https://orcid.org/0000-0001-7962-856X
Abstract
Laparoscopic transabdominal preperitoneal (TAPP) repair has become a standard approach for inguinal hernia repair; however, rare but serious complications, such as small bowel obstruction (SBO) caused by peritoneal dehiscence, can occur. We report the case of an 82-year-old man who developed early postoperative SBO due to peritoneal dehiscence after TAPP. Although conservative management was initially attempted, it failed to resolve the symptoms. Laparoscopic reoperation on postoperative day 21 revealed small bowel loops adherent to the mesh through a peritoneal defect. As the peritoneum was retracted and fragile, primary closure was not feasible. The defect was successfully repaired using a pedicled omental flap reinforced with an anti-adhesion barrier. The postoperative course was uneventful. Four years later, laparoscopic observation confirmed complete peritoneal regeneration without adhesions. When primary peritoneal reclosure is not feasible, reconstruction using a pedicled omental patch and an anti-adhesion barrier is a simple, safe, and durable method.
Introduction
Laparoscopic transabdominal preperitoneal (TAPP) repair has become an established procedure for inguinal hernia repair because of its low invasiveness, reduced postoperative pain, and faster recovery. However, the technique involves peritoneal incision and closure, which introduces a unique risk of postoperative complications, such as peritoneal dehiscence and small bowel obstruction (SBO). Several studies have shown that SBO after TAPP occurs more frequently than after totally extraperitoneal (TEP) or open Lichtenstein repair, with reported incidences of 0.5%, 0.07%, and 0.16%, respectively [1–3]. The mechanism usually involves bowel herniation into the preperitoneal space through a dehisced peritoneal closure, leading to entrapment or adhesion to the mesh. Abe et al. reviewed 22 cases and reported that 72.7% occurred within 10 days after surgery, suggesting that this complication predominantly arises during the early postoperative period [4]. Although rare, this condition can lead to significant morbidity. Awareness of its pathophysiology and management strategies is critical. We herein present a case of early postoperative SBO due to peritoneal dehiscence after TAPP repair. As primary peritoneal closure was not feasible, we employed a pedicled omental flap and an anti-adhesion barrier to cover the defect, achieving complete healing without adhesions even four years after surgery.
Case presentation
An 82-year-old man with a history of cerebral infarction underwent laparoscopic TAPP repair for a left inguinal hernia. The peritoneum was incised from the medial umbilical fold to the lateral aspect, and a polypropylene mesh was placed to cover the myopectineal orifice. Peritoneal closure was performed using a continuous absorbable barbed suture (3–0). The operation was completed without complications, and the patient was discharged on postoperative day (POD) 3. On POD 5, he presented with abdominal pain and vomiting. CT suggested a SBO caused by herniation of the small intestine into the preperitoneal space through a peritoneal defect (Fig. 1A and B). A diagnosis of simple SBO was made, and conservative management with nasogastric decompression was initiated. However, the obstruction persisted despite conservative treatment. Laparoscopic reoperation was performed on POD 21. Intraoperatively, a 5 × 3 cm peritoneal defect was identified at the site of the previous closure. The small bowel was herniated through this defect and adherent to the mesh (Fig. 2A). After careful adhesiolysis, the peritoneum was found to be retracted and too fragile to allow primary closure (Fig. 2B). To prevent recurrence, a pedicled omental flap was mobilized and sutured to the surrounding peritoneal margins with absorbable sutures to cover the defect (Fig. 3A). Oxidized regenerated cellulose (Interceed®) was placed over the omental patch to reinforce it and minimize adhesion (Fig. 3B). The postoperative course was uneventful, and the patient was discharged on POD 12. Four years later, contralateral TAPP repair was performed. Laparoscopic inspection revealed that the previous repair site was smooth, covered by regenerated peritoneum, and entirely free of adhesion or fibrosis (Fig. 4).
(A) Intraoperative view during the initial TAPP repair showing mesh placement to cover the myopectineal orifice. (B) Peritoneal closure with continuous barbed suture (3–0).
