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Inguinal Hernia Repair
CHAPTER
53A
Inguinal Hernia Repair: Laparoscopic Namir Katkhouda
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Kulmeet K. Sandhu
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Kamran Samakar
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Evan Alicuben
I
nguinal hernia repair is a frequently performed operation, and laparoscopic inguinal hernia repair has become increasingly prevalent, particularly for the repair of bilateral or recurrent hernias. The first described laparoscopic inguinal hernia repair was completed in 1990 by Ger in canines1; the procedure has since evolved to include the use of a prosthetic mesh to cover the myopectineal orifice. There are two commonly performed techniques: the transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal repair (TEP). This chapter reviews the anatomy, technical considerations, benefits, and possible complications of laparoscopic inguinal hernia repair.
SURGICAL ANATOMY OF THE REGION A comprehensive understanding of the anatomy of the preperitoneal space is critical to the performance of a safe and effective laparoscopic inguinal hernia repair.2 The anterior approach to inguinal hernia repair involves recognition of the anatomy from a superficial to deep position; this is in contrast to laparoscopic repair, which requires identification of the critical structures from a reversed viewpoint. The median umbilical ligament covers the urachus and travels from the umbilicus to the bladder (Fig. 53A.1). The paired medial umbilical ligaments are remnants of the fetal umbilical arteries. The inferior epigastric vessels originate from the external iliac vessels and have a peritoneal covering creating the paired lateral umbilical folds. These folds originate medial to the deep inguinal ring and travel to the arcuate line, where the inferior epigastric vessels enter the rectus sheath. The medial inguinal fossa is the space located between the medial umbilical ligament and lateral umbilical fold bilaterally. This is the space associated with direct inguinal hernias. The lateral inguinal fossa is the depression lateral to the lateral umbilical fold. Indirect inguinal hernias develop at this site. The pectineal (Cooper) ligament is formed from fascia and periosteum and travels along the pectineal line of the pubic bone. The iliopubic tract is a thickened band of fibers from the transversalis fascia that joins laterally to the iliac crest and inserts medially on the pubic tubercle and pectineal line. The major vascular structures in this region are generally located medial to the deep inguinal ring. The inferior epigastric vessels branch from the external iliac vessels and travel to supply the anterior abdominal wall. A vascular connection may be noted in some patients between the obturator and external iliac vessels crossing the superior pubic ramus. This is known as the “corona mortis,” or
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crown of death, as injury due to dissection in this area can lead to significant hemorrhage. There are several other dangerous areas of dissection with laparoscopic hernia repair. The “triangle of doom” is located between the vas deferens medially and the gonadal vessels laterally. The external iliac vessels, deep circumflex iliac vein, genital branch of the genitofemoral nerve, and femoral nerve are located within this triangle. The key nerves in this area are located lateral to the deep inguinal ring (Fig. 53A.2). In the laparoscopic approach, the following nerves with cutaneous innervation may be encountered from laterally to medially: the lateral femoral cutaneous nerve, the anterior femoral cutaneous nerve, femoral nerve, femoral branch of the genitofemoral nerve, and genital branch of the genitofemoral nerve. The area inferior to the iliopubic tract and lateral to the gonadal vessels is known as the “triangle of pain,” where the lateral femoral cutaneous nerve and femoral branch of the genitofemoral nerve are found. Tacks placed in this area may injure either of these nerves. Together, the area between the vas deferens medially and the iliopubic tract superiorly and laterally constitutes “the square of doom,” where tacks and electrocautery should never be applied to avoid nerve injury. The previous anatomic discussion is required to understand the landmarks that define the three spaces associated with groin hernias (Fig. 53A.3): 1. Indirect inguinal hernia—lateral to the inferior epigastric vessels. 2. Direct inguinal hernia—medial to the inferior epigastric vessels and lateral to the border of the rectus abdominis muscle within the triangle of Hesselbach. 3. Femoral hernia—below the iliopubic tract, medial to the external iliac vein, and lateral to Cooper ligament. All three of these spaces should be covered during the laparoscopic approach with an appropriately sized mesh.
LAPAROSCOPIC VERSUS OPEN REPAIR The decision to perform an inguinal hernia repair via a laparoscopic versus an anterior approach remains difficult, complex, and nuanced. Tension-free anterior mesh repair has been the gold standard because of its low recurrence rate and lack of need for specialized equipment. Critiques of the laparoscopic approach include the higher in-hospital costs due to more expensive equipment, the possibility of intraabdominal organ or vascular injury, and the steep learning curve. Studies have indicated that greater than 250 operations are required to become experienced in this technically challenging operation.3-5 In fact, a recurrence rate of greater than 10% has been reported for surgeons
Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
ABSTRACT Symptomatic inguinal hernias are a commonly encountered surgical problem. Repair can be performed with an open or minimally invasive approach. Laparoscopic inguinal hernia repair is now widely performed, especially in the setting of bilateral or recurrent inguinal hernias. This chapter reviews the anatomy, benefits, and possible complications of laparoscopic inguinal hernia repair. Laparoscopic inguinal hernia repair is also compared with the traditional anterior approach, and the operative techniques of both the transabdominal preperitoneal repair and the totally extraperitoneal repair are reviewed. The outcomes of these two procedures are also examined.
KEYWORDS Inguinal hernia, femoral hernia, hernia repair, mesh, laparoscopy, transabdominal preperitoneal repair, totally extraperitoneal repair
590.e1
Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
Median umbilical fold Medial umbilical fold Bladder Lateral umbilical fold (inferior epigastric vessels)
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Right direct inguinal hernia Deep inguinal ring and indirect inguinal hernia Line of peritoneal incision
Vas deferens Spermatic vessels Iliac vessels Left ureter
FIGURE 53A.1 Laparoscopic view of the groin. (From Eubanks S. Hernias. In: Sabiston DC Jr, Lyerly HK, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: Saunders; 1997:1226.)
Sigmoid colon
Femoral branch genitofemoral nerve Danger zone
Femoral nerve
Genital branch genitofemoral nerve
Lateral femoral cutaneous nerve
Iliacus muscle
Psoas muscle
FIGURE 53A.2 Nerves in the inguinal region.
who have performed fewer than 250 procedures.3 For this reason, some have argued that the laparoscopic approach should be reserved for experienced centers. Conversely, many trials have shown significantly less early postoperative pain resulting in less narcotic use and swifter return to normal activity.6,7
Nevertheless, most large trials have failed to consistently show a difference in recurrence rates between the two approaches.8-11 The biggest exception is a study out of the Veterans Administration (VA) system from 2004.3 In this study, more than 2000 male patients within the VA system were randomized to an open or laparoscopic
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SECTION I Esophagus and Hernia
Area of direct hernia Area of indirect hernia
Internal inguinal ring Pubic tubercle
Inferior epigastric vein
Edge of inguinal ligament
Iliopubic tract Cooper ligament Gonadal vessels
Femoral canal
Vas deferens
External iliac vessels
FIGURE 53A.3 Preperitoneal inguinal anatomy.
