What is the best approach for hernia (hernia repair) involving Bogros space?

Laparoscopic Total Extraperitoneal (TEP) Approach Is Optimal for Hernia Repair Involving Bogros Space

The laparoscopic total extraperitoneal (TEP) approach is the preferred surgical technique for hernia repair involving Bogros space due to its lower wound infection rates, faster recovery, and comparable recurrence rates compared to open repair techniques. 1

Understanding Bogros Space in Hernia Repair

Bogros space is a critical anatomical area in the preperitoneal region that plays an important role in inguinal hernia repairs. It is a potential space located:

• Above the inguinal ligament
• In the extraperitoneal fat
• Between the transversalis fascia and peritoneum

Evidence-Based Surgical Approach

Laparoscopic TEP Technique

The laparoscopic TEP approach offers several advantages for accessing and repairing hernias involving Bogros space:

1. Preservation of peritoneal integrity: TEP is preferred over TAPP (transabdominal preperitoneal) as it maintains peritoneal integrity 2

2. Superior visualization: Provides excellent view of the inguinal region and hernias at their origin 3

3. Lower complication rates:

   • Significantly lower wound infection rates compared to open repair (p<0.018) 1
   • No increase in recurrence rates compared to open techniques (p<0.815) 1

4. Better patient outcomes:

   • Less severe postoperative pain (7.9% vs 15.1% in open repair) 4
   • Shorter hospital stays (2.68 days vs 3.86 days) 4
   • Earlier return to normal activities (13.6 days vs 19.8 days) 4
   • Significantly less chronic groin pain (3.4% vs 22.09%) 4

Technical Considerations for TEP in Bogros Space

When performing TEP repair involving Bogros space:

1. Space creation and dissection:

   • Initial dissection along posterior sheath of rectus abdominis 5
   • Camera enters retro-rectus space between rectus abdominis and transversalis fascia 5
   • Careful dissection through transversalis fascia into preperitoneal space 5

2. Plane identification:

   • The preperitoneal space is divided into parietal and visceral planes by preperitoneal fascia 5
   • Dissection of the median area should be on the parietal plane ("surgical space") 5
   • Dissection of indirect hernia area should be on visceral plane ("anatomical space") 5

3. Mesh placement:

   • Use of synthetic mesh is recommended for clean surgical fields 1
   • Ensure adequate overlap (minimum 3-5 cm) of the defect 6
   • Proper flattening of mesh requires dissection of preperitoneal fascia 5

Overcoming Challenges in TEP Approach

The TEP approach has been described as having a "steep learning curve" but can be mastered with proper training:

1. Learning curve considerations:

   • Perform at least 10 open Stoppa's preperitoneal procedures to learn anatomy before attempting laparoscopic TEP 2
   • Enhanced view TEP (e-TEP) technique can help overcome space limitations 3

2. Alternative approaches when needed:

   • Balloon dissection of Bogros space via femoral canal can be used in cases where general anesthesia is contraindicated 7
   • Conversion to open preperitoneal repair should be considered if difficulties arise during laparoscopic approach 2

Special Considerations

1. Emergency situations:

   • In cases of incarceration with signs of strangulation or intestinal obstruction, immediate surgical intervention is required 6
   • Open approach may be preferable when bowel resection is anticipated 1

2. Contraindications to TEP approach:

   • Hemodynamic instability
   • Peritonitis
   • Suspected bowel ischemia requiring resection

Postoperative Management

1. Pain management and early mobilization to prevent complications 6

2. Monitor for common complications:

   • Hematoma (1.6-1.86%)
   • Seroma (0.4%)
   • Wound infection (0.4-1.6%)
   • Orchitis (0.48%) 6

3. Progressive rehabilitation with focus on core strengthening, particularly the transverse abdominis muscle 6

By following these evidence-based approaches to hernia repair involving Bogros space, surgeons can achieve optimal outcomes with minimal complications and recurrence rates.