(A) Laparoscopic view at reoperation showing small bowel loops incarcerated and adherent to the mesh through a large peritoneal defect. (B) After careful adhesiolysis, a 5 × 3 cm defect was confirmed with retracted, fragile peritoneum.
(A) The defect was covered using a pedicled omental flap sutured to the peritoneal edges. (B) The omental flap was reinforced by oxidized regenerated cellulose (Interceed®) to prevent adhesion.
Laparoscopic view four years later showing smooth regenerated peritoneum at the previous site with no adhesion.
Discussion
SBO after TAPP is uncommon, but it can lead to significant morbidity if not recognized early. The reported mechanisms include (i) peritoneal dehiscence with bowel herniation into the preperitoneal space, (ii) adhesion between bowel and exposed mesh, and (iii) bowel entrapment by exposed barbed sutures [4–6]. Of these, peritoneal dehiscence is the most frequent cause and typically occurs within the first 10 PODs [4]. The widespread use of barbed sutures for peritoneal closure in laparoscopic hernia repair has introduced new complications. Although barbed sutures simplify laparoscopic closure by eliminating knot tying and maintaining even tension, their exposed ends can lead to small bowel entanglement, obstruction, or perforation [5, 6]. Segura-Sampedro et al. reported two such cases of SBO caused by exposed barbs, emphasizing the need for preventive strategies [5]. Several technical modifications have been proposed to mitigate these risks. These include reverse stitching the final few bites (“back-stitch technique”), burying the suture end under the peritoneum (“buried technique”), or applying an absorbable anti-adhesion barrier over the closure line [7, 8]. Oxidized regenerated cellulose (Interceed®) has been reported to reduce adhesion formation in laparoscopic abdominal surgery by providing a temporary physical barrier between the peritoneal surface and the bowel, which is gradually absorbed as the mesothelial layer regenerates. In the present case, peritoneal reclosure was not feasible because of extensive tissue retraction and fragility. Standard alternatives, such as medial umbilical fold advancement or absorbable mesh coverage, were not suitable. Therefore, we used a pedicled omental flap to cover the defect, supplemented by an anti-adhesion barrier. Several studies have documented the successful use of omental flaps in abdominal wall reconstruction, contaminated surgical fields, and infected mesh removal [8–10]. Experimental and clinical studies have demonstrated that physical separation between prosthetic mesh and the bowel is a key factor in preventing postoperative adhesion formation, supporting the concept of interposing biological tissue such as the omentum between the mesh and intestinal loops [9, 10]. In our case, the combination of a pedicled omental patch and oxidized regenerated cellulose achieved complete defect closure and long-term durability. The 4-year postoperative laparoscopic observation showed regenerated peritoneum with no adhesion, confirming the sustained efficacy of this method. The omentum likely promoted mesothelial regeneration, while the anti-adhesion barrier prevented early bowel contact during the healing phase. This case highlights the clinical importance of recognizing peritoneal dehiscence as an early postoperative complication of TAPP repair. Early identification and prompt surgical intervention are essential when conservative management fails. When primary closure is not possible, the combined use of an omental flap and anti-adhesion barrier provides a biologically sound, technically simple, and durable reconstruction method. This approach can be particularly beneficial in elderly patients or those with fragile peritoneal tissue.
Conclusions
Peritoneal dehiscence following TAPP repair is a rare but serious cause of early postoperative SBO. When peritoneal re-suturing is not feasible, covering the defect with a pedicled omental flap combined with an anti-adhesion barrier is a safe, simple, and durable solution. Long-term follow-up confirmed complete peritoneal regeneration without adhesion, demonstrating the biological efficacy of this approach. This combined technique should be considered a valuable option for irreparable peritoneal defects encountered during laparoscopic hernia surgery.
Acknowledgements
During the preparation of this work, the authors used artificial intelligence tools for English language editing and reference formatting. The authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Author contributions
SY performed the operation and drafted the manuscript. JF, ST, and YS contributed to postoperative management and provided critical feedback. All authors read and approved the final manuscript.
Conflicts of interest
The authors declare no conflicts of interest.
Funding
No funding was received for this study.
Ethical approval
This work does not require ethical considerations or approval.
Informed consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