inguinal hernia repair with mesh. With 2-year postoperative follow-up, the laparoscopic group had a significantly higher recurrence rate than the anterior approach in the repair of primary hernias (10.1% vs. 4.0%). However, recurrence rates were similar if the repairs of recurrent hernias were compared (10.0% vs. 14.1%). This study has steered many surgeons to repair unilateral primary inguinal hernias through an open approach. More recent research has attempted to clarify this dilemma. In a meta-analysis of 27 randomized controlled trials of primary unilateral inguinal hernia repair including 7161 patients, O’Reilly et al. found that the laparoscopic approach resulted in an increased risk of recurrence.12 Interestingly, compared with open repair, TEP had increased rates of recurrence but TAPP had equivalent rates. Additionally, the laparoscopic approach was associated with higher perioperative complication risk. This was attributed to a higher complication risk with TAPP but equivalent risk with TEP. However, laparoscopic repair resulted in reduced risk of chronic groin pain and numbness compared with the anterior approach. The laparoscopic repair technique may be better suited for bilateral or recurrent inguinal hernias and hernias in women. Bilateral hernias may be repaired through the same set of port sites and do not require
additional incisions. In recurrent hernias, especially those with previous open repair, a posterior approach results in dissection through native tissue planes. Some studies have suggested this may lead to improved recurrence compared to redo anterior repair.13 Inguinal hernias in females may be better performed laparoscopically given that the posterior placement of mesh allows for coverage of the femoral space, therefore addressing the incidence of femoral recurrence seen in Lichtenstein repair. The importance of this concept was illustrated in a series of hernia repairs in women which showed a 41.6% rate of femoral hernia found during operations for recurrences.14
OPERATIVE TECHNIQUE TRANSABDOMINAL PREPERITONEAL REPAIR The patient is placed in the supine position with both arms tucked. An indwelling catheter is placed in the bladder to prevent view obstruction and decrease the risk of injury to the bladder during dissection of the preperitoneal space. The monitor is placed at the foot of the table. The surgeon stands behind the shoulder opposite to the hernia, and the camera assistant stands on the other side of the patient. Steep Trendelenburg is
Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
10-mm trocar with camera and insufflation in umbilicus
Medial umbilical ligament
Direct hernia
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Lateral umbilical fold
Indirect hernia
5-mm trocar
5-mm trocar Bladder
Optional additional grasper
Vas deferens
Spermatic vessels Iliac vessels
FIGURE 53A.5 Creation of the peritoneal flap. (From Eubanks S. Hernias. In: Sabiston DC Jr, Lyerly HK, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: Saunders; 1997:1226.)
FIGURE 53A.4 Trocar placement for transabdominal preperitoneal hernia repair.
required to remove the small bowel from the pelvis and adequately visualize the area to be dissected. Three ports are required for this operation. A 10-mm port for the laparoscope is placed at the umbilicus. Two additional 5-mm ports are placed lateral to the rectus muscle on either side at the junction of a line between the umbilicus and the anterior superior iliac spine (Fig. 53A.4). Alternately, the two 5-mm ports can be placed at the midline between the umbilicus and pubic bone for the TEP repair. A 30-degree laparoscope is required, as the oblique orientation of the inguinal canal makes it difficult to visualize small hernias and it is challenging to open the peritoneum at the anterior abdominal wall without the 30-degree angle. Following the establishment of pneumoperitoneum— which is maintained at 15 mm Hg—and port introduction, attention is turned to raising the peritoneal flap. If the trocars are inserted too low, it can be very difficult to produce an adequately sized peritoneal flap or easily maneuver the tacking device or the fibrin glue sprayer. On the other hand, if they are placed too high, the small bowel may get in the way. Therefore optimal placement of trocars and a 30-degree laparoscope are essential to success. The peritoneal flap may be incised from lateral to medial or medial to lateral. If a lateral-to-medial dissection is chosen, the incision begins medially to the anterior superior iliac spine (Fig. 53A.5). This then extends medially, staying at least 2 cm above the deep inguinal ring and hernia defect, and ends at the medial umbilical ligament. Blunt dissection is used to enlarge the peritoneal flap and expose the critical landmarks in the preperitoneal space, including the pubic tubercles, Cooper ligament, and the iliopubic tract (Fig. 53A.6).This dissection of the areolar tissue can be done with minimal hemostasis, and
Inferior epigastric vessels Rectus abdominis Pubis
Musculoaponeurotic arch of transversus abdominis
Iliopubic tract
Cooper ligament Iliac vessels
Peritoneum Spermatic vessels Vas deferens
FIGURE 53A.6 Dissection of the inguinal region. (From Eubanks S. Hernias. In: Sabiston DC Jr, Lyerly HK, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: Saunders; 1997:1226.)
electrocautery is used with care in this area to avoid nerve injury. The femoral nerve is present under the iliopubic tract at the lateral aspect of the dissection, but this nerve is not commonly visualized during this procedure. In thin patients, the lateral femoral cutaneous nerve and the genitofemoral nerve may be identified. In males, the spermatic cord structures are dissected free of the peritoneal flap. This involves separating the cord structures, including the vas deferens, from the peritoneum and the hernia sac. The peritoneum must be dissected quite inferiorly, as inadequate mobilization can result in folding of the mesh after peritoneal closure and early recurrence. If the view of the operative site is obscured with blood, it can be irrigated and aspirated
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SECTION I Esophagus and Hernia
Optional additional grasper
Mesh stapled into Cooper ligament and around medial edge first
FIGURE 53A.7 Placement and fixation of the mesh. (From Eubanks S. Hernias. In: Sabiston DC Jr, Lyerly HK, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: Saunders; 1997:1226.)
ring to avoid nerve injury. Nerve injury can lead to severe chronic pain due to neuroma formation around the staple or tack. Then tacks may be placed laterally and medially; laterally, it is essential to stay above the iliopubic tract, but tacks placed medially are inserted into the rectus muscle and on Cooper ligament. Usually two staples or tacks are placed in Cooper ligament and one or two in the rectus muscle. Staples or tacks are often used for fixation in laparoscopic inguinal hernia repair due to the risk of shrinkage or migration of the mesh. After the mesh is secured, pneumoperitoneum pressure is reduced to 10 mm Hg. The peritoneal flap is then positioned over the mesh and closed with tacks. Absorbable tacks are preferred to prevent subsequent adhesions to the tacks. Complete mesh coverage is essential to prevent exposure of the mesh to the underlying small bowel. This can lead to the creation of adhesions and possible small bowel obstruction. If possible, tacking is performed in an overlap fashion. The peritoneal flap can also be closed using a continuous running suture per surgeon preference. The fascia is routinely sutured at the umbilical port during closure.
