Laparoscopic Inguinal Hernia Repair Technique

Updated: Aug 09, 2016
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Approach Considerations

A number of considerations should be kept in mind in the performance of laparoscopic inguinal repair, whether via the totally extraperitoneal (TEP) approach or via the transabdominal preperitoneal (TAPP) approach.

Extreme care must be exercised in placing the mesh fixation tacks. This point cannot be overstated. A nerve injury caused by an errant tack can be truly debilitating to the patient and very challenging to treat. Tacks should be placed only above the iliopubic tract. [90] Proper placement may be ensured by drawing a line from the pubic tubercle to the anterior superior iliac spine (ASIS) at the start of the procedure. Before firing each tack, carefully palpate the tacker head through the abdominal wall to ensure that it is above this line.

Violation of the peritoneum during TEP repair causes loss of insufflation from the preperitoneal space into the peritoneal cavity, which, in turn, causes the preperitoneal space to collapse to some degree. This collapse can make the procedure more difficult to complete; in addition, it places intra-abdominal organs at risk for injury and may lead to adhesion formation.

Accordingly, efforts should always be made to avoid tearing the peritoneum if at all possible. If the rent is small, endoscopic clips can be placed to close the defect and minimize the leak. Otherwise, conversion to a TAPP repair or an open repair may be necessary. Another option is to place a Veress needle through a stab incision into the abdominal cavity to drain the carbon dioxide.

Trocar placement should always be done under direct vision. To prevent bleeding and hematoma formation, the trocars should be placed exactly in the midline so as to avoid tearing the fibers of the rectus abdominis.

During preperitoneal dissection, the inferior epigastric artery and vein sometimes become separated from the abdominal wall and then hang down into the operative field. Clipping and dividing these vessels may be required in order to complete the procedure.

It is very helpful to place the mesh in such a way as to facilitate its subsequent flush deployment. This may be accomplished by folding the mesh in half lengthwise, grasping it by the fold, and advancing it through the trocar toward the ASIS. When the grasper is released, the natural memory of the mesh causes it to spring open in a properly oriented position, without any need for time-consuming manipulation.

Vascular injury is a relatively uncommon but nonetheless potentially disastrous adverse event. It can be avoided by respecting the proximity of the femoral vessels, particularly when the mesh is being tacked to the Cooper ligament. [91]

Recurrence of the hernia is a significant concern. The key to minimizing the recurrence rate is to use an ample-sized piece of mesh. The mesh must be large enough to extend 2 cm medial to the pubic tubercle, 3-4 cm above the Hesselbach triangle, and 5-6 cm lateral to the internal ring.

If the patient is male, the surgeon should always remember to pull the testes gently back down to their normal scrotal position at the end of the procedure.

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Totally Extraperitoneal Repair

Before independently performing a TEP repair, surgeons should receive specific training in the technique. [92] Sound laparoscopic skills provide a solid foundation, but mentoring in the technique leads to improved outcomes. Mentoring is most valuable with regard to gaining familiarity with the preperitoneal anatomy and its variations. A complete TEP procedure is shown in the video below.

Laparoscopic inguinal hernia repair: TEP. Video courtesy of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

Variations of TEP repair that use only one port have been described; some promising results have been obtained, but further study is required. [93, 94]

Laparoscopic access and port placement

A 10-mm longitudinal or a curvilinear infraumbilical skin incision is made, and then deepened to separate the subcutaneous fat and expose the anterior rectus sheath. [56]

Next, a longitudinal incision is made in the anterior rectus sheath slightly off the midline over the body of the rectus abdominis (thus avoiding entering the peritoneal space in the midline, where the anterior and posterior rectus sheaths merge). [56, 57, 13] The midline raphe is grasped with a Kelly clamp, and the underlying rectus muscle fibers are retracted laterally, revealing the glistening white surface of the posterior rectus sheath.

With the posterior rectus sheath as a guide, a dissecting balloon is introduced and slipped along the rectus sheath (see the video below). The balloon is advanced past the arcuate line and into the preperitoneal space, down to the pubic symphysis. The dissecting balloon is then inflated under direct laparoscopic vision (ie, with the scope in the lumen of the balloon) to dissect the preperitoneal space. [56, 57, 13, 95]

Laparoscopic inguinal hernia repair: TEP. Balloon dissection.

Instead of pumping the dissecting balloon to a preset number of pumps (30-40, according to manufacturer recommendations), it may be preferable to pump under direct vision until no further movement of the tissues is visible, indicating no benefit from further dissection.

