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Laparoscopic mesh hernia repair is an effective form of management of inguinal hernias.1 Polypropylene mesh is generally placed at the internal rings extending across the midline resulting in an intense fibrotic reaction that can make subsequent radical retropubic prostatectomy and lymphadenectomy difficult. We report the first case of laparoscopic radical prostatectomy following laparoscopic bilateral mesh hernia repair.
A 65-year-old man presented to our institution for laparoscopic radical prostatectomy, for stage T1c prostate cancer. Prostate specific antigen (PSA) and Gleason Grade were 7 and 6, respectively. The patient's only past history was an intraperitoneal laparoscopic bilateral mesh hernia repair via a 3-port approach 7 years earlier.
A transabdominal laparoscopic radical prostatectomy was perfomed using the 5-trocar technique, as described by Guillonneau et al.2 Pneumoperitoneum was achieved by inserting a Veress needle in the abdominal cavity 2 fingerbreadths below the left subcostal margin in the mid clavicular line. A 5-mm bladeless trocar was first placed in the left lower quadrant, 3 cm cephalad to a previous herniorrhaphy trocar site. The remaining trocars were placed after verifying the absence of visceral injury. Ileal and colonic adhesions to the internal rings were lysed with subsequent exposure of the clips used to close the peritoneum over the mesh (Figure 1). Following the dissection of the seminal vesicles, the bladder was distended with 200 mL of saline. The space of Retzius was entered medial to the umbilical ligaments bilaterally. The 2 pieces of mesh were stapled in the midline to the pubic symphysis (Figure 2). The pubic symphysis and endopelvic fascia were identified without difficulty. A radical prostatectomy was carried out with a watertight vesicourethral anastomosis. The postoperative course was uncomplicated with the patient being discharged from the hospital 40 hours postoperatively.
Laparoscopic prostatectomy has been performed in patients with a variety of previous surgical histories.2 To our knowledge, this is the first reported case of laparoscopic radical prostatectomy following laparoscopic bilateral mesh hernia repair. Katz et al3 recently reported on the difficulty of open radical prostatectomy in 2 patients after laparoscopic herniorrhaphy. One patient was deemed inoperable because of complete obliteration of the space of Retzius, while a second patient had a difficult prostatectomy after removal of the mesh.
Currently, a history of previous hernia surgery however has been an exclusion criteria for laparoscopic prostatectomy.2 Our patient was successfully treated laparoscopically without untoward effects. The mesh was completely covered by the peritoneum with no significant adhering viscera. The fibrosis encountered in the space of Retzius did not compromise the mobilization of the bladder. The transabdominal route negated the need to mobilize the mesh from the anterior abdominal wall. The mesh was stapled to the pubic bone in the midline but did not extend to the level of the puboprostatic ligaments or endopelvic fascia.
The interval between the previous hernia surgery and the laparoscopic prostatectomy may have been the most significant factor making this operation feasible. Meticulous closure of the peritoneum over the mesh by the previous surgeon may have also been a contributing factor. Despite the feasibility of this operation, patients with a recent laparoscopic hernia repair should be counseled regarding the difficulty of this operation and the possibility for conversion to open surgery. Those who present several years following mesh herniorrhaphy may benefit from a laparoscopic approach.