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42 Groin Hernia Repair: Open Techniques
447
hand, open techniques allow for direct visualization of all three nerves. This important technical
consideration is unfortunately not uniformly
practiced but minimizes the risk of chronic pain
and injury. Studies have suggested that postoperative chronic pain is improved with laparoscopic
repairs compared to open, but long- term data suggest the chronic pain rates are the same. What is
known is that pain consequent to a posterior mesh
placement can be more diffi cult to manage.
Among the open repairs, mesh is preferred to
tissue, and Lichtenstein repair remains the gold
standard, performing reliably in the hands of
surgeons at large, in all settings. RCTs have
been conducted or are ongoing to compare alternative open approaches to Lichtenstein, and all
of those mentioned in this chapter have demonstrated their effectiveness [ 33 , 39 , 40 ].
Additionally, several of the open repairs discussed above have shown equivalent or improved
outcomes in terms of chronic pain, recurrence,
and ease of implementation.
In our own practice, we concur with the EHS
recommendations and offer either an open
Lichtenstein approach or laparoscopic total
extraperitoneal repair for primary inguinal hernias. Patients are routinely counseled that both of
these techniques have similar excellent outcomes
without superiority of one technique over the
other, especially with regard to the two primary
outcomes of recurrence and chronic pain. Rather,
each has different considerations and limitations.
For patients that wish to avoid general anesthesia, those with increased cardiopulmonary risk,
or prior lower abdominal surgery/prostatectomy,
the open Lichtenstein approach minimizes the
operative risk and has excellent outcomes for
both unilateral and bilateral primary hernias. It is
effective for all variations of inguinal hernia, but
may be more challenging or require modifi cation
for femoral hernias or recurrence after prior anterior mesh repair. For primary bilateral hernias,
recurrences after prior anterior repair, females,
and known femoral hernias, the relative advantages of a laparoscopic approach (TEP/TAPP)
are discussed and commonly accepted. In cases
where mesh is either contraindicated or refused,
we perform a Shouldice operation.
From our extensive experience with chronic
pain and mesh complications, we are partial to
the avoidance of three-dimensional meshes and
those that cross both the anterior and posterior
planes (plug, plug and patch, PHS). While they
are effective techniques for the repair of hernia,
remediation of complications is more problematic than those with the standard fl at mesh used
in Lichtenstein, TIPP, TREPP, and laparoscopic
(TEP, TAPP) approaches. After treating thousands of patients with inguinodynia, recurrence,
and mesh-based complications, it is important to
clearly assert that all techniques (tissue, open,
and laparoscopic) have complications and problems. That being said, everything that the individual surgeon can do to perfect his or her
preferred technique will optimize personal
results and patient outcomes. Regardless of the
approach chosen, the fundamental principles
underlying every successful hernia repair, that
avoids both recurrence and chronic pain, are a
profound understanding of the neuroanatomy of
the inguinal canal and the use of a technique that
results in the lowest possible amount of tension
on native tissues.
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39. Pélissier E, Ngo P. Subperitoneal inguinal hernioplasty
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Laparoscopic TAPP Inguinal Hernia
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Repair
Sergio Roll and James Skinovsky
4 3
Introduction
Laparoscopic repair of inguinal and femoral hernia is increasingly popular because they offer the
potential for less postoperative pain and a quick
return to normal activities [ 1 ]. When performing
laparoscopic inguinal or femoral hernia repair,
the hernia defect is approached from its posterior
aspect and the repair involves placing mesh in the
preperitoneal space. The anatomic approach to
the preperitoneal space depends upon the laparoscopic technique used for hernia repair. The two
commonly used approaches to laparoscopic
repair of inguinal and femoral hernias are the
transabdominal preperitoneal hernia repair
Electronic supplementary material: The online version
of this chapter (doi:
tains supplementary material, which is available to authorized users.
