Laparoscopic Inguinal Hernia Repair

Inguinal hernia repairs are one of the most common general surgical operations performed.

Diagnosis of inguinal hernias is typically performed using a thorough history, and physical and is typically signified by a bulge in the groin.

This activity explores several treatment options for patients with inguinal hernias including watchful waiting, open primary repair, open tension-free repairs with the use of mesh prosthetics, and laparoscopic repairs which are typically performed with mesh prosthetics.

Anatomy and Physiology

The anatomy of the inguinal canal can be quite complex and thorough knowledge of anatomy from the preperitoneal view is imperative to perform a good laparoscopic inguinal hernia repair.

Several important landmarks include the inferior epigastric vessels (which help distinguish between a direct and indirect hernia), the pubic bone / Cooper’s ligament, the vas deferens/cord structures/round ligament, and the iliopubic tract.

Surgeons performing laparoscopic inguinal hernia repair should also be aware of the triangle of pain and doom.

The triangle of doom is a triangle bound by the vas deferens, testicular vessels, and the peritoneal fold.

The importance of this triangle is in this area you can find the external iliac artery and vein.

The triangle of pain is bound by the iliopubic tract, testicular vessels, and the peritoneal fold.

This triangle holds the lateral femoral cutaneous nerve, the femoral branch of the genitofemoral nerve, and the femoral nerve.

Secondary to the important structures located in these two triangles it has been strongly recommended to avoid traumatic fixation of mesh in these areas as it could cause major vascular injuries or nerve injury that could result in chronic pain. 

Laparoscopic inguinal hernia repair has become a valid option for repair of an inguinal hernia, although the primary indication for the use of laparoscopic inguinal hernia repairs has been for bilateral and recurrent inguinal hernias.

As more experience has been gained with the laparoscopic techniques, it is now used for the repair of the primary / unilateral inguinal hernia.

Potential benefits of the laparoscopic approach include quicker postoperative recovery and possible decreased incidence of long-term groin pain.

Contraindications

There are no absolute contraindications to laparoscopic inguinal hernia repair except for the inability to tolerate general anesthesia.

Patients at high risk for anesthesia and unilateral inguinal hernia may be better served with an open repair under local anesthesia.

Relative contraindications include large inguinoscrotal hernias (which should not be attempted early in the learning curve as they can be quite difficult operations) and patients on anticoagulation (secondary to the difficulty with dealing with postoperative bleeding in the retroperitoneal space compared to dealing with bleeding after open surgery).

Treatment

There are two main ways to perform laparoscopic inguinal hernia repair – the Transabdominal Preperitoneal (TAPP) approach and the Totally Extraperitoneal (TEP) approach.

The two techniques are similar except in the TAPP approach the peritoneum is incised, and this requires closure after mesh placement.

The laparoscopic port placements typically vary between the two techniques.

In a TEP technique, the e ports are placed typically in a line from the pubic bone to the umbilicus.

In the TAPP technique, the three ports are placed at the umbilicus and the area of the midclavicular line at the level of the umbilicus on the left and right side of the abdomen.

With these port positions, the surgeon can fix bilateral inguinal hernias either using the TEP or TAPP technique.

In the TEP approach, the preperitoneal space is entered at the level of the umbilicus and is not violated during the procedures.

In the TAPP technique, the surgeon must open and close a peritoneal flap that usually starts at the medial umbilical ligament and is incised laterally towards the anterior superior iliac spine.

It is recommended that the surgeon close the peritoneal flap after mesh placement and this may be either done with sutures or tack fixation.

This allows the mesh to be preperitoneal and not in contact with the abdominal cavity and viscera.

Laparoscopic inguinal hernia repair, either by the TAPP or TEP method, involves placing a large mesh prosthetic that covers the entire myopectineal orifice.

This allows for coverage of indirect, direct, and femoral hernias.