TOTALLY PREPERITONEAL HERNIA REPAIR or cleaned with gauze placed intraabdominally. Direct hernia sacs and small indirect hernia sacs can often be easily reduced during this dissection. In the case of a very large indirect inguinoscrotal hernia, the distal part of the sac can be divided and left within the scrotum if it cannot be reduced. This dissection begins with gentle and atraumatic separation of the sac from the spermatic cord structures. As the sac is separated, it is divided, but care should always be taken to ensure that the vas deferens is not included with the sac. It may be easier to locate the vas deferens before starting the division of the hernia sac, but often a gradual division of the sac will allow for complete separation of the sac from the cord. Once the peritoneal sac is completely excised, the operation continues as usual. The distal portion of the divided sac is left open in the inguinal canal and the proximal part is ligated using an Endoloop or clips. This method is employed if the complete sac cannot be reduced as significant dissection at the distal sac in larger hernias can cause hematoma formation, ischemic orchitis, or atrophy of the testicle. When the hernia sac has been completely reduced and dissection of the preperitoneal space is complete, the mesh is rolled and introduced through the umbilical port using a grasper (Fig. 53A.7). Mesh of an appropriate size should be used, typically a 15- by 10-cm piece will be adequate for one side. Once inside the abdominal cavity, the mesh is unrolled and positioned so that it covers the direct, indirect, and femoral spaces. Fixation is then performed with fibrin glue, tacks, or suture. Some surgeons feel that complications of fixation, and associated vascular or nerve entrapment can be avoided if a significantly large piece of mesh is placed. Our technique of choice currently is to use fibrin glue. The fibrin glue is sprayed over the mesh in a thin layer, especially over Cooper ligament and the lateral aspect of the mesh. However, if one chooses to use tacks, the mesh fixation can begin at the midportion, “three fingers” above the superior limit of the internal
The arcuate line of Douglas is a transitional line; above it, the rectus muscle has a defined anterior and posterior sheath composed of the aponeurotic fascia of the internal oblique and transversus abdominis muscles. Below the arcuate line, all fascial layers of the abdominal muscles are anterior to the rectus muscle, and behind the rectus muscle itself there is only the transversalis fascia. Preperitoneal dissection is performed below the arcuate line, which is located approximately midway between the umbilicus and pubis. The operation is begun by making a 10-mm incision below the umbilicus. Two retractors are used to slide the incision to the right if the hernia is located on the right side, or to the left if the hernia is located on that side. The anterior rectus sheath on the side of the hernia is then opened under direct vision, and two stay sutures are placed on each edge. The rectus muscle is then bluntly separated using two retractors so that the posterior fascia can be visualized. At this point, it is essential not to open the posterior fascia of the rectus muscle but instead to dissect inferiorly toward the symphysis pubis in an oblique fashion, using either the index finger or a small peanut with an angulation of about 30 degrees. That will lead to the preperitoneal space below the arcuate line of Douglas. The preperitoneal space is then dissected using a balloon space maker under direct vision with a 30-degree laparoscope (Fig. 53A.8). While the balloon is inflated, the rectus muscle should be seen anteriorly and superiorly, and the preperitoneal fat and peritoneum should be seen posteriorly. It is preferred that the inferior epigastric vessels stay anteriorly with the rectus muscle, as otherwise they may hamper dissection and possibly require ligation. The balloon should stay in place for approximately 15 seconds to tamponade any bleeding. The space-maker balloon is then removed and the Hasson port is introduced. Two 5-mm ports are placed at the midline between the umbilicus and the symphysis pubis to allow for operating on both sides. The space created using this technique is small
Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
Endoscope with balloon in preperitoneal space
Peritoneum Pubis
Bladder
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Endoscope with balloon advanced inferiorly in preperitoneal space
Intestine
Peritoneum Pubis
Bladder
A
B
Expanded preperitoneal space maintained with insufflation
Balloon inflated in preperitoneal space
Pubis
Peritoneum
C
Bladder
D
FIGURE 53A.8 Balloon dissection of the preperitoneal space. (A) A balloon dissector is introduced into the preperitoneal space. (B) The balloon dissector is advanced to the pubis in the preperitoneal space. (C) The balloon is inflated under direct vision with the laparoscope. (D) The balloon is removed and the preperitoneal space is insufflated with carbon dioxide. (From Shadduck PP, Schwartz LB, Eubanks WS. Laparoscopic inguinal herniorrhaphy. In: Pappas TN, Schwartz LB, Eubanks WS, eds. Atlas of Laparoscopic Surgery. Philadelphia: Current Medicine; 1996. Copyright 1996 by Current Medicine.)
and limits the movement of the laparoscopic instruments. Care should be taken to avoid perforating the peritoneum, since an opening in the peritoneum will allow CO2 to escape into the abdominal cavity, which will subsequently compress the space and reduce it further. If this occurs, a Veress needle can be inserted into the abdomen to allow for the exit of CO2. The perforation can be then be closed using an Endoloop or a 5-mm clip applier. After the ports are in place, Cooper ligament is identified medially and the iliac vein’s position is noted as well. These two structures are key anatomic landmarks in this procedure, as they aid in defining the inferior aspect of the dissection. It is possible to injure the iliac vein, and there have been reports of ligation of the iliac vein when it was mistaken for the hernia sac. Once the iliac vein is identified after careful dissection, the next step is locating the inferior epigastric vessels. This will help delineate the internal ring and Hesselbach triangle. The vas deferens is identified by following the internal ring medially and toward the iliac vein. Gentle, blunt dissection is then
used to separate the sac from the cord structures and vas deferens. Small hernia sacs are usually easily reduced. If the hernia sac is large and dissection difficult, it may be prudent to amputate the sac, leave the distal part of the sac open, and close the proximal opening either with clips or an Endoloop. The mesh is then placed into the preperitoneal space and positioned as mentioned in the previous section. Once the mesh is in place, fibrin sealant or tacks can be used to fix the mesh in position. The fibrin sealant can be applied as an aerosol spray, which is attached to one of the open trocars to prevent excessive pressure inside the abdomen. This fibrin glue can be placed above or below the lightweight, large-pore mesh. It is important to use a lightweight, large-pore mesh to avoid or minimize the risk of mesh contraction and a foreign body reaction. The operation ends by desufflating the preperitoneal space and gradually removing the ports. A grasper is used to hold the mesh in place as the CO2 is evacuated. After port removal, the anterior fascia is closed with the previously placed stay sutures.
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SECTION I Esophagus and Hernia
TRANSABDOMINAL PREPERITONEAL REPAIR VERSUS TOTALLY EXTRAPERITONEAL REPAIR An obvious advantage of the TEP technique over the TAPP hernia repair is that the peritoneum does not have to be closed over the mesh, theoretically reducing operative time. Despite this advantage, the operative area is smaller and the anatomy more difficult to grasp. The potential intraabdominal complications that may be associated with the transabdominal approach—such as visceral injury, adhesions, and trocar site hernias—are avoided in the TEP repair, as the peritoneum is not entered. However, small, unrecognized peritoneal violations are likely common in the TEP method, therefore making those complications possible with both techniques. To date there have been no studies that have definitively shown an advantage of one approach over the other.5,15-20 The largest published series is from the Herniamed registry, which is a multicenter Internet-based database with participating surgeons in Germany, Austria, and Switzerland. In their published series of 17,587 patients who underwent laparoscopic repair of a primary unilateral inguinal hernia, the TEP and TAPP techniques had similar intraoperative complication rates but the TEP method had significantly fewer postoperative complications.21 Subgroup analysis indicated that these findings could be attributed to a difference in bleeding and seroma formation. Risk factors for the development of complications included increased defect size and the presence of a scrotal hernia. Of note, these characteristics were more commonly seen in the TAPP group, and this may explain the difference in complication rate. Nevertheless, the rate of reoperation for recurrence was equivalent between the two groups. With regard to recurrent hernias, in a series of 1309 patients, the TEP approach was associated with a significantly increased rate of intraoperative complications (TEP 6.3% vs. TAPP 2.8%) and a longer operative time (TEP 80.3 minutes vs. TAPP 73.0 minutes), but the rates of postoperative complication were similar.22 Overall these differences were felt to be clinically insignificant; therefore the procedures were deemed equivalent. In a recent meta-analysis of 10 randomized controlled trials, Wei et al. reported no significant difference in operative time, cost, complications, or time to return to usual activities.23 Given the failure to show benefit in the TEP group, this study suggested that the TAPP approach may be the preferred strategy, especially for nonexpert laparoscopic surgeons.
COMPLICATIONS The incidence of complications following laparoscopic inguinal hernia repair has gradually declined and should continue to decline as the procedure becomes more prevalent. The reported rates of complications vary widely and reach as high as 25%, depending on the definition of morbidity put forth by the studies.7,24 Vascular Injuries Significant vascular injury during the procedure is most likely to occur while gaining access to the peritoneal cavity.