Once adequate dissection is attained, the dissecting balloon is deflated and removed. The patient is then placed in the reverse Trendelenburg position, and the preperitoneal space is insufflated with carbon dioxide to a pressure of 12 mm Hg.

A 10-mm 30° laparoscope is introduced through the umbilical port, [56, 57, 13] and a visual inspection is performed. When the preperitoneal space is properly accessed, the undersurface of the rectus muscles should be visualized at the top of the operative field. Two additional ports are placed in the midline between the umbilicus and pubis: a 5-mm trocar, placed two fingerbreadths cephalad to the pubic symphysis, and a 5- or 11-mm trocar, placed at the midway point between the lower port and the camera port (see the image below).

Laparoscopic inguinal hernia repair: TEP. Trocar p Laparoscopic inguinal hernia repair: TEP. Trocar placement.

Dissection

The most consistent anatomic landmark in this area is the Cooper ligament. It is common to begin the dissection with exposure of the Cooper ligament and the pubic tubercle. This can be done with a two-handed technique, whereby two blunt graspers are placed against the bone at a single point, then gently spread apart (see the video below). Gentle dissection with meticulous hemostasis is continued to expose the direct space and the femoral space by clearing the Cooper ligament down to the iliac vessels.

Laparoscopic inguinal hernia repair: TEP. Direct space dissection.

Direct and femoral hernias will be encountered during this initial dissection. A direct hernia often reduces spontaneously with pneumopreperitoneum, but careful, gentle traction and freeing of fibrous bands may be necessary to achieve complete reduction. Clearing the Cooper ligament in its entirety ensures that a direct hernia is fully reduced. On occasion, a large direct hernia may obscure the anatomy, in which case its reduction should be postponed until other anatomic structures are clarified.

Great care must be exercised as the dissection approaches the iliac vessels. In addition, obturator vessels often cross the dissection planes and may need to be clipped and divided.

The inferior epigastric vessels are identified, and dissection lateral to the vessels leads to the space of Bogros, the cord structures, and indirect hernias (see the video below). The proper plane of dissection is between the transversalis fascia and the peritoneum. This is identified by retracting the inferior epigastric vessels upward against the rectus muscle. A plane containing areolar tissue is identified, and this plane is dissected toward the pelvic sidewall. [56, 57, 13, 95]

Laparoscopic inguinal hernia repair: TEP. Lateral abdominal wall dissection.

Care must be exercised in separating the peritoneum from the muscle layers of the abdominal wall. The peritoneum is often very thin and may be tightly adherent. Attempting to disconnect these structures may result in a peritoneal rent; this is especially evident cephalad. Inferolaterally, the abdominal wall must be cleared to below the iliopubic tract.

Management of hernia sac

After the initial medial and lateral dissection, the surgeon should assess the anatomy and location of the hernia. The Cooper ligament should be clearly visualized. Small direct hernias may already have been reduced by the dissecting balloon, rendering the defect visible. The location of the cord structures should be clear. Cord lipomas and indirect hernias lie lateral to the cord structures. The location of the external iliac vein should be assessed; it may not yet be eminently clear, but the approximate location should be noted.

With the anatomy clarified, the hernias can now be safely reduced. Direct and femoral hernias are reduced by applying cephalad traction to the hernia sac with appropriate countertraction (see the video below). The trajectory of dissection should be away from the external iliac vessels.

Laparoscopic inguinal hernia repair: TEP. Reduction of small direct hernia.

Next, attention is shifted to the internal ring to identify an indirect hernia sac, which may be more difficult to reduce than a direct hernia. The indirect hernia sac is located on the superolateral aspect of the spermatic cord as it enters the deep inguinal ring. It is carefully and gently separated from the cord structures by elevating the cord-sac bundle and then delicately stripping the areolar tissue downward until a window is found between the sac and the cord structures (see the video below). [56, 57, 13, 95]

Laparoscopic inguinal hernia repair: TEP. Indirect sac isolation.

Once the sac is separated cephalad, retraction of the sac from its apex typically allows it to be reduced. Cord lipomas may also be visualized during these maneuvers. They are situated lateral to the cord and course toward the deep ring. Cord lipomas should be reduced cephalad and laterally.

If the sac cannot be reduced back into the peritoneal cavity, it should be ligated proximally and left open to drain distally so as to prevent hydrocele formation. The simplest way of doing this in a wide-mouth sac is to fire a vascular 30-mm linear stapler across the sac and then divide the sac distal to the staple line. An alternative method is to use endoscopic clips or an endoscopic loop ligature. Care must be taken to avoid injury to any intra-abdominal sac contents or sliding component.