S. Roll , M.D., Ph.D. (*)
Division of General Surgery , Center of Abdominal
Wall Surgery, Santa Casa of São Paulo ,
São Paulo , SP , Brazil
School of Medical Science Santa Casa of São Paulo ,
São Paulo , SP , Brazil
sroll@uol.com.br
e-mail:
J. Skinovsky , M.D., Ph.D.
Positivo University , Curitiba , Paraná , Brazil
Surgical Residence of the Red Cross Hospital ,
Curitiba , Paraná , Brazil
10.1007/978-3-319-27470-6_43 ) con-
(TAPP) and the totally extraperitoneal hernia
repair (TEP) approaches.
Laparoscopic transabdominal preperitoneal
hernia repair (TAPP) is discussed here.
Patient preference plays perhaps the greatest
role in the choice of one type of repair over
another; however, surgical expertise plays a key
part as well. Data show that the recurrence rate
drops signifi cantly as surgeons gain experience
with the laparoscopic technique. The learning
curve for laparoscopic hernia repair is prolonged
with most estimates ranging between 50 and 75
procedures. However, when performed by an
experienced surgeon (>75 repairs), hernia recurrence is low [ 2 ]. The learning curve of TAPP
groin hernia repair is longer than in open procedures and some studies suggest that the learning
curve for TEP may be as high as 250 cases [ 3 ].
It is generally believed that TAPP is easier to
teach and learn, although there is no level 1 evidence in the literature to support this belief.
Both minimally invasive techniques are considered effective approaches to recurrent hernia
following open repair; however, adequate experience is recommended [ 2 ].
According to several systematic reviews comparing TAPP and TEP, both methodologies seem
to be more effective than open hernia repair,
although there is not yet suffi cient evidence to
recommend the use of TAPP rather than TEP [ 4 ].
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_43
451© Springer International Publishing Switzerland 2016
452
S. Roll and J. Skinovsky
Why Choose the TAPP Procedure
1. TAPP enables a thorough intra-abdominal
examination,
2. Provides visualization of both inguinal regions
(Occult hernia—For patients in whom a groin
hernia is suspected but has been diffi cult to
confi rm on imaging studies, a TAPP approach
may offer a better view to determine the presence and location of the hernia)
3. As soon as you enter at the abdominal cavity,
even without dissecting the peritoneum—you
can see the anatomy landmarks
4. Permits thorough exploration of the entire
myopectineal orifi ce
5. Allows visualization of incarcerated hernias
and evaluation of possibly strangulated tissue
6. Prior pelvic surgery—In the setting of prior
preperitoneal pelvic dissection, it may not be
possible to develop the proper exposure purely
extraperitoneal
7. Easier in females with indirect inguinal hernia, because the sac is frequently more intimately attached to the round ligament
8. Is easily taught and learned.
rect sacs laparoscopically can be diffi cult, so we
usually prefer an open Lichtenstein technique [ 6 ].
Preoperative Evaluation
and Preparation
Preoperative preparation includes thromboprophylaxis and prophylactic antibiotics. To minimize the risk of bladder injury, the bladder should
be emptied before surgery. In cases of potential
diffi cult surgery, we place a bladder catheter prior
to the beginning of the case [ 7 ].
OR Preparation to the Repair
Equipment
Appropriate instrumentation and supplies should
be readily available, and the proper functioning
of laparoscopic imaging equipment verifi ed prior
to initiating anesthesia. In recent years, I have
been using a 5-mm 30° laparoscope, two 5-mm
trocars, and one 10/12-mm trocar.
Contraindication to the TAPP
Technique
Absolute contraindications are few. In general,
the inability to tolerate general anesthesia, though
there are reports of spinal anesthesia being used
for this procedure. Other prohibitive patient factors include coagulopathy and intra-abdominal
infections that would preclude the use of a prosthetic mesh [ 5 ].
Relative contraindications include previous
abdominal surgery, especially pelvic surgery and
previous radical prostatectomy (more diffi cult
and carry a higher morbidity). In a large Brazilian
Multicenter trial, 8549 TAPP hernias were performed in 6955 patients and with only 2.3%
intraoperative complications, with bladder injury
being most common.
