic inguinal pain, no tacks should be used here. Suturing the extended transversalis fascia to Cooper’s ligament is a safer technique [3]. Reduction of this fixed space can effectively prevent the problem of postoperative seroma formation, which manifests externally as a persistent protrusion and is therefore also known as a pseudorecurrence [4]. This postoperative problem also obviates the need for punctures, with their attendant risk of infection. If this fixed space is not reduced in the manner described by Berney or by us, this serohematoma, giving rise to clinical protrusion of the inguinal skin, can be misinterpreted as an early recurrence and in the past has led to reoperations because of a suspected early recurrence [4]. …