Does Prior Mesh Repair for Inguinal Hernia Limit Subsequent Adrenal Surgery?
Prior inguinal hernia mesh repair does not limit or contraindicate subsequent laparoscopic or robotic adrenalectomy, though it may increase technical complexity requiring experienced surgeons.
Technical Feasibility and Safety
Laparoscopic and robotic approaches remain safe and effective for adrenalectomy even after prior pelvic or lower abdominal surgery, including inguinal hernia repair with mesh. 1
Minimally invasive surgery after prior lower abdominal procedures demonstrates equivalent complication rates, 30-day readmission rates, and recurrence rates compared to patients without prior surgery. 1
The key consideration is surgeon experience with laparoscopic adrenal surgery, as the ESMO-EURACAN guidelines emphasize that laparoscopic adrenalectomy "must be carried out only in centres with consolidated experience in laparoscopic adrenal surgery." 2
Approach Selection for Adrenalectomy
For small adrenocortical carcinomas (ACC) without evidence of local invasiveness, laparoscopic adrenalectomy is safe and effective in experienced hands, though this remains debated due to limited prospective comparative studies. 2
Both transperitoneal and retroperitoneal approaches are viable options, with no evidence of superiority of one over the other in the literature. 2
If during laparoscopic surgery involvement of surrounding tissues is discovered or there is risk of capsular rupture, immediate conversion to open surgery is mandatory to maintain oncological principles. 2
Impact of Prior Mesh on Surgical Planning
Prior inguinal mesh repair creates adhesions in the lower abdomen/pelvis but does not preclude safe dissection during adrenalectomy, particularly when using a transperitoneal approach that accesses the adrenal gland from above. 1
Laparoscopic and robotic approaches after prior pelvic surgery lead to faster cessation of narcotics and return to activities of daily living compared to open approaches (all p <0.05). 1
Robotic technology offers enhanced precision and endowrist movement that "facilitates the dissection near important adjacent structures," which may be advantageous when encountering adhesions from prior mesh. 3
Critical Surgical Principles
The primary determinant of approach is tumor characteristics, not prior mesh repair: tumor size, evidence of local invasion, and suspicion for malignancy guide the decision between laparoscopic versus open adrenalectomy. 2
For ACC tumors not invading the kidney, concomitant nephrectomy does not improve disease-free survival or overall survival and can be avoided. 2
Routine lymphadenectomy should include at least periadrenal and hilar nodes when performing adrenalectomy for ACC. 2
Common Pitfalls to Avoid
Do not assume prior mesh is a contraindication to minimally invasive adrenalectomy - this outdated concern is not supported by current evidence showing equivalent safety profiles. 1
Avoid laparoscopic approach if you lack consolidated experience in laparoscopic adrenal surgery, as outcomes are highly dependent on surgical expertise. 2
Do not persist with laparoscopic approach if intraoperative findings reveal local invasion or risk of capsular rupture - convert to open immediately to maintain oncological principles. 2
Ensure proper preoperative management of hormone hypersecretion, particularly cortisol excess, with hydrocortisone administration (e.g., 150 mg/day) during and after surgery to prevent adrenal crisis. 2