NOTE : Large inguinoscrotal hernias can be
challenging to manage because reducing these indi-
Choice of the Mesh
Lightweight mesh has been compared with
heavyweight, and the recent data has demonstrated some benefi t in lightweight mesh.
Lightweight mesh has been shown to result in
reduced chronic groin pain, although there was
no associated increase in quality of life [ 8 ]. My
preference is to use a macroporous lightweight
polypropylene mesh (35–45 g/m 2 ). The size
depends on the anatomy and the type of hernia
defect encountered during dissection. The available mesh sizes are 15 × 15 cm and 30 × 30 cm.
Although in most cases the mesh size used is
15 × 12 cm, in some recurrent hernia cases, we
use a larger mesh (17 × 14 cm) [ 9 ].
The size should be large enough to produce a
wide overlap beyond the defect’s edges. The
mesh can either be fl at and rectangular or preformed to fi t the myopectineal orifi ce.
43 Laparoscopic TAPP Inguinal Hernia Repair
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453
Fig. 43.1 Left side— mesh fi xation with absorbable
mechanic device
In general, a standard polypropylene or polyester uncoated mesh is used for laparoscopic repairs,
because the mesh will be covered by peritoneum,
and as such isolated from the intra-abdominal
cavity. When faced with a thin or brittle peritoneum which is diffi cult to close and cannot be
repaired, a coated polypropylene or polyester
meshes or other meshes, approved for intraabdominal applications, should be used [ 10 ].
NOTE : In cases of bilateral hernias, due to the
diffi culty in handling and positioning the lightweight mesh, a single large mesh covering both
defects can be used.
Mesh Fixation
Although some surgeons support nonfi xation of
mesh, we suggest mesh fi xation during TAPP
procedure to avoid mesh migration and mesh
shrinkage. We utilize absorbable staples or fi brin
glue for mesh fi xation [ 11 ] (Fig. 43.1 ).
Stapling or tacking injuries to the nerves are
the most common source of postoperative neuralgia following laparoscopic hernia repair. This
complication should be suspected if severe groin
pain develops in the recovery room and during
the immediate postoperative period. Although
the nerves are essentially never seen during laparoscopic hernia repair, nerve injuries can be prevented by following some strategies: avoid
stapling below the ileopubic tract and lateral to
Fig. 43.2 Right Side— mesh fi xation (the stars denote
attachment points)
the gonadal vessels (the lateral cutaneous nerve
and the femoral branch of genitofemoral nerve
are the two nerves vulnerable to trauma) as well
as avoiding dissection of the nerves and leaving
them in direct contact with the mesh [ 12 ].
NOTE : During recent years, with increasing
concern for the chronic postoperative pain, we
have signifi cantly decreased the number of fi xations on the mesh, and today I have used an average of four/fi ve positions tacks (Fig. 43.2 ).
Technique for Repair
Patient and Team Position
The patient is positioned supine with both arms
tucked. During the procedure, the patients are
shifted in 15–20° of Trendelenburg position to
improve exposure of the working area and to
move the small bowel away from the area of
dissection.
The surgeon should stand on the opposite side
of the defect to be corrected; surgical nurse
should be in front of the surgeon, and the assistant with the camera near the patient’s head, on
the same side of the surgeon. Alternatively, the
assistant can stand on the same side as a hernia,
provided that the camera is positioned through
the port on the ipsilateral side as well. The monitor is placed at the foot of the operating bed
(Fig. 43.3 ).
454
Fig. 43.3 Patient and time
position
S. Roll and J. Skinovsky
Operative Steps
for the Transabdominal Preperitoneal
Repair
Access of the peritoneal cavity is achieved using
standard techniques with a Veress needle to create the pneumoperitoneum. An incision at the
supra umbilicus is then made for placement of a
5 mm trocar (I use a 5 mm 30° laparoscope).
Once access to the peritoneal cavity has been
established, an inspection of the abdominal cavity is made in search of other affections.
We place two additional trocars bilaterally in a
horizontal plane with the umbilicus. This moment
requires additional care in order to avoid injury of
the superfi cial epigastric vessels. This can be
facilitated through their visualization by means
of abdominal wall transillumination [ 13 ]
(Fig. 43.4 ).
