Emergency laparoscopic trans-abdominal pre-peritoneal repair (TAPP) for irreducible inguinal hernia in Covid-19 patient: A case report and literature review

Abstract

Introduction

With the global pandemic of COVID-19 for over two years, we might have to proceed surgical operation of patients with COVID-19 infection because of its emergency. Here we present a case who received an emergency operation for an irreducible inguinal hernia with COVID-19. We safely performed trans-abdominal pre-peritoneal repair (TAPP) in one surgery without any problems.

Presentation of case

52-year-old male with no specific past medical history came to the emergency department with complaints of right inguinal bulging and abdominal pain. On physical examination, a bulge in the right inguinal region was observed, so a right irreducible inguinal hernia was suspected. Since he had fever, we conducted a COVID-19 antigen test and it was positive. Because we could not return with manually, we decided to perform emergency surgery with appropriate infection control techniques. After laparoscopic return of the intestinal tract, a mesh was implanted using TAPP. The patient was discharged 2 days after surgery.

Discussion

Even in pandemic of COVID-19, cases of irreducible inguinal hernia could be occur. COVID-19 has systemic inflammation, so we worried about mesh infection. But this patient took TAPP safely in emergency surgery with COVID-19.

Conclusion

We experienced a case of TAPP proceeded patient with COVID-19. We considered that placement of a foreign material is acceptable when it is necessary in COVID-19 patient safely.

Highlights

• •This case study presents a COVID-19 positive patient who underwent TAPP for irrreducible inguinal hernia.
• •Even in pandemic of COVID-19, cases of irreducible inguinal hernia could be occur. COVID-19 has systemic inflammation, so we worried about mesh infection. But this patient took TAPP safely.

1. Introduction

This work has been reported as in line with the SCARE 2020 criteria [1]. A novel corona virus infection disease was firstly occurred Wuhan in China, generally called COVID-19 by the World Health Organization (WHO), a respiratory tract infection caused by the SARS corona virus 2 (SARS-CoV-2), still now continues in all over the world. The main symptoms of COVID-19 are fever, fatigue, cough, diarrhea, lethargy, and headache, but in some cases it can causes severe complications [2], [3]. In this pandemic, operations of benign diseases such as hernia and appendicitis are suspended, but it is impossible to avoid emergency surgery. When surgeons operate a patient with COVID-19, appropriate infection control techniques are recommended [4]. In our hospital, we also take sufficient procedures to prevent COVID-19 for medical staff and other hospitalized patients before performing emergency surgery. In this case report, we experienced a COVID-19 patient with an irreducible inguinal hernia who underwent laparoscopic trans-abdominal pre-peritoneal repair (TAPP) after the obstructed intestinal tract was returned. Mesh infection in TAPP is the one of the worst adverse event, and treatment for mesh infection is often difficult [5]. Here we report a case of a hernia repair by TAPP in a patient with COVID-19 infection without mesh infection.

2. Case presentation

The patient was a 52-year-old male with no specific past medical history. He came to the emergency department with complaints of right inguinal bulging and abdominal pain. On physical examination, a bulge in the right inguinal region was observed, and an inguinal hernia obstruction was suspected. We attempted manual return but we could not achieve. The patient's body temperature was 37.9 °C, so a COVID-19 antigen test was performed, and it was positive. Blood exam findings was white blood cell 9.3 × 103/μl, hemoglobin 13.7 g/ml, platelet 226 × 103/μl, albumin 4.5 g/ml, creatinine 0.94 mg/ml, blood urea nitrogen 20.2 mg/ml, c-reactive protein 0.12 mg/ml, PT-INR 1.04, APTT 29.9 s. A PCR test for COVID-19 was performed, and it was also positive. The diagnosis of COVID-19 was made. Contrast-enhanced computed tomography (CT) confirmed that there was no obvious intestinal ischemia (Fig. 1). We firstly attempted to return manually with conscious sedation, however we could not. So we decided to perform emergency surgery with adequate infection control techniques.

Fig. 1.

Contrast-enhanced computed tomography (CT) confirmed that there was no obvious intestinal ischemia.

We used the negative pressure operating room for a COVID-19 positive patient. Medical staffs entering the operating room were restricted. Intubation at the time of induction of general anesthesia was considered to be the highest risk of infection, so only one nurse and one anesthesiologist were in the operating room, and both took sufficient infection control techniques. The anesthesiologist performed tracheal intubation using video-laryngoscope. After intubation was completed, the primary surgeon (first author) and first assistant (second author) entered the room to begin surgery. Totally, only four medical staffs entered the operating room during operation. All of them were wearing N95 masks, face shield, clean gown, gloves.