Placement and fixation of mesh

Wide preperitoneal dissection ensures that adequate space is available for placement of a large mesh prosthesis. The lateral dissection should take the peritoneum up to the umbilicus. The peritoneum should be taken off the spermatic vessels as far cephalad as possible (see the video below). The peritoneum should be dissected off the vas deferens to the point where the vas courses medially. The external iliac vein should be visualized by dissecting the overlying fatty tissue medially, toward the urinary bladder. Finally, the obturator space should be dissected.

Laparoscopic inguinal hernia repair: TEP. Dissection of peritoneum off cord with small hole in peritoneum.

After this complete and meticulous dissection, the operative site is assessed. The deep ring should be visualized with only the cord structures traversing its opening into the inguinal canal. Any holes that were made in the peritoneum should be closed before placement of the mesh.

Once the requisite dissection is complete, the mesh is folded and introduced under direct vision, then dragged as far laterally as possible toward the ASIS (see the videos below). Next, the mesh is flattened out across the myopectineal orifice and draped over the cord structures. A single tack is placed at the pubic tubercle; this serves as a fixation point to facilitate arrangement of the mesh in the tight preperitoneal space.

Laparoscopic inguinal hernia repair: TEP. Pearl mesh deployment.
Laparoscopic inguinal hernia repair: TEP. Mesh deployment and fixation.

The mesh is maneuvered so that its upper border lies above a line from the pubic symphysis to the ASIS. The remaining tacks are then placed down the Cooper ligament, up the midline, and along the upper border of the mesh.

It is essential that each firing of the tacker beyond the inferior epigastric artery-vein complex be above a line from the pubic symphysis to the ASIS. This ensures that no tacks are placed in proximity to nerve structures or iliac vessels (the triangle of pain and triangle of doom). Correct placement can be further verified by carefully palpating the tacker head through the abdominal wall and comparing its relation to this line before each firing. No more than one or two tacks are needed in this hazardous location.

If the patient has bilateral pathology, the surgical team’s attention is now turned to the contralateral side.

Port removal and closure

At the completion of the operation but before desufflation, an additional step that may be considered is to spray the preperitoneal space with 20 mL of 0.5% bupivacaine with epinephrine for long-acting local analgesia and improved hemostasis (see the video below). [96]

Laparoscopic inguinal hernia repair: TEP. Local anesthesia infiltration.

While the preperitoneal space is being desufflated under direct vision, a blunt grasper should be placed against the lower corner of the mesh just lateral to the cord structures (see the image below). This prevents the mesh from rolling upward and exposing the lateral aspect of the internal ring to recurrence.

Laparoscopic inguinal hernia repair: TEP. Desufflation.

Finally, larger trocar site fascial defects are closed with a figure-eight 0 absorbable suture, the skin is approximated, and the Foley catheter (if used) is removed.

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Transabdominal Preperitoneal Repair

A TAPP repair for recurrent inguinal hernia is shown in the video below.

Laparoscopic repair of recurrent inguinal hernia: TAPP. Video courtesy of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

Laparoscopic access and port placement

One of the main criticisms of the TAPP procedure is the potential for intra-abdominal injuries. Accordingly, safe laparoscopic access is an essential initial step. A number of techniques, both open and closed, have been described. An excellent method of obtaining laparoscopic access at the umbilicus is the umbilical stalk technique (see the video below). [97]

Laparoscopic inguinal hernia repair: TAPP. Umbilical stalk technique for obtaining laparoscopic access.

An infraumbilical incision is made, through which the subcutaneous tissues are dissected bluntly and the umbilical stalk is grasped with Kocher clamps and retracted upward. Fascia inferior to the umbilical stalk is then grasped with a second pediatric Kocher clamp, and the fascia is incised between the two clamps in a transverse fashion with a No. 15 blade scalpel. A Kelly clamp is gently placed through the incision to ensure that the peritoneal cavity has been entered.

At this point, a 5-mm trocar is placed, and the abdomen is insufflated. A 5-mm 30° scope is then placed through the trocar, allowing the peritoneal cavity to be viewed.

Two lateral 5-mm trocars are placed at the level of the umbilicus and lateral to the rectus at approximately the midclavicular line. It is important that the lateral ports not be placed too far inferiorly; a large preperitoneal pocket must be made to place the mesh, and the peritoneal flap can be hard to visualize if the port is placed too low. Care must also be taken to avoid the epigastric vessels during the placement of these trocars. The 5-mm trocar initially placed at the umbilicus is then upsized to an 11-mm trocar to facilitate entry of a large mesh prosthesis.

After ports are established, diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. Evaluation of the pelvis should follow. It is easy to identify hernia defects and to determine whether they are direct or indirect defects.

