Laparoscopic Inguinal Hernia Repair

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Chapter 29

Laparoscopic Inguinal Hernia Repair

Introduction

Inguinal hernias form because of a defect in the myopectineal orifice that allows intraabdominal contents to protrude into the groin. Accounting for approximately 800,000 cases annually in the United States alone, inguinal hernia repair is one of the most common operations performed by general surgeons. Open anterior surgical repair with mesh prosthesis was the technique of choice until the early 1990s, when the introduction of laparoscopy revolutionized inguinal hernia repair. Benefits of the laparoscopic technique include lower incidence of chronic pain and faster return to work. The laparoscopic approach also affords significant advantages for patients with bilateral hernias, recurrent hernias previously repaired by an anterior approach, and femoral hernias. Regardless of the approach, an in-depth knowledge of groin anatomy is essential to achieve a durable repair.

Laparoscopic Approaches

The two most common laparoscopic hernia repair approaches are the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP). In the TAPP technique the abdominal cavity is entered and a transverse incision is made in the peritoneum, starting at the medial umbilical ligament and continuing out laterally just short of the anterior superior iliac spine (ASIS). The peritoneum is peeled down from the transversalis fascia to expose the entire myopectineal orifice and create a “pocket.” Mesh is then placed into this pocket in the preperitoneal position and secured with tacks and/or glue. The peritoneum is then reclosed with suture or tacks, thus excluding the mesh from the intraabdominal contents to prevent bowel adhesions and minimize the risk of intestines being “trapped” in the preperitoneal space.

The TEP approach differs by avoiding entry into the abdominal cavity. Instead, balloon dissection creates a pocket for the mesh between the rectus abdominis muscle and the transversalis fascia.

No significant difference has been found between TAPP and TEP with regard to length of surgery, return to normal activity, or rate of recurrence. Some studies suggest a higher incidence of port-site hernias and visceral injuries with TAPP, whereas more conversions may occur with TEP. Ultimately, surgeons should choose the technique they are most comfortable with to obtain the best outcomes.

Regardless of the approach taken, the goal of laparoscopic herniorrhaphy remains a durable repair. In contrast to the open repair, the failures of the laparoscopic repair occur at the inferior border as the viscera “sneaks in” underneath the inferior edge of the mesh. As a result, sufficient dissection of the pocket along the inferior border is paramount to reduce recurrence. In addition, the authors often use fibrin glue to fixate the inferior edge of the mesh.

Key Anatomic Concepts for Laparoscopic Repair

Myopectineal Orifice

The myopectineal orifice is one of the most important anatomic features of the groin anatomy (Fig. 29-1, dashed ovals). All hernias of the groin originate from this single zone of weakness, which is covered only by transversalis fascia and peritoneum. Bisected by the inguinal ligament, the myopectineal orifice comprises the inguinal canal superiorly and the femoral canal inferiorly. The inferior border consists of the superior pubic ramus and the pectineal (Cooper’s) ligament. Medially, the myopectineal orifice is bordered by the rectus abdominis muscle and the inguinal falx (conjoined tendon). The conjoined (conjoint) tendon (fusion of internal oblique muscle and transversalis fascia) is also the superior border of the orifice. Laterally, the boundaries consist of the iliopsoas muscle and lateral border of the femoral sheath.

Inguinal Ligament versus Ileopubic Tract

Although a key anatomic landmark for open (anterior) inguinal hernia repair, the inguinal ligament is not seen in the laparoscopic (posterior) repair because it is an anterior lamina structure (Fig, 29-2, A). The inguinal (Poupart’s) ligament is the inferior edge of the external oblique aponeurosis, extending from the ASIS to the pubic tubercle, turning posteriorly to form the “shelving edge.” This shelving edge is used to secure the inferior border of the mesh in an open inguinal hernia repair (see Chapter 28). The iliopubic tract is the continuation of the transversus abdominis aponeurosis and fascia. It is located posterior to the inguinal ligament, extends from the pubic tubercle medially, and passes over the femoral vessels to insert on the ASIS laterally. This posterior lamina structure is an important landmark in laparoscopic inguinal hernia repair; lateral to the internal ring, no tacks should be placed below the iliopubic track because of the risk of injury to the lateral femoral cutaneous, genitofemoral, and femoral nerves.