The obstructed intestine was easily returned into the body cavity after muscle relaxant. The returned intestine was well-colored and necrosis was not visualized. The hernia was an external inguinal hernia, and the hernia orifice was about 3 cm long. The mesh was fixed and the peritoneum was closed. We used BardⓇ 3D MaxⓇ (light type) L size. The operation was successfully completed. Video of the surgery could not be taken for infection control. Total operating time was 1 h 24 min, total anesthesia time was 2 h 8 min. Postoperatively, the patient was followed up in a reclusive room for infection control. The patient was discharged two days after surgery. The patient did not complain of pain, and his postoperative course was good after discharge. After discharge, he was isolated at home for 2 weeks. All stuffs were checked our body temperature after surgery for 1 week. Since our temperatures were normal, it was determined that no secondary infection had occurred.

3. Discussion

Although emergency surgery may be inevitable in the COVID-19 pandemic, a 59.1 % reduction of emergency surgeries has been reported [6], especially in the pandemic, there were 92 % fewer surgeries performed for irreducible hernia. There was no statistically significant difference in the patients who underwent small bowel resection between before the pandemic and in the pandemic [6]. This study may mean that much more surgeons try to return intestinal tract into the abdominal cavity before the pandemic, and this effort resulted in decreasing emergency irreducible hernia operation. The frequency of bowel resection is the same, and action prior to resection is still required. If possible, surgery should be postponed for at least 7 weeks after SARS-CoV-2 infection, and a report recommends further postponement for COVID-19 patients who are still symptomatic [7]. As to some reports, an emergency surgery for a COVID-19 patient requires careful selection of a treatment strategy, but that necessary surgery should be performed with adequate infection control techniques [4]. In our case, it was difficult to return the irreducible hernia, and emergency surgery was deemed inevitable. Because the decision was made relatively early, bowel resection could be avoided. Under this pandemic, surgery for benign diseases has been postponed, and many cases of hernias are also postponed. Some reports have proposed early repair of inguinal hernias to prevent complications such as strangulation and obstruction which are called hernia accidents [8]. A recent meta-analysis showed a mortality rate of 4 % for hernia accidents compared to 0.2 % for elective repair [8]. Before hernia accident, mortality is significantly decreased. In COVID-19 pandemic, hernia accidents were suspected to increase because surgery for symptomatic hernias has also been postponed, but the number of emergency surgeries for irreducible hernia has been decreasing [9], [10]. Although emergency surgery for irreducible hernia in pandemic has decreased, considering the increased mortality associated with hernia accidents, it is better to operate at the appropriate timing before the intestinal tract becomes necrotic. In this case, we decided to perform the repair under general anesthesia, and there were no necrosis findings in the operation. The absence of necrosis was confirmed laparoscopically, thus avoiding a fatal hernia accident. Because TAPP has been reported to be associated with less wound infection and chronic pain than the Lichtenstein method [11], this patient was treated with TAPP. There seems to be no reports of the safety of implanting a mesh in a COVID-19 positive irreducible hernia patient. Since the placement of an artificial blood vessel is permitted in acute aortic dissection [12], we considered that placement of a foreign material is acceptable when it is necessary. In this case, we considered performing a high ligation or laparoscopic percutaneous extraperitoneal closure (LPEC), but since there was no intestinal necrosis and the infection was viral, we concluded that there was no causal relationship with the mesh infection, and therefore, we decided to perform TAPP. Patient was discharged without mesh infection. We believe that the curative treatment of an irreducible hernia in a COVID-19-positive patient in a single operation is worth reporting. The major limitation is we presented only one case, in one institute, and in Japan. Further cases accumulation might be to make clear this clinical question.

4. Conclusion

The COVID-19 pandemic seems to continue for more time. Surgeons are now performing surgeries only after careful consideration of the need for surgery. Irreducible inguinal hernia will occur a severe hernia accident. Surgeons should take appropriate strategy. TAPP for COVID-19 patient is need to discuss more because safety and efficacy of the TAPP as a primary curative procedure for an irreducible inguinal hernia without necrosis in a COVID-19 patient remains inconclusive. We proceeded TAPP safely in this case. Furthermore foreign materials such as mesh may be able to be placed in COVID-19 safely.

Author contribution

All authors namely, Dr. Satoru Takayama, Dr. Hisanori Kani, Dr. Ken Ishikawa, Dr. Keisuke Tomoda, Dr. Nobuyasu Yosimoto and Dr. Shoryu Takayama were involved in the management of this patient. This manuscript has been drafted by all authors.

Sources of funding

Authors did not receive funding for this research.

Ethical approval

Ethical approval obtained.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Registration of research studies

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Guarantor

Shoryu Takayama.

Declaration of competing interest

The authors report no declarations of interest.