NOTE : The major advantage of the posterior
approach to groin hernias is that all three hernia
defects (direct, indirect, and femoral) are
well-visualized.
Using a 5 mm, 30-degree angled laparoscope,
the groin anatomy is inspected. The inferior epigastric vessels, the internal inguinal ring with the
spermatic vessels, and the vas deferens should be
identifi ed. These three structures form the socalled Mercedes-Benz star . This easy identifi ca-
tion is done by transparency through the
peritoneum [ 14 ] Fig. 43.5a, b ).
The peritoneum is incised 4–5 cm above the
hernia defect or internal ring, from the edge of
the median umbilical ligament toward the anterior superior iliac spine. Often, at the opening of
the peritoneum, we have a tendency to fall toward
the region of the nerves. Therefore, before making the incision, mark three points: median
umbilical ligament, anterior superior iliac spine,
and the line between the two (Figs. 43.6 and
43.7 ) Dissection is performed in the preperito-
neal avascular plane between the peritoneum and
the transversalis fascia to provide visualization of
the myopectineal orifi ces. It is very important not
to dissect preperitoneal fat from sensitive structures, like psoas muscle and nerves.
After dissection of the preperitoneal space, a
surgeon should be able to identify the inferior
epigastric vessels, vas deferens, spermatic cord,
iliac vessels, bladder, psoas, nerves location, and
hernia defects. It is important to make a wide dissection suffi ciently above and medial to the hernia defect to allow a 3–4 cm of normal fascia to
provide suffi cient mesh overlap (Fig. 43.8 ).
43 Laparoscopic TAPP Inguinal Hernia Repair
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Fig. 43.4 Trocar position
455
Fig. 43.5 ( a ) Right side—inferior epigastric vessels,
spermatic vessels, and the vas deferens (“Mercedes-Benz
Fig. 43.6 Left side—opening of the peritoneum Fig. 43.7 Left side—opening of the peritoneum
star”). ( b ) Left side—inferior epigastric vessels, sper-
matic vessels, vas deferens, median umbilical ligament,
and direct hernia
456
S. Roll and J. Skinovsky
Fig. 43.8 Left side— preperitoneal space dissected
For an indirect hernia, the cord structures are
isolated and dissected free from the surrounding
tissues. In the process, the indirect hernia sac is
identifi ed, usually found on the anterolateral side
of the cord and adherent to it. When separating
the sac from the cord, it is important to handle the
vas deferens and the spermatic vessels with care
to minimize trauma. If the sac is suffi ciently
small, it should be completely dissected free
from the cord and returned to the peritoneal cavity. Occasionally, a large sac will be encountered,
in which case it should be dissected and may be
divided beyond the internal ring, with the resultant peritoneal defect closed with a suture or
endoloop. The distal end of the transected sac
should be left open to avoid formation of a hydrocele or hematic cyst [ 15 ].
Direct hernia sacs are typically easier to reduce
than indirect sacs. Once the preperitoneal space
has been dissected out laterally, the direct hernia
defect is addressed by separating the peritoneum
from the overlying myopectineal orifi ce. When
reducing the direct hernia sac, a “pseudosac” may
be present, which is transversalis fascia that overlies and adheres to the peritoneum and invaginates into the preperitoneal space during the
dissection. This layer must be separated from the
true hernia sac in order for the peritoneum to be
released back fully into the peritoneal cavity.
Once the pseudosac is freed, it will typically
retract anteriorly into the direct hernia defect. We
must always alert surgeons who are starting in the
TAPP technique, that the “pseudosac” is the
“sick” transversalis fascia and not the true hernia
sac. At this time, before placing the mesh, I fi x the
transversalis fascia (“pseudosac”) in the anterior
abdominal wall in order to prevent seroma formation at this site postoperatively (Fig. 43.9a–c ).
The mesh (sized at least 15 × 12 cm) is then
rolled and placed in the preperitoneal space to
cover the entire myopectineal orifi ces, including
the direct, indirect, and femoral hernia spaces.
