Chapter 51 Laparoscopic Inguinal Hernia Repair
INTRODUCTION
Laparoscopic inguinal hernia repair has evolved to become a safe and effective alternative for inguinal herniorrhaphy. The first report of a laparoscopic approach was in 1990 by Ger and associates1 in which indirect inguinal hernias were repaired by a transabdominal laparoscopic staple closure of a patent processus vaginalis. Following this study, other reports were published including a transabdominal rolled mesh plug technique2 and an intraperitoneal onlay mesh technique.3 These methods were eventually abandoned owing to high recurrence rates. Over time, the laparoscopic approach built upon the idea of applying a prosthetic to the posterior wall of the groin developed by Nyhus, Stoppa, and Wantz.4 The hallmarks of this approach included complete dissection of the groin in the preperitoneal space, identification of all myopectineal orifices, and placement of mesh over the entire inguinal-femoral region (Fig. 51-1). This has now become the laparoscopic procedure of choice.
Several reports have demonstrated the efficacy of the laparoscopic approach to inguinal hernia repairs. Liem and coworkers5 compared laparoscopic versus conventional anterior hernia repair and found that the laparoscopic group had faster postoperative recovery and a recurrence rate similar to that of the open group. A study by Andersson and colleagues6 found that laparoscopic totally extraperitoneal hernia repair resulted in less postoperative pain, shorter time to recovery, earlier return to work, and no difference in overall complications when compared with open tension-free repair. The results from the Veterans Administration (VA) Cooperative Study showed that, although laparoscopic repair of inguinal hernias resulted in less pain and earlier return to normal activity, recurrence was significantly more common after laparoscopic repair.7 However, this study also reported similar recurrence rates between laparoscopic and open inguinal hernia repairs when surgeons with a large volume of experience performed the laparoscopic procedures. This finding underscores the challenge in learning this approach and the need for technical mastery in order to achieve consistently satisfactory results.8
The laparoscopic approach to inguinal hernia repair can be divided into two types: the transabdominal preperitoneal approach (TAPP) and the totally extraperitoneal approach (TEP). Initially, most procedures were performed with the TAPP approach for exposure of the posterior floor of the groin because the groin anatomy was easier to delineate. However, the TEP approach avoids violation of the peritoneal cavity, potentially reducing some of the complications associated with the TAPP technique. Although understanding the inguinal anatomy from an extraperitoneal posterior view can be difficult, hernia surgeons have become more comfortable with this exposure and can achieve similarly low recurrence rates using this technique.4 By and large, the TEP approach can be applied to most clinical circumstances in which laparoscopic inguinal hernia repair is performed, and it is described here.
OPERATIVE PROCEDURE
Trocar Insertion
Trocar insertion should be controlled and under direct vision to avoid serious complications. A standard three-trocar technique is used: a 10-mm port subumbilically, a 5-mm port in the right lower quadrant, and a 5-mm port in the left lower quadrant (Fig. 51-2). All ports are placed within the preperitoneal space. Complications of trocar insertion are discussed in Section I, Chapter 7, Laparoscopic Surgery.
Exposure of the Pubic Bone and Cooper’s Ligament
This step is done at the outset of the procedure in order to clearly define the midline. Cooper’s ligaments are found just lateral and slightly cephalad to the pubic bone (Fig. 51-3). Cooper’s ligament is where the mesh will be anchored medially. Small veins overlie the pubic bone, and they can be injured during exposure.
Figure 51-3 Midline view of preperitoneal space. Left, left Cooper’s ligament; Right, right Cooper’s ligament.