As a rule, the operating surgeon stands opposite the side of the hernia and operates using both hands, one for the umbilical trocar and the other for the trocar on his or her side of the table (ie, the side opposite the hernia defect). The assistant places the 5-mm 30° camera through the 5-mm trocar on the side of the hernia defect. If bilateral inguinal hernias are present, the surgeon and assistant first approach one side in this manner and then switch sides to repair the contralateral hernia.

Although the approach described above is preferred by the authors, it should be kept in mind that different approaches to port placement and camera location can be employed, depending on the assistant (who may be a resident, a surgeon, or a surgical technologist assistant) and his or her ability to assist with the operation and run the camera.

Obtaining an appropriate laparoscopic view during all portions of the TAPP procedure can be very difficult for the person controlling the camera and often requires considerable skill and experience. It is important, especially during the learning curve, that the camera operator/assistant have some previous experience with using a 30° camera.

Dissection

The procedure should always begin with careful inspection of the anatomy of the pelvis and bilateral groins (see the video below).

Laparoscopic inguinal hernia repair: TAPP. Inspection of inguinal anatomy and identification of key structures.

The following key structures should be identified:

  • Median and medial umbilical folds
  • Lateral umbilical folds and epigastric vessels (see the first image below)
  • Vas deferens and spermatic vessels (see the second image below)
  • Iliac vessels
  • Hernia defect (direct or indirect) (see the third image below)
Laparoscopic inguinal hernia repair: TAPP. Inferio Laparoscopic inguinal hernia repair: TAPP. Inferior epigastric vessels running up abdominal wall. These vessels help distinguish indirect from direct inguinal hernia.
Laparoscopic inguinal hernia repair: TAPP. Normal Laparoscopic inguinal hernia repair: TAPP. Normal anatomy of left inguinal region in male, with testicular vessels and vas deferens entering medially.
Laparoscopic inguinal hernia repair: TAPP. Right i Laparoscopic inguinal hernia repair: TAPP. Right indirect inguinal hernia.

After the anatomy is identified, laparoscopic scissors are used to make a small incision in the peritoneum at (or just lateral to) the medial umbilical ligament, just below the umbilicus (see the videos below).

Laparoscopic inguinal hernia repair: TAPP. Cutting of peritoneum and dissection of pubis.
Laparoscopic inguinal hernia repair: TAPP. Cutting of peritoneum.

This incision is then extended laterally to the ASIS with scissors (see the image below). A common mistake is to make this incision too inferiorly. Special attention is required to keep the incision superior to the potential spaces for both direct and indirect hernia defects. The peritoneal flap must be extended far enough cephalad to ensure that it can cover the mesh and completely exclude it from the peritoneal cavity.

Laparoscopic inguinal hernia repair: TAPP. Sharp d Laparoscopic inguinal hernia repair: TAPP. Sharp dissection to take down peritoneum for access to inguinal region.

Next, the peritoneum is bluntly dissected away from the abdominal wall with blunt laparoscopic graspers. This is best done by grasping the edge of the peritoneal flap with one instrument and retracting superiorly and posteriorly while making an upward sweeping motion with the other instrument to sweep away the tissue of the posterior abdominal wall. The result should be an avascular plane, which is first carried down along the medial border of the flap until the pubis is identified and then dissected laterally in the same fashion.

Management of hernia sac

Before dissection of the hernia sac, the following important structures should be identified:

  • Pubic symphysis
  • Cooper ligament
  • Iliopubic tract

During the dissection, care should be taken to identify the triangle of doom, which contains the external iliac vessels and is bounded by the vas deferens medially and the gonadal vessels laterally. If the hernia sac is not reduced in conjunction with the dissection of the peritoneal flap, it can usually be reduced by means of gentle traction on the peritoneal attachments within the defect (see the video below).

Laparoscopic inguinal hernia repair: TAPP. Reduction of indirect hernia with gentle traction.

The spermatic cord is then skeletonized by means of careful dissection. Once the cord structures have been clearly identified, any peritoneum of an indirect component is identified, separated from cord structures, and reduced. If there is a long indirect sac, the sac can be transected. It is essential, however, to minimize the risk of injury by first identifying the cord structures and reducing any peritoneal contents of the sac (see the images below).