For the direct hernias, my concerns about recurrences is greater and I dissect further toward the
midline and I also have a tendency to use large
meshes and additional fi xation (Fig. 43.10 ).
NOTE : Some surgeons slit the mesh longitu-
dinally or vertically to accommodate the cord
structures, however, I prefer to simply place the
mesh over the cord.
I always fi xate the mesh, most often with
absorbable staples and some cases with fi brin
glue. The landmarks for fi xation of the mesh are
the pubic tubercle, Cooper’s ligament, posterior
rectus sheath, and the transversalis fascia at least
3 cm above the hernia defect and the anterior
superior iliac spine to prevent movement of the
mesh. When fi xating the mesh laterally with tacks
or staples, it is important to feel the tip of the
device on the outside of the abdomen with the
opposite hand to ensure that fi xation occurs above
the inguinal ligament. The mesh should cover the
entire posterior fl oor of the groin and since it can
shrink between 10 and 30%, the mesh should not
be fully stretched, but having a little “slack” [ 16 ].
NOTE : Do not tack or staple the mesh below
the iliopubic tract lateral to the spermatic cord
and the epigastric vessels to minimize the chance
of damaging nerves and vascular structures. This
area contains the “triangle of pain,” which contains the lateral cutaneous nerve of the thigh and
the femoral branch of the genitofemoral nerve,
and the adjacent “triangle of doom,” which
contains the external iliac artery and vein defi ned
medially by the vas deferens and laterally by the
spermatic vessels (Fig. 43.11 ).
After the mesh is positioned, the peritoneum
is re-closed with a running suture or tacks. It is
important to leave no gaps in the peritoneum to
isolate the mesh from the viscera and to minimize
the risk of small bowel herniation and obstruc-
43 Laparoscopic TAPP Inguinal Hernia Repair
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Fig. 43.9 ( a ) Left side—direct hernia. ( b ) Left side—“Pseudosac” is the “sick” transversalis fascia. ( c ) Left side—fi xa-
tion the transversalis fascia (“pseudosac”) in the anterior abdominal wall
457
Fig. 43.10 Right side— mesh position and visualization
of anatomy by transparency
tion in the gaps/peritoneal fenestrations [ 17 ]
(Fig. 43.12a, b ).
The mechanism of recurrences after TAPP is
inferiorly, due to insuffi cient coverage of the inferior edge of the myopectineal orifi ce or due to mesh
migration. It is thus very important to confi rm mesh
positioning during closure and desuffl ation, because
it can fold on itself by the inferior peritoneal fl ap
during suturing. The ports are removed under direct
vision and the abdominal cavity is decompressed.
The fascia at the 10 mm cannula should be sutured
to reduce the chance for future incisional hernia.
Postoperative Care and Follow-up
Most laparoscopic hernia repairs are performed on
an outpatient basis. Postoperative pain is usually
well-controlled using nonsteroidal antiinfl ammatory agents (NSAIDS) , if not contraindicated, with or without low-dose narcotic agents. I
Fig. 43.11 Right side—triangle of doom and trapezoid
of pain. Posterior anatomy of the inguinal nerves – a study
on 30 fi xed cadavers Wolfgang Reinpold, M.D.,
Wilhelmsburg Gross Sand Hospital and Hernia Center,
Hamburg, Germany (in press).
recommend an ice pack to be used four times a
day, in the inguinal region, for 2 days and local
heat for the next 2 days. I maintain the use of a
groin hernia support (Tensor) for up to a month.
Complications
As with any hernia repair, postoperative c omplications are possible. There are two sorts of complications: corresponding to the laparoscopic
technique and procedure-correlated.
Morbidity is usually low after a TAPP procedure.
R. Bittner in his article, Laparoscopic transperitoneal procedure for routine repair of groin hernia,
published at BJS, 2002 reported a rate of 2.6% [ 18 ].
Between February 1991 and April 2001, I
treated 803 patients: 445 (55.4%) with TAPP and
358 (44.6%) with TEP. The incidence of intraop-
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