The risk of intraoperative bleeding has been reported at 2.3%, with the risk of major injury at 0.08%.25 In a large series of Veress needle insertions, the rate of major vascular injury was 0.018% and most commonly involved injury to the iliac vessels and aorta.26 Specifically to laparoscopic inguinal hernia repair, one series of TEP repairs has reported a postoperative hemorrhage rate of 0.4%.27 Although some attribute these injuries to introduction of the Veress needle, similar injuries have been described with the open approach for insertion of the Hasson cannula. Once a major vascular injury is recognized, management should be done via laparotomy for best exposure and preparation for vessel repair. Laparoscopy may underestimate the degree of blood loss and may limit retraction and exposure of the bleeding vessel. Significant abdominal wall hemorrhage is likely from injury to the epigastric vessels. Initial bleeding can be controlled with a cannula while preparations are made for suture ligation using transfascial sutures placed with fascial closure devices. Bowel Injury Injury to bowel most commonly occurs during entry into the abdomen with the trocar or Veress needle and is estimated to occur in 0.13% of cases.28 Most frequently, the small bowel is injured and this can be detected intraoperatively in two-thirds of cases. Missed bowel injuries usually present with peritonitis and sepsis approximately one week postoperatively. An experienced laparoscopic surgeon may repair the injury via intracorporeal suturing or stapling, taking care to avoid narrowing of the intraluminal diameter. Bladder Injury Bladder injury is possible from placement of a suprapubic trocar or during dissection. Small injuries can be managed with urinary drainage, but larger defects require repair. If such an injury is recognized, laparoscopic repair is an option if the experience of the surgeon is sufficient. If unrecognized, injury may present later with hematuria, abdominal pain, or peritonitis. Urinary Retention The risk of developing urinary retention is significantly higher in laparoscopic repair compared with the anterior approach, given the use of general anesthesia compared with the possibility of local anesthesia for open repairs. The actual reported incidence varies widely up to 22%, and is higher in older patients with history of prostatic symptoms.29-31 In one study, postoperative narcotic use of 6.5 mg or greater of morphine or morphine equivalent was an independent risk factor for the development of urinary retention. 31 Narcotic avoidance with the usage of antiinflammatory medications, acetaminophen, and regional nerve blocks may help to decrease the risk of retention. The amount of intraoperative fluids given, the presence of a urinary catheter during surgery, and operative time were not associated with increased risk. Intermittent catheterization or a temporary indwelling catheter usually resolves the symptoms.
Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
Recurrence The rate of recurrence has been reported to be between 0% and 13% with the VA trial showing a recurrence rate of 10% for primary unilateral hernias.3 Diagnosing a recurrence may necessitate imaging studies, often ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT). Anterior repair for recurrent hernias is a popular option given that the tissue planes have not been previously violated. However, if the initial laparoscopic repair was performed due to a recurrent hernia, dissection in either space can be difficult. Ischemic Orchitis Disruption of the vascular supply to the testis may cause pain, fever, and an enlarged, firm testicle associated with ischemic orchitis. This more commonly results from damage to the venous plexus as opposed to the testicular artery. Duplex ultrasound should be performed to evaluate for testicular torsion. Patients are managed expectantly with antiinflammatory agents for symptoms. Testicular necrosis may ensue and eventually result in testicular atrophy; however, this happens in a minority of cases.24 Some believe that laparoscopic repair may result in less testicular ischemia due to a higher dissection on the spermatic cord. However, postoperative color Doppler ultrasonography has shown no measurable difference in blood flow.32 Groin Pain The etiology and management of postinguinal groin pain following hernia repair remains poorly understood and reflects the complex nature of this problem. The incidence has varied greatly but has been reported to be as high as 53%, with 1% requiring referral to specialty pain clinic.33,34 Laparoscopic repair causes significantly less early postoperative pain compared with the anterior approach. With long-term follow-up, overall rates of pain tend to equalize, but the laparoscopic approach has been shown to have less pain during strenuous activity.35 It is difficult to make definitive recommendations given that pain is reported by a variety of scales. Etiology of the pain may be related to factors present prior to the hernia repair, including muscle strain, osteitis pubis, and other lumbosacral disorders. MRI offers the advantage of soft tissue and neural resolution for diagnosis and can serve to evaluate for hernia recurrence. Neuropathic pain, which is most difficult to manage, is usually described by patients as sharp, originating close to the inguinal region or scar, and worsened with activity, especially movements around the hip joint. The pain may be related to entrapment or damage of the ilioinguinal, iliofemoral, or genital branch of the genitofemoral nerve due to suture, tacks, or mesh inflammation and scarring. Long-term studies have shown that the pain improves in the majority of patients. Until recently, there has been controversy with regard to neurectomy. A recently published meta-analysis showed that routine neurectomy in open inguinal hernia repair resulted in significantly less pain with no difference in sensation.36 Management of the pain should initially consist of nonoperative measures including antiinflammatory
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medications, nerve blocks, and physical therapy. Operative exploration should only be considered after all these measures have been exhausted. A popular option is laparoscopic exploration for mesh removal including securing devices (i.e., sutures, tacks, etc.), followed by open repair.
REFERENCES 1. Ger R, Monroe K, Duvivier R, Mishrick A. Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac. Am J Surg. 1990;159:370. 2. Katkhouda N. Inguinal hernia repair. In: Karkhouda N: Advanced Laparoscopic Surgery: Techniques and Tips. 2nd ed. Heidelberg [u.a.]: Springer; 2010:149-168 [Chapter 10]. 3. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004;350:1819. 4. Neumayer LA, Gawande AA, Wang J, et al. Proficiency of surgeons in inguinal hernia repair. Ann Surg. 2005;242:344. 5. Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant AM. Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2005;(1):CD004703. 6. Grant AM. Laparoscopic versus open groin hernia repair: meta-analysis of randomized trials based on individual patient data. Hernia. 2002;6:2. 7. Memon MA, Cooper NJ, Memon B, Memon MI, Abrams KR. Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg. 2003;90:1479. 8. Pikoulis E, Tsigris C, Diamantis T, et al. Laparoscopic preperitoneal mesh repair or tension-free mesh plug technique? A prospective study of 471 patients with 543 inguinal hernias. Eur J Surg. 2002;168:587. 9. Eklund A, Rudberg C, Smedberg S, et al. Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair. Br J Surg. 2006;93:1060. 10. Eklund AS, Montgomery AK, Rasmussen C, Sandbue RP, Bergkvist LA, Rudberg CR. Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair. Ann Surg. 2009;249:33. 11. Langeveld HR, van’t Riet M, Weidema WF, et al. Total extraperitoneal inguinal hernia repair compared with Lichtenstein (the LEVEL-trial). Ann Surg. 2010;251:819. 12. O’Reilly EA, Burke JP, O’Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg. 2012;555:846. 13. Bisgaard T, Bay-Nielsen M, Kehlet H. Re-recurrence after operation for recurrent inguinal hernia. A nationwide 8-year follow-up study on the role of type of repair. Ann Surg. 2008;247:707. 14. Koch A, Edwards A, Haapaniemi S, Nordin P, Kald A. Prospective evaluation of 6895 groin hernia repairs in women. Br J Surg. 2005;92:1553. 15. Krishna A, Misra MC, Kumar Bansal V, Kumar S, Rajeshwari S, Chabra A. Laparoscopic inguinal hernia repair: transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) approach: a prospective randomized controlled trial. Surg Endosc. 2012;26: 639. 16. McCormack K, Wake BL, Fraser C, Grant A. Transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review. Hernia. 2005;9:109. 17. Gass M, Banz VM, Rosella L, Adamina M, Candinas D, Güller U. TAPP or TEP? Population-based analysis of prospective data on 4,552 patients undergoing endoscopic inguinal hernia repair. World J Surg. 2012;36:2782. 18. Bracale U, Melillo P, Pignata G, et al. Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with a network meta-analysis. Surg Endosc. 2012;26:3355. 19. Antoniou SA, Antoniou GA, Bartsch DK, et al. Transabdominal preperitoneal versus totally extraperitoneal repair of inguinal hernia: a meta-analysis of randomized studies. Am J Surg. 2013;206: 245.