Laparoscopic inguinal hernia repair: TAPP. Reducti Laparoscopic inguinal hernia repair: TAPP. Reduction of hernia sac and lipoma with upward traction.
Laparoscopic inguinal hernia repair: TAPP. Dissect Laparoscopic inguinal hernia repair: TAPP. Dissection of remaining hernia sac by blunt dissection using traction and countertraction.
Laparoscopic inguinal hernia repair: TAPP. Reducti Laparoscopic inguinal hernia repair: TAPP. Reduction of hernia, showing hernia defect.
Laparoscopic inguinal hernia repair: TAPP. Evaluat Laparoscopic inguinal hernia repair: TAPP. Evaluation of peritoneum to ensure that entire hernia sac has been reduced.

Complete dissection of the pubis should be carried out to facilitate placement of the mesh prosthesis. The Cooper ligament should be cleared of preperitoneal fat and identified completely, and the musculoaponeurotic arch of the transversus abdominis should be cleared to approximately 2 cm superior and lateral to the internal inguinal ring.

Placement and fixation of mesh

After dissection and hernia reduction, the mesh prosthesis is placed in the extraperitoneal space. The authors typically use a piece of lightweight polypropylene mesh that is approximately 12 × 16 cm; this can be trimmed as necessary to fit the potential space. The mesh is rolled longitudinally and introduced with a grasper through the 11-mm trocar. It is then spread in the peritoneal cavity and positioned with two graspers (see the video below).

Laparoscopic inguinal hernia repair: TAPP. Mesh placement.

Early in the learning curve, the surgeon may find it difficult to position the mesh appropriately in the preperitoneal space. To facilitate proper placement, the corner of the mesh that is to rest on the pubic bone can be grasped with a blunt grasper and placed through the trocar while the surgeon’s other hand holds the opposite corner of the mesh outside the trocar.

With one hand, the surgeon uses a grasper to push the mesh in and places the grasper on the pubic bone. With the other hand, he or she uses a blunt grasper placed through the 5-mm trocar to help position the mesh in the preperitoneal space. In the course of this process, it is important to use both hands and always hold the mesh in place in one area while pushing or pulling the mesh in the other direction. If the mesh becomes tangled or turned around, it is sometimes quicker and easier to remove it and start over.

In cases where placement of a flat sheet of polypropylene mesh proves challenging, a potential solution is to consider one of the preformed polypropylene meshes that have a right side and a left side; these are generally easier to place. When positioned correctly, the mesh should cover the direct, indirect, and femoral spaces for a potential hernia.

Once proper positioning has been confirmed, the mesh is anchored into place with a 5-mm laparoscopic tacking device. A common approach is to place two tacks in the pubis or Cooper ligament and two tacks on the anterior abdominal wall, medially and laterally, for fixation (see the video below).

Laparoscopic inguinal hernia repair: TAPP. Mesh fixation.

If absorbable tacks are being used, they may have to be placed in the Cooper ligament rather than the pubis; some absorbable tacks may not penetrate the pubic bone. Although it can be tempting to place more tacks in an effort to guarantee that the mesh will be adequately secured, the temptation should be resisted; the use of too many tacks has been associated with postoperative pain. [63]

Once the mesh is fixed to the pubis or Cooper ligament, it is spread out laterally to remove any folds. Placement of the anteromedial and anterolateral tacks is done with a bimanual technique, in which the surgeon places one hand on the outside of the abdominal wall and applies pressure so that he or she can feel the tacking device and ensure proper placement above the iliopubic tract at a perpendicular angle. Avoiding tack placement posterior to the iliopubic tract helps avoid damage to the neural structures located below in the triangle of pain.

Port removal and closure

After the mesh is in place, the previously created peritoneal flap is lifted with graspers and tacked (or sutured) to the abdominal wall. To avoid injury to important structures, the same anatomic landmarks as in mesh placement and fixation are used (see the image below).

Laparoscopic inguinal hernia repair: TAPP. Closure Laparoscopic inguinal hernia repair: TAPP. Closure of peritoneum over inserted mesh; this may be done with sutures or tacks.

Closure of the peritoneum with titanium tacks has been a common practice, but many surgeons are switching to absorbable tacks. Starting laterally, the peritoneal flap is tacked with the bimanual technique of exerting external pressure on the abdominal wall to confirm that the fixation device is placed at a right angle (see the video below). The peritoneum can also be repaired with sutures, but this requires expertise in laparoscopic suturing.

Laparoscopic inguinal hernia repair: TAPP. Tacking of peritoneum.

After peritoneal closure, the ports are removed under direct vision, and the fascial defect at the 11-mm port is closed with a 0 polyglactin suture, either laparoscopically or by means of an open technique. In the laparoscopic approach, the fascial defect at the 11-mm port can be closed by using a suture passer under direct laparoscopic vision. All skin incisions are then closed with 4-0 poliglecaprone subcuticular sutures and the dressing of choice.

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