Pectineal Ligament

The pectineal (Cooper’s) ligament refers to the periosteum found along the superior ramus of the pubic bone, posterior to the iliopubic tract (Fig. 29-2, B). The pectineal ligament is an extension of the lacunar (Gimbernat’s) ligament, which connects the inguinal ligament to Cooper’s ligament near their insertion site at the pubic tubercle. Cooper’s ligament is frequently used for medial fixation of the mesh in a laparoscopic hernia repair.

Inguinal Geometry

Hesselbach’s (inguinal) triangle is formed by the lateral border of the rectus sheath, inferior epigastric vessels, and inguinal ligament (see Fig. 29-1, B). Direct hernias occur through this space, medial to the inferior epigastric arteries. Indirect hernias are found lateral to Hesselbach’s triangle and the lateral umbilical ligaments, which contain the epigastric arteries.

The “triangle of doom” contains the external iliac artery and vein (Fig. 29-3, A). It is formed medially by the vas deferens, laterally by the gonadal vessels, and inferiorly by the peritoneal edge. No tacks should be placed in this triangle to avoid injury to the iliac vessels.

The “triangle of pain” is defined by the gonadal vessels medially, iliopubic tract laterally, and peritoneal edge inferiorly (Fig. 29-3, A). It contains the lateral femoral cutaneous nerve, femoral branch of the genitofemoral nerve, and the femoral nerve. Tacks in this area risk nerve entrapment, causing pain on the anterolateral aspect of the thigh.

The “circle of death,” also known as corona mortis, is a vascular ring formed by the anastomosis of an aberrant artery from the external iliac artery with the obturator artery, branching from the internal iliac artery (Fig. 29-3, B). Tacks should be avoided here because profuse bleeding can occur if the ring is injured.

Principles of Laparoscopic Repair

General anesthesia is preferred in most TEP cases and is required for the TAPP approach. Patients are asked to void immediately before surgery, obviating the need for catheterization and helping prevent bladder injuries. Identification of the anatomic landmarks of Cooper’s ligament medially, psoas muscle inferiorly, as well as the peritoneal sac, gonadal vessels, round ligament or vas deferens, iliac vessels, and the iliopubic tract, is key to operative safety and efficacy. Separation of the hernia sac from the cord structures before reduction of the sac helps avoid injury to the gonadal vessels and vas deferens.

Complete reduction of the hernia sac is critical to preventing recurrent hernias, as is dissection of a wide pocket for placement of the mesh and ample coverage of the direct, indirect, and femoral spaces. Minimal use of tacks, including avoidance of tacks below the iliopubic tract, is mandatory to avoid complications of chronic pain caused by nerve injury.

Importantly, a number of anatomic structures seen during the open anterior inguinal hernia approach are not visualized in the laparoscopic approach, including the inguinal and lacunar ligaments and the ilioinguinal and iliohypogastric nerves. Also, the spermatic cord, consisting of the cremasteric fibers from the internal oblique muscle, cremasteric vessels, testicular vessels, genital branch of genitofemoral nerve, vas deferens, and lymphatics, only becomes an entity within the inguinal canal, which is not seen in the laparoscopic view. The gonadal vessels, vas deferens, and genital branch of the genitofemoral nerve are seen entering the internal ring, at the entrance to the inguinal canal.

Transabdominal Preperitoneal Approach

The patient is positioned supine, with both arms tucked at the sides. Port placement for the TAPP approach typically begins by placing a 12-mm port at the umbilicus. Once pneumoperitoneum is established to 15 mm Hg, an angled laparoscope is introduced into the abdomen. Two additional, 5-mm ports are then placed, one at the lateral border of each rectus muscle, taking care to avoid injury to the inferior epigastric artery.

Next, both inguinal areas are inspected for hernias. Identification of the following landmarks are critical to begin dissection: medial umbilical ligament (containing obliterated umbilical artery), testicular vessels, inferior epigastric vessels (lateral umbilical ligament), and external iliac vessels (Fig. 29-4, A).

To begin the incision, the laparoscopic scissors are used to make a transverse incision in the peritoneum, starting at the medial umbilical ligament and continuing laterally along the anterior abdominal wall, ending just short of the ASIS. This incision line essentially parallels the arcuate line of Douglas. The peritoneum is then grasped along its edge and dissected away from the transversalis fascia, which remains on the anterior abdominal wall. When creating this peritoneal flap, great care must be taken to avoid injury to the epigastric vessels and to sweep all layers toward the anterior abdominal wall, except the thin peritoneal layer. This pocket is dissected out medially to expose the pubic symphysis and Cooper’s ligament, a white glistening structure along the superior pubic ramus (Fig. 29-4, B). Lateral exposure continues 3 to 5 cm lateral to the opening of the internal inguinal ring and inferiorly until the edge of the psoas muscle is visible.