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20. Sharma D, Yadav K, Hazrah P, Borgharia S, Lal R, Thomas S. Prospective randomized trial comparing laparoscopic transabdominal preperitoneal (TAPP) and laparoscopic totally extraperitoneal (TEP) approach for bilateral inguinal hernias. Int J Surg. 2015;22:110. 21. Kockerling F, Bittner R, Jacob DA, et al. TEP versus TAPP: comparison of the perioperative outcome in 17,587 patients with a primary unilateral inguinal hernia. Surg Endosc. 2015;29:3750. 22. Gass M, Scheiwiller A, Sykora M, Metzger J. TAPP or TEP for recurrent inguinal hernia? Population-based analysis of prospective data on 1309 patients undergoing endoscopic repair for recurrent inguinal hernia. World J Surg. 2016;40(10):2348-2352. 23. Wei FX, Zhang YC, Han W, Zhang YL, Shao Y, Ni R. Transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) for laparoscopic hernia repair: a meta-analysis. Surg Laparosc Endosc Percutan Tech. 2015;25:375. 24. Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ. Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg. 2002;89:1062. 25. Schafer M, Lauper M, Krahenbuhl L. A nation’s experience of bleeding complications during laparoscopy. Am J Surg. 2000;180:73. 26. Azevedo JLMC, Azevedo OC, Miyahira SA, et al. Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review. Surg Endosc. 2009;23:1428. 27. Tamme C, Scheidbach H, Hampe C, Schneider C, Kockerling F. Totally extraperitoneal endoscopic inguinal hernia repair (TEP). Surg Endosc. 2003;17:190.
28. Van der Voort M, Heijnsdijk EAM, Gouma DJ. Bowel injury as a complication of laparoscopy. Br J Surg. 2004;91:1253. 29. Koch CA, Grinberg GG, Farley DR. Incidence and risk factors for urinary retention after endoscopic hernia repair. Am J Surg. 2006;191:381. 30. Dulucq JL, Wintringer P, Mahajna A. Laparoscopic totally extraperitoneal inguinal hernia repair: lessons learned from 3,100 hernia repairs over 15 years. Surg Endosc. 2009;23:482. 31. Patel JA, Kaufman AS, Howard RS, Rodriguez CJ, Jessie EM. Risk factors for urinary retention after laparoscopic inguinal hernia repairs. Surg Endosc. 2015;29:3140. 32. Gurbulak EK, Gurbulak B, Algun IE, et al. Effects of totally extraperitoneal (TEP) and Lichtenstein hernia repair on testicular blood flow and volume. Surgery. 2015;158:1297. 33. Poobalan AS, Bruce J, Cairns W, et al. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain. 2003;19:48. 34. Gitelis ME, Patel L, Deasis F, et al. Laparoscopic totally extraperitoneal groin hernia repair and quality of life at 2-year follow-up. J Am Coll Surg. 2016;223:153. 35. Singh AN, Bansal VK, Misra MC, et al. Testicular functions, chronic groin pain, and quality of life after laparoscopic and open mesh repair of inguinal hernia: a prospective randomized controlled trial. Surg Endosc. 2012;26:1304. 36. Barazanchi AWH, Fagan PVB, Smith BB, Hill AG. Routine neurectomy of inguinal nerves during open onlay mesh hernia repair. Ann Surg. 2016;264:64.
53A
Inguinal Hernia Repair: Laparoscopic Namir Katkhouda
|
Kulmeet K. Sandhu
|
Kamran Samakar
|
Evan Alicuben
I
nguinal hernia repair is a frequently performed operation, and laparoscopic inguinal hernia repair has become increasingly prevalent, particularly for the repair of bilateral or recurrent hernias. The first described laparoscopic inguinal hernia repair was completed in 1990 by Ger in canines1; the procedure has since evolved to include the use of a prosthetic mesh to cover the myopectineal orifice. There are two commonly performed techniques: the transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal repair (TEP). This chapter reviews the anatomy, technical considerations, benefits, and possible complications of laparoscopic inguinal hernia repair.
SURGICAL ANATOMY OF THE REGION A comprehensive understanding of the anatomy of the preperitoneal space is critical to the performance of a safe and effective laparoscopic inguinal hernia repair.2 The anterior approach to inguinal hernia repair involves recognition of the anatomy from a superficial to deep position; this is in contrast to laparoscopic repair, which requires identification of the critical structures from a reversed viewpoint. The median umbilical ligament covers the urachus and travels from the umbilicus to the bladder (Fig. 53A.1). The paired medial umbilical ligaments are remnants of the fetal umbilical arteries. The inferior epigastric vessels originate from the external iliac vessels and have a peritoneal covering creating the paired lateral umbilical folds. These folds originate medial to the deep inguinal ring and travel to the arcuate line, where the inferior epigastric vessels enter the rectus sheath. The medial inguinal fossa is the space located between the medial umbilical ligament and lateral umbilical fold bilaterally. This is the space associated with direct inguinal hernias. The lateral inguinal fossa is the depression lateral to the lateral umbilical fold. Indirect inguinal hernias develop at this site. The pectineal (Cooper) ligament is formed from fascia and periosteum and travels along the pectineal line of the pubic bone. The iliopubic tract is a thickened band of fibers from the transversalis fascia that joins laterally to the iliac crest and inserts medially on the pubic tubercle and pectineal line. The major vascular structures in this region are generally located medial to the deep inguinal ring. The inferior epigastric vessels branch from the external iliac vessels and travel to supply the anterior abdominal wall. A vascular connection may be noted in some patients between the obturator and external iliac vessels crossing the superior pubic ramus. This is known as the “corona mortis,” or
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crown of death, as injury due to dissection in this area can lead to significant hemorrhage. There are several other dangerous areas of dissection with laparoscopic hernia repair. The “triangle of doom” is located between the vas deferens medially and the gonadal vessels laterally. The external iliac vessels, deep circumflex iliac vein, genital branch of the genitofemoral nerve, and femoral nerve are located within this triangle. The key nerves in this area are located lateral to the deep inguinal ring (Fig. 53A.2). In the laparoscopic approach, the following nerves with cutaneous innervation may be encountered from laterally to medially: the lateral femoral cutaneous nerve, the anterior femoral cutaneous nerve, femoral nerve, femoral branch of the genitofemoral nerve, and genital branch of the genitofemoral nerve. The area inferior to the iliopubic tract and lateral to the gonadal vessels is known as the “triangle of pain,” where the lateral femoral cutaneous nerve and femoral branch of the genitofemoral nerve are found. Tacks placed in this area may injure either of these nerves. Together, the area between the vas deferens medially and the iliopubic tract superiorly and laterally constitutes “the square of doom,” where tacks and electrocautery should never be applied to avoid nerve injury. The previous anatomic discussion is required to understand the landmarks that define the three spaces associated with groin hernias (Fig. 53A.3): 1. Indirect inguinal hernia—lateral to the inferior epigastric vessels. 2. Direct inguinal hernia—medial to the inferior epigastric vessels and lateral to the border of the rectus abdominis muscle within the triangle of Hesselbach. 3. Femoral hernia—below the iliopubic tract, medial to the external iliac vein, and lateral to Cooper ligament. All three of these spaces should be covered during the laparoscopic approach with an appropriately sized mesh.
