Laparoscopic inguinal hernia repair takes a totally different approach from open repair. It is most nearly analogous to a preperitoneal open repair, sometimes termed the Nyhus repair, performed with mesh. The logic is similar to that employed during laparoscopic ventral herniorrhaphy: Because the problem is a weakness in the transversalis fascia (or a persistently patent processus vaginalis), approach the defect from inside. Peritoneum is stripped from the region, and the defect is repaired with a large sheet of prosthetic mesh. Intra-abdominal pressure holds the mesh buttressed against the muscular and aponeurotic layers of the abdominal wall, which are not dissected. Tacks are placed to secure the mesh in place. The anatomy that is stressed for this repair is very different than that stressed in Chapter 115. There is little emphasis on the muscular and aponeurotic layers of the abdominal wall, because these layers are not encountered. Rather, avoiding complications during these procedures requires intimate knowledge of the anatomy of crucial nerves and blood vessels that must be avoided when the mesh is secured. Major complications of the procedure include vascular injury and neurapraxia. The procedure may be done transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP). In this chapter, the transabdominal approach is shown first, followed by the modification employed for TEP.

The muscular and aponeurotic structures of the anterior abdominal wall appear different when viewed from inside with the peritoneum removed (Fig. 116.1A). Note how the ductus (or vas) deferens enters through the deep inguinal ring and then passes inferiorly and medially to join the seminal vesicles in the region of the base of the bladder. The internal spermatic vessels pass from lateral to medial and ascend to pass through the deep inguinal ring. The inferior epigastric vessels ascend and pass medially, defining the lateral border of Hesselbach triangle. The medial umbilical ligaments, the obliterated remnants of the umbilical arteries, form useful visual landmarks. The median umbilical landmark is rarely seen. Figure 116.1B shows peritoneum intact on the right side, demonstrating the peritoneal folds and visual landmarks with peritoneum intact. On the left side, the peritoneum has been removed to reveal underlying structures of significance. Note the iliopubic tract, the femoral canal, Cooper ligament, and the arch of the aponeurosis of the transversus abdominis. Contrast this view with the anterior and posterior views shown in Chapter 115, Figure 115.1.

Multiple nerves and vessels, most never encountered during open inguinal or femoral herniorrhaphy, are at risk during laparoscopic repair. Nerves include the lateral femoral cutaneous nerve, the anterior femoral cutaneous nerve, the femoral nerve, the femoral branch of the genitofemoral nerve, and the genital branch of the genitofemoral nerve. The vascular structures at risk include the external iliac artery and vein and aberrant obturator arteries. The latter, also termed the “artery of death,” is a potential pitfall when a femoral hernia is repaired from above (see Figure 115.9 in Chapter 115).

Two triangles, which lie together to form a rough trapezoid, encompass the majority of these structures and form a useful mnemonic device (Fig. 116.1C). The “triangle of pain” is bounded by the iliopubic tract superiorly, the testicular vessels medially, and the cut edge of the peritoneum inferiorly. It contains most of the nerves previously mentioned. The “triangle of doom,” bounded by the testicular vessels laterally, the ductus deferens medially, and the cut peritoneal edge inferiorly, contains the vessels. Extreme care must be exercised while dissecting in these triangles, and no staples or other fixation devices should be placed in these regions.