Dissection of the hernia sac, if present, is performed by placing inward traction on the peritoneum and carefully separating the sac from the cord structures. As the hernia sac is “reduced,” the spermatic cord (running posterolaterally to sac) is identified and protected. If a direct hernia is present, the sac must be separated from the transversalis fascia within Hesselbach’s triangle. It is important to separate the cord structures from the sac before reducing the sac, to avoid inadvertent injury to the vessels or vas deferens. Laterally, the gonadal vessels are also identified and dissected away from the lateral edge of the sac.

Once the peritoneal sac is completely reduced and the pocket enlarged to expose the entire myopectineal orifice, the pocket is ready for placement of the mesh. The surgeon must inspect the peritoneum for any defects made during dissection that could allow exposure of the mesh to the abdominal cavity. All defects must be repaired, or mesh with a barrier coating should be selected. The mesh is then introduced into the abdominal cavity through the umbilical port, then placed in the peritoneal pocket and unrolled to cover the entire myopectineal orifice with significant overlap. Essentially, the mesh is then positioned to cover the direct, indirect, and femoral openings. The authors typically use mesh that is 14 cm in medial-to-lateral dimension by 11 to 12 cm in craniocaudal direction (Fig. 29-4, C).

The authors use an endoscopic tacker to fixate the mesh medially to Cooper’s ligament, anteromedially to the rectus abdominis muscle, and anterolaterally to the area above the internal ring. If tacks are used lateral to the internal inguinal ring, all tacks must be placed above the iliopubic tract, to avoid the triangle of pain and triangle of doom (see Fig. 29-3, A). The surgeon ensures this placement by manually palpating the tip of the tacker from the outside the abdominal cavity, above the inguinal ligament. If desired, fibrin glue is an excellent adjunct for mesh fixation inferiorly.

The peritoneal flap is then reapproximated over the mesh with the endoscopic tacker. Great care must be taken to avoid placing tacks into the epigastric vessels. No large gaps may be left in the closure, which would expose the mesh to the bowel and potentially allow for bowel to herniate inside the peritoneal flap. At the conclusion of the procedure, the surgeon should check to ensure both testicles are in their normal anatomic position within the scrotum.

Totally Extraperitoneal Approach

The patient is positioned supine with both arms tucked at the sides and a single laparoscopic tower at the foot of the bed. Port placement differs from TAPP technique in that all ports for a TEP approach are placed vertically in the midline. To begin, a 10-mm infraumbilical incision (port) is made, and the anterior rectus sheath on the side of the hernia defect is opened longitudinally. The rectus abdominis muscle fibers are retracted laterally to expose the posterior rectus sheath. Finger dissection is performed to free the muscle fibers from their posterior attachments, to accommodate the dissection balloon. The key here is to avoid entering the peritoneal cavity, since the dissection plane is in the preperitoneal space. The dissecting-balloon trocar is slid into the space between the rectus muscles anteriorly and the transversalis fascia and peritoneum posteriorly until the tip reaches the pubic symphysis (Fig. 29-5). Great care must be taken in this step not to injure the epigastric vessels. Insufflation is done under direct laparoscopic visualization until an adequate space is developed. The dissecting balloon is deflated and replaced with a blunt-tipped trocar.

After placement of two additional, 5-mm ports in the lower midline, dissection is carried out similar to a TAPP repair. The landmarks of the pubic tubercle, Cooper’s ligament, and inferior epigastric vessels aid in orienting the dissection. Often a direct hernia, if present, will reduce spontaneously with pneumopreperitoneum. Otherwise, clearing off the Cooper’s ligament until the iliac vessels are reached, ensures exposure of the direct and femoral space.

Unlike TAPP technique, the indirect space must always be dissected out because a hernia here may not be readily apparent in a TEP approach. The peritoneum must be gently dissected from the anterior abdominal wall, from the level of the ASIS to below the iliopubic tract. If the peritoneal cavity is violated during dissection, insufflations of the abdomen may obscure the working space.

When all hernia sacs have been reduced, the mesh is ready for implantation, as in a TAPP approach. The choice of whether or not to use tacks depends on surgeon preference. Most will recommend one or two tacks in Cooper’s ligament if a direct hernia component is present. Once positioned, the insufflation is released as graspers hold the lower edge of the mesh in place. All trocars are removed, and the anterior rectus fascia at the 10-mm port site is closed.

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