LAPAROSCOPIC VERSUS OPEN REPAIR The decision to perform an inguinal hernia repair via a laparoscopic versus an anterior approach remains difficult, complex, and nuanced. Tension-free anterior mesh repair has been the gold standard because of its low recurrence rate and lack of need for specialized equipment. Critiques of the laparoscopic approach include the higher in-hospital costs due to more expensive equipment, the possibility of intraabdominal organ or vascular injury, and the steep learning curve. Studies have indicated that greater than 250 operations are required to become experienced in this technically challenging operation.3-5 In fact, a recurrence rate of greater than 10% has been reported for surgeons
Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
ABSTRACT Symptomatic inguinal hernias are a commonly encountered surgical problem. Repair can be performed with an open or minimally invasive approach. Laparoscopic inguinal hernia repair is now widely performed, especially in the setting of bilateral or recurrent inguinal hernias. This chapter reviews the anatomy, benefits, and possible complications of laparoscopic inguinal hernia repair. Laparoscopic inguinal hernia repair is also compared with the traditional anterior approach, and the operative techniques of both the transabdominal preperitoneal repair and the totally extraperitoneal repair are reviewed. The outcomes of these two procedures are also examined.
KEYWORDS Inguinal hernia, femoral hernia, hernia repair, mesh, laparoscopy, transabdominal preperitoneal repair, totally extraperitoneal repair
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Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
Median umbilical fold Medial umbilical fold Bladder Lateral umbilical fold (inferior epigastric vessels)
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Right direct inguinal hernia Deep inguinal ring and indirect inguinal hernia Line of peritoneal incision
Vas deferens Spermatic vessels Iliac vessels Left ureter
FIGURE 53A.1 Laparoscopic view of the groin. (From Eubanks S. Hernias. In: Sabiston DC Jr, Lyerly HK, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: Saunders; 1997:1226.)
Sigmoid colon
Femoral branch genitofemoral nerve Danger zone
Femoral nerve
Genital branch genitofemoral nerve
Lateral femoral cutaneous nerve
Iliacus muscle
Psoas muscle
FIGURE 53A.2 Nerves in the inguinal region.
who have performed fewer than 250 procedures.3 For this reason, some have argued that the laparoscopic approach should be reserved for experienced centers. Conversely, many trials have shown significantly less early postoperative pain resulting in less narcotic use and swifter return to normal activity.6,7
Nevertheless, most large trials have failed to consistently show a difference in recurrence rates between the two approaches.8-11 The biggest exception is a study out of the Veterans Administration (VA) system from 2004.3 In this study, more than 2000 male patients within the VA system were randomized to an open or laparoscopic
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SECTION I Esophagus and Hernia
Area of direct hernia Area of indirect hernia
Internal inguinal ring Pubic tubercle
Inferior epigastric vein
Edge of inguinal ligament
Iliopubic tract Cooper ligament Gonadal vessels
Femoral canal
Vas deferens
External iliac vessels
FIGURE 53A.3 Preperitoneal inguinal anatomy.
inguinal hernia repair with mesh. With 2-year postoperative follow-up, the laparoscopic group had a significantly higher recurrence rate than the anterior approach in the repair of primary hernias (10.1% vs. 4.0%). However, recurrence rates were similar if the repairs of recurrent hernias were compared (10.0% vs. 14.1%). This study has steered many surgeons to repair unilateral primary inguinal hernias through an open approach. More recent research has attempted to clarify this dilemma. In a meta-analysis of 27 randomized controlled trials of primary unilateral inguinal hernia repair including 7161 patients, O’Reilly et al. found that the laparoscopic approach resulted in an increased risk of recurrence.12 Interestingly, compared with open repair, TEP had increased rates of recurrence but TAPP had equivalent rates. Additionally, the laparoscopic approach was associated with higher perioperative complication risk. This was attributed to a higher complication risk with TAPP but equivalent risk with TEP. However, laparoscopic repair resulted in reduced risk of chronic groin pain and numbness compared with the anterior approach. The laparoscopic repair technique may be better suited for bilateral or recurrent inguinal hernias and hernias in women. Bilateral hernias may be repaired through the same set of port sites and do not require
additional incisions. In recurrent hernias, especially those with previous open repair, a posterior approach results in dissection through native tissue planes. Some studies have suggested this may lead to improved recurrence compared to redo anterior repair.13 Inguinal hernias in females may be better performed laparoscopically given that the posterior placement of mesh allows for coverage of the femoral space, therefore addressing the incidence of femoral recurrence seen in Lichtenstein repair. The importance of this concept was illustrated in a series of hernia repairs in women which showed a 41.6% rate of femoral hernia found during operations for recurrences.14
OPERATIVE TECHNIQUE TRANSABDOMINAL PREPERITONEAL REPAIR The patient is placed in the supine position with both arms tucked. An indwelling catheter is placed in the bladder to prevent view obstruction and decrease the risk of injury to the bladder during dissection of the preperitoneal space. The monitor is placed at the foot of the table. The surgeon stands behind the shoulder opposite to the hernia, and the camera assistant stands on the other side of the patient. Steep Trendelenburg is
Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
10-mm trocar with camera and insufflation in umbilicus
Medial umbilical ligament
Direct hernia
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Lateral umbilical fold
Indirect hernia
5-mm trocar
5-mm trocar Bladder
Optional additional grasper
Vas deferens
Spermatic vessels Iliac vessels
FIGURE 53A.5 Creation of the peritoneal flap. (From Eubanks S. Hernias. In: Sabiston DC Jr, Lyerly HK, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: Saunders; 1997:1226.)
FIGURE 53A.4 Trocar placement for transabdominal preperitoneal hernia repair.
required to remove the small bowel from the pelvis and adequately visualize the area to be dissected. Three ports are required for this operation. A 10-mm port for the laparoscope is placed at the umbilicus. Two additional 5-mm ports are placed lateral to the rectus muscle on either side at the junction of a line between the umbilicus and the anterior superior iliac spine (Fig. 53A.4). Alternately, the two 5-mm ports can be placed at the midline between the umbilicus and pubic bone for the TEP repair. A 30-degree laparoscope is required, as the oblique orientation of the inguinal canal makes it difficult to visualize small hernias and it is challenging to open the peritoneum at the anterior abdominal wall without the 30-degree angle. Following the establishment of pneumoperitoneum— which is maintained at 15 mm Hg—and port introduction, attention is turned to raising the peritoneal flap. If the trocars are inserted too low, it can be very difficult to produce an adequately sized peritoneal flap or easily maneuver the tacking device or the fibrin glue sprayer. On the other hand, if they are placed too high, the small bowel may get in the way. Therefore optimal placement of trocars and a 30-degree laparoscope are essential to success. The peritoneal flap may be incised from lateral to medial or medial to lateral. If a lateral-to-medial dissection is chosen, the incision begins medially to the anterior superior iliac spine (Fig. 53A.5). This then extends medially, staying at least 2 cm above the deep inguinal ring and hernia defect, and ends at the medial umbilical ligament. Blunt dissection is used to enlarge the peritoneal flap and expose the critical landmarks in the preperitoneal space, including the pubic tubercles, Cooper ligament, and the iliopubic tract (Fig. 53A.6).This dissection of the areolar tissue can be done with minimal hemostasis, and
Inferior epigastric vessels Rectus abdominis Pubis
Musculoaponeurotic arch of transversus abdominis
Iliopubic tract
Cooper ligament Iliac vessels
Peritoneum Spermatic vessels Vas deferens
FIGURE 53A.6 Dissection of the inguinal region. (From Eubanks S. Hernias. In: Sabiston DC Jr, Lyerly HK, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: Saunders; 1997:1226.)
electrocautery is used with care in this area to avoid nerve injury. The femoral nerve is present under the iliopubic tract at the lateral aspect of the dissection, but this nerve is not commonly visualized during this procedure. In thin patients, the lateral femoral cutaneous nerve and the genitofemoral nerve may be identified. In males, the spermatic cord structures are dissected free of the peritoneal flap. This involves separating the cord structures, including the vas deferens, from the peritoneum and the hernia sac. The peritoneum must be dissected quite inferiorly, as inadequate mobilization can result in folding of the mesh after peritoneal closure and early recurrence. If the view of the operative site is obscured with blood, it can be irrigated and aspirated
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SECTION I Esophagus and Hernia
Optional additional grasper
Mesh stapled into Cooper ligament and around medial edge first
FIGURE 53A.7 Placement and fixation of the mesh. (From Eubanks S. Hernias. In: Sabiston DC Jr, Lyerly HK, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed. Philadelphia: Saunders; 1997:1226.)
