Difficult hernias can come in two forms: technically difficult hernias with complex anatomy or unique locations, and simple hernias that present as challenging because of a patient's past surgical history. Sometimes these overtly simple hernias present with bigger technical challenges.
Such is the case when patients present with inguinal hernias and an indication to perform them laparoscopically (bilaterality, recurrence, or unique patient preference) in the setting of prior prostatectomy or other surgical procedure that precludes a safe development of an extraperitoneal plane.
In this setting, the surgeon must rely on the characteristics that the prosthesis in order to alter his/her routine operative algorithm to provide the patient with a safe, while reproducible outcome. TEP and TAPP techniques may prove unreliable because of the potential inability to reperitonealize a bare prosthetic mesh.
The use of an intraperitoneal onlay technique using a barrier mesh, such as C Qur (Atrium Medsystems) allows for the performance of a laparoscopic repair without the need to generate peritoneal flap coverage to avoid bowel exposure to the prosthetic. We have successfully use this technique in almost 200 patients with low morbidity and recurrence.