ring to avoid nerve injury. Nerve injury can lead to severe chronic pain due to neuroma formation around the staple or tack. Then tacks may be placed laterally and medially; laterally, it is essential to stay above the iliopubic tract, but tacks placed medially are inserted into the rectus muscle and on Cooper ligament. Usually two staples or tacks are placed in Cooper ligament and one or two in the rectus muscle. Staples or tacks are often used for fixation in laparoscopic inguinal hernia repair due to the risk of shrinkage or migration of the mesh. After the mesh is secured, pneumoperitoneum pressure is reduced to 10 mm Hg. The peritoneal flap is then positioned over the mesh and closed with tacks. Absorbable tacks are preferred to prevent subsequent adhesions to the tacks. Complete mesh coverage is essential to prevent exposure of the mesh to the underlying small bowel. This can lead to the creation of adhesions and possible small bowel obstruction. If possible, tacking is performed in an overlap fashion. The peritoneal flap can also be closed using a continuous running suture per surgeon preference. The fascia is routinely sutured at the umbilical port during closure.
TOTALLY PREPERITONEAL HERNIA REPAIR or cleaned with gauze placed intraabdominally. Direct hernia sacs and small indirect hernia sacs can often be easily reduced during this dissection. In the case of a very large indirect inguinoscrotal hernia, the distal part of the sac can be divided and left within the scrotum if it cannot be reduced. This dissection begins with gentle and atraumatic separation of the sac from the spermatic cord structures. As the sac is separated, it is divided, but care should always be taken to ensure that the vas deferens is not included with the sac. It may be easier to locate the vas deferens before starting the division of the hernia sac, but often a gradual division of the sac will allow for complete separation of the sac from the cord. Once the peritoneal sac is completely excised, the operation continues as usual. The distal portion of the divided sac is left open in the inguinal canal and the proximal part is ligated using an Endoloop or clips. This method is employed if the complete sac cannot be reduced as significant dissection at the distal sac in larger hernias can cause hematoma formation, ischemic orchitis, or atrophy of the testicle. When the hernia sac has been completely reduced and dissection of the preperitoneal space is complete, the mesh is rolled and introduced through the umbilical port using a grasper (Fig. 53A.7). Mesh of an appropriate size should be used, typically a 15- by 10-cm piece will be adequate for one side. Once inside the abdominal cavity, the mesh is unrolled and positioned so that it covers the direct, indirect, and femoral spaces. Fixation is then performed with fibrin glue, tacks, or suture. Some surgeons feel that complications of fixation, and associated vascular or nerve entrapment can be avoided if a significantly large piece of mesh is placed. Our technique of choice currently is to use fibrin glue. The fibrin glue is sprayed over the mesh in a thin layer, especially over Cooper ligament and the lateral aspect of the mesh. However, if one chooses to use tacks, the mesh fixation can begin at the midportion, “three fingers” above the superior limit of the internal
The arcuate line of Douglas is a transitional line; above it, the rectus muscle has a defined anterior and posterior sheath composed of the aponeurotic fascia of the internal oblique and transversus abdominis muscles. Below the arcuate line, all fascial layers of the abdominal muscles are anterior to the rectus muscle, and behind the rectus muscle itself there is only the transversalis fascia. Preperitoneal dissection is performed below the arcuate line, which is located approximately midway between the umbilicus and pubis. The operation is begun by making a 10-mm incision below the umbilicus. Two retractors are used to slide the incision to the right if the hernia is located on the right side, or to the left if the hernia is located on that side. The anterior rectus sheath on the side of the hernia is then opened under direct vision, and two stay sutures are placed on each edge. The rectus muscle is then bluntly separated using two retractors so that the posterior fascia can be visualized. At this point, it is essential not to open the posterior fascia of the rectus muscle but instead to dissect inferiorly toward the symphysis pubis in an oblique fashion, using either the index finger or a small peanut with an angulation of about 30 degrees. That will lead to the preperitoneal space below the arcuate line of Douglas. The preperitoneal space is then dissected using a balloon space maker under direct vision with a 30-degree laparoscope (Fig. 53A.8). While the balloon is inflated, the rectus muscle should be seen anteriorly and superiorly, and the preperitoneal fat and peritoneum should be seen posteriorly. It is preferred that the inferior epigastric vessels stay anteriorly with the rectus muscle, as otherwise they may hamper dissection and possibly require ligation. The balloon should stay in place for approximately 15 seconds to tamponade any bleeding. The space-maker balloon is then removed and the Hasson port is introduced. Two 5-mm ports are placed at the midline between the umbilicus and the symphysis pubis to allow for operating on both sides. The space created using this technique is small
Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
Endoscope with balloon in preperitoneal space
Peritoneum Pubis
Bladder
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Endoscope with balloon advanced inferiorly in preperitoneal space
Intestine
Peritoneum Pubis
Bladder
A
B
Expanded preperitoneal space maintained with insufflation
Balloon inflated in preperitoneal space
Pubis
Peritoneum
C
Bladder
D
FIGURE 53A.8 Balloon dissection of the preperitoneal space. (A) A balloon dissector is introduced into the preperitoneal space. (B) The balloon dissector is advanced to the pubis in the preperitoneal space. (C) The balloon is inflated under direct vision with the laparoscope. (D) The balloon is removed and the preperitoneal space is insufflated with carbon dioxide. (From Shadduck PP, Schwartz LB, Eubanks WS. Laparoscopic inguinal herniorrhaphy. In: Pappas TN, Schwartz LB, Eubanks WS, eds. Atlas of Laparoscopic Surgery. Philadelphia: Current Medicine; 1996. Copyright 1996 by Current Medicine.)
and limits the movement of the laparoscopic instruments. Care should be taken to avoid perforating the peritoneum, since an opening in the peritoneum will allow CO2 to escape into the abdominal cavity, which will subsequently compress the space and reduce it further. If this occurs, a Veress needle can be inserted into the abdomen to allow for the exit of CO2. The perforation can be then be closed using an Endoloop or a 5-mm clip applier. After the ports are in place, Cooper ligament is identified medially and the iliac vein’s position is noted as well. These two structures are key anatomic landmarks in this procedure, as they aid in defining the inferior aspect of the dissection. It is possible to injure the iliac vein, and there have been reports of ligation of the iliac vein when it was mistaken for the hernia sac. Once the iliac vein is identified after careful dissection, the next step is locating the inferior epigastric vessels. This will help delineate the internal ring and Hesselbach triangle. The vas deferens is identified by following the internal ring medially and toward the iliac vein. Gentle, blunt dissection is then
used to separate the sac from the cord structures and vas deferens. Small hernia sacs are usually easily reduced. If the hernia sac is large and dissection difficult, it may be prudent to amputate the sac, leave the distal part of the sac open, and close the proximal opening either with clips or an Endoloop. The mesh is then placed into the preperitoneal space and positioned as mentioned in the previous section. Once the mesh is in place, fibrin sealant or tacks can be used to fix the mesh in position. The fibrin sealant can be applied as an aerosol spray, which is attached to one of the open trocars to prevent excessive pressure inside the abdomen. This fibrin glue can be placed above or below the lightweight, large-pore mesh. It is important to use a lightweight, large-pore mesh to avoid or minimize the risk of mesh contraction and a foreign body reaction. The operation ends by desufflating the preperitoneal space and gradually removing the ports. A grasper is used to hold the mesh in place as the CO2 is evacuated. After port removal, the anterior fascia is closed with the previously placed stay sutures.
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SECTION I Esophagus and Hernia
TRANSABDOMINAL PREPERITONEAL REPAIR VERSUS TOTALLY EXTRAPERITONEAL REPAIR An obvious advantage of the TEP technique over the TAPP hernia repair is that the peritoneum does not have to be closed over the mesh, theoretically reducing operative time. Despite this advantage, the operative area is smaller and the anatomy more difficult to grasp. The potential intraabdominal complications that may be associated with the transabdominal approach—such as visceral injury, adhesions, and trocar site hernias—are avoided in the TEP repair, as the peritoneum is not entered. However, small, unrecognized peritoneal violations are likely common in the TEP method, therefore making those complications possible with both techniques. To date there have been no studies that have definitively shown an advantage of one approach over the other.5,15-20 The largest published series is from the Herniamed registry, which is a multicenter Internet-based database with participating surgeons in Germany, Austria, and Switzerland. In their published series of 17,587 patients who underwent laparoscopic repair of a primary unilateral inguinal hernia, the TEP and TAPP techniques had similar intraoperative complication rates but the TEP method had significantly fewer postoperative complications.21 Subgroup analysis indicated that these findings could be attributed to a difference in bleeding and seroma formation. Risk factors for the development of complications included increased defect size and the presence of a scrotal hernia. Of note, these characteristics were more commonly seen in the TAPP group, and this may explain the difference in complication rate. Nevertheless, the rate of reoperation for recurrence was equivalent between the two groups. With regard to recurrent hernias, in a series of 1309 patients, the TEP approach was associated with a significantly increased rate of intraoperative complications (TEP 6.3% vs. TAPP 2.8%) and a longer operative time (TEP 80.3 minutes vs. TAPP 73.0 minutes), but the rates of postoperative complication were similar.22 Overall these differences were felt to be clinically insignificant; therefore the procedures were deemed equivalent. In a recent meta-analysis of 10 randomized controlled trials, Wei et al. reported no significant difference in operative time, cost, complications, or time to return to usual activities.23 Given the failure to show benefit in the TEP group, this study suggested that the TAPP approach may be the preferred strategy, especially for nonexpert laparoscopic surgeons.
COMPLICATIONS The incidence of complications following laparoscopic inguinal hernia repair has gradually declined and should continue to decline as the procedure becomes more prevalent. The reported rates of complications vary widely and reach as high as 25%, depending on the definition of morbidity put forth by the studies.7,24 Vascular Injuries Significant vascular injury during the procedure is most likely to occur while gaining access to the peritoneal cavity.
The risk of intraoperative bleeding has been reported at 2.3%, with the risk of major injury at 0.08%.25 In a large series of Veress needle insertions, the rate of major vascular injury was 0.018% and most commonly involved injury to the iliac vessels and aorta.26 Specifically to laparoscopic inguinal hernia repair, one series of TEP repairs has reported a postoperative hemorrhage rate of 0.4%.27 Although some attribute these injuries to introduction of the Veress needle, similar injuries have been described with the open approach for insertion of the Hasson cannula. Once a major vascular injury is recognized, management should be done via laparotomy for best exposure and preparation for vessel repair. Laparoscopy may underestimate the degree of blood loss and may limit retraction and exposure of the bleeding vessel. Significant abdominal wall hemorrhage is likely from injury to the epigastric vessels. Initial bleeding can be controlled with a cannula while preparations are made for suture ligation using transfascial sutures placed with fascial closure devices. Bowel Injury Injury to bowel most commonly occurs during entry into the abdomen with the trocar or Veress needle and is estimated to occur in 0.13% of cases.28 Most frequently, the small bowel is injured and this can be detected intraoperatively in two-thirds of cases. Missed bowel injuries usually present with peritonitis and sepsis approximately one week postoperatively. An experienced laparoscopic surgeon may repair the injury via intracorporeal suturing or stapling, taking care to avoid narrowing of the intraluminal diameter. Bladder Injury Bladder injury is possible from placement of a suprapubic trocar or during dissection. Small injuries can be managed with urinary drainage, but larger defects require repair. If such an injury is recognized, laparoscopic repair is an option if the experience of the surgeon is sufficient. If unrecognized, injury may present later with hematuria, abdominal pain, or peritonitis. Urinary Retention The risk of developing urinary retention is significantly higher in laparoscopic repair compared with the anterior approach, given the use of general anesthesia compared with the possibility of local anesthesia for open repairs. The actual reported incidence varies widely up to 22%, and is higher in older patients with history of prostatic symptoms.29-31 In one study, postoperative narcotic use of 6.5 mg or greater of morphine or morphine equivalent was an independent risk factor for the development of urinary retention. 31 Narcotic avoidance with the usage of antiinflammatory medications, acetaminophen, and regional nerve blocks may help to decrease the risk of retention. The amount of intraoperative fluids given, the presence of a urinary catheter during surgery, and operative time were not associated with increased risk. Intermittent catheterization or a temporary indwelling catheter usually resolves the symptoms.
Inguinal Hernia Repair: Laparoscopic CHAPTER 53A
Recurrence The rate of recurrence has been reported to be between 0% and 13% with the VA trial showing a recurrence rate of 10% for primary unilateral hernias.3 Diagnosing a recurrence may necessitate imaging studies, often ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT). Anterior repair for recurrent hernias is a popular option given that the tissue planes have not been previously violated. However, if the initial laparoscopic repair was performed due to a recurrent hernia, dissection in either space can be difficult. Ischemic Orchitis Disruption of the vascular supply to the testis may cause pain, fever, and an enlarged, firm testicle associated with ischemic orchitis. This more commonly results from damage to the venous plexus as opposed to the testicular artery. Duplex ultrasound should be performed to evaluate for testicular torsion. Patients are managed expectantly with antiinflammatory agents for symptoms. Testicular necrosis may ensue and eventually result in testicular atrophy; however, this happens in a minority of cases.24 Some believe that laparoscopic repair may result in less testicular ischemia due to a higher dissection on the spermatic cord. However, postoperative color Doppler ultrasonography has shown no measurable difference in blood flow.32 Groin Pain The etiology and management of postinguinal groin pain following hernia repair remains poorly understood and reflects the complex nature of this problem. The incidence has varied greatly but has been reported to be as high as 53%, with 1% requiring referral to specialty pain clinic.33,34 Laparoscopic repair causes significantly less early postoperative pain compared with the anterior approach. With long-term follow-up, overall rates of pain tend to equalize, but the laparoscopic approach has been shown to have less pain during strenuous activity.35 It is difficult to make definitive recommendations given that pain is reported by a variety of scales. Etiology of the pain may be related to factors present prior to the hernia repair, including muscle strain, osteitis pubis, and other lumbosacral disorders. MRI offers the advantage of soft tissue and neural resolution for diagnosis and can serve to evaluate for hernia recurrence. Neuropathic pain, which is most difficult to manage, is usually described by patients as sharp, originating close to the inguinal region or scar, and worsened with activity, especially movements around the hip joint. The pain may be related to entrapment or damage of the ilioinguinal, iliofemoral, or genital branch of the genitofemoral nerve due to suture, tacks, or mesh inflammation and scarring. Long-term studies have shown that the pain improves in the majority of patients. Until recently, there has been controversy with regard to neurectomy. A recently published meta-analysis showed that routine neurectomy in open inguinal hernia repair resulted in significantly less pain with no difference in sensation.36 Management of the pain should initially consist of nonoperative measures including antiinflammatory
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medications, nerve blocks, and physical therapy. Operative exploration should only be considered after all these measures have been exhausted. A popular option is laparoscopic exploration for mesh removal including securing devices (i.e., sutures, tacks, etc.), followed by open repair.
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