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26
J. Blank and M. I. Goldblatt
inguinal ligament to the iliopubic tract, an aponeurotic band overlying the superior
pubic ramus (blue line, Fig.3.2). The iliopubic tract also connects the ASIS to the
pubic tubercle; it is connected to the inguinal ligament medially by Cooper’s ligament (yellow line, Fig.3.2) [10, 11]. The internal and external rings refer to the open-
ings of the inguinal canal, through which the spermatic cord structures pass (green
line, Fig.3.2). The internal ring is visible on laparoscopy at the inferior portion of the
eld. It is formed by a hiatus in the transversalis fascia [9]. The external ring is not
visible in the laparoscopic view; it is formed by a hiatus in the external oblique aponeurosis [9].
There are two triangular portions of the inguinal region that deserve special
attention. The “triangle of pain” contains the lateral femoral cutaneous nerve, the
femoral branch of the genitofemoral femoral, and the femoral nerves [9]. This triangle is bounded superiorly by the inguinal ligament, inferomedially by the spermatic cord, and laterally by the iliac crest [11]. Placement of staples or tacks in this
area may predispose the patient to chronic pain or paresthesias in the inguinal
region, testicle, or thigh [1, 10]. The “triangle of doom” contains the external iliac
vessels and the deep circumex iliac vein. This triangle is bounded by the vas deferens medially and the spermatic vessels laterally and may cause signicant hemorrhage if violated [1, 11].
The three types of hernias that may be encountered in the inguinal region are
indirect, direct, and femoral hernias. Often, these are indistinguishable on preoperative physical exam. Indirect hernias run with the spermatic cord and are found lateral to the inferior epigastric vessels (polygon, Fig.3.2). Large indirect hernias may
extend into the scrotum. Direct hernias protrude through Hesselbach’s triangle, a
triangle superior to the inguinal ligament and medial to the epigastric vessels, which
forms the “oor” of an open inguinal hernia repair (Fig. 3.3; circle, Fig. 3.2).
Femoral hernias occur inferior to the inguinal ligament within the femoral canal,
medial to the femoral artery and vein [9, 11].
Indirect, direct, and femoral hernias all begin within the myopectineal orice,
rst described in 1956 by Fruchaud [12]. This is a weakness in the transversalis
fascia that is bounded by internal oblique and transverse abdominal muscles superiorly, the iliopsoas muscle laterally, and the rectus muscle medially [13]. The region
Fig. 3.3 Direct right
inguinal hernia repair, with
Cooper’s ligament (yellow
line), inferior epigastric
vessels (buried in fat,
under red line), and direct
hernia medial to the
epigastric vessels, in the
white circle. Med medial,
Sup supercial, Lat lateral
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is divided in half by the inguinal ligament and contains the ve major nerves of the
region: the genital and femoral branches of the genitofemoral nerve, the femoral
nerve, and the anterior and lateral femoral cutaneous nerves, from medial to lateral
[14]. This region also contains the femoral vessels, as well as the round ligament in
women and the spermatic cord in men [13].
Access tothePreperitoneal/Intraperitoneal Space:
Laparoscopic Dissection
Access to the preperitoneal space for a totally extraperitoneal (TEP) or the intraperitoneal space for a transabdominal preperitoneal (TAPP) approach differs. We will
rst describe preperitoneal access in the TEP approach. Three laparoscopic ports
are placed in the midline: one 10-mm or 12-mm port directly below the umbilicus
and two 5-mm infraumbilical ports (Fig.3.1a). Local anesthetic (the authors prefer
a 50:50 mix of 0.5% bupivacaine and 1% lidocaine with epinephrine) is inltrated
in the patient’s skin inferior to the umbilicus. The 10-mm/12-mm port incision is
then made just inferior to the umbilicus, and the subcutaneous tissues are dissected
down to the fascia. A 1-cm horizontal incision is made in the anterior rectus sheath,
just off midline and ipsilateral to the inguinal hernia (the authors prefer the left side
in bilateral inguinal hernias). The anterior rectus sheath is opened to expose the
underlying rectus muscle, which is retracted anteriorly and laterally with an
S-retractor.
A dissecting balloon is then placed in the preperitoneal space posterior to the
rectus muscle and anterior to the posterior rectus sheath. The surgeon’s nger may
be used to develop a tunnel in the preperitoneal space prior to inserting the dissecting balloon [1]. The dissecting balloon is inserted to the pubic symphysis and
inated. For unilateral hernia repair, the assistant places pressure on the contralateral lower quadrant to prevent unnecessary tissue dissection (or a unilateral balloon
may be used), and the balloon is gradually inated under direct laparoscopic vision.
For bilateral hernia repair, the dissecting balloon is fully inated under direct laparoscopic vision to open the preperitoneal space bilaterally. Care must be taken to
ensure that the balloon is dissecting posterior to the epigastric vessels. If the balloon
begins to dissect between the rectus muscle and the epigastric vessels, ination is
halted, the balloon is removed, and the dissection is performed manually.
After deation, the dissecting balloon is removed, and a 10-mm or 12-mm
Hasson trocar is placed in the same incision. The preperitoneal space is then insufated to 12mmHg pressure. This insufation pressure is lower than that required
for a TAPP repair to avoid barotrauma to the peritoneum. The two 5-mm trocars are
then placed in the midline under direct vision, one trocar two ngerbreadths below
the umbilicus and one trocar ve ngerbreadths below the umbilicus. Alternatively,
some surgeons prefer their trocars closer to the pubic symphysis [8]. The dissection
is initially carried out in a medial to lateral fashion. A laparoscopic Kittner or blunt
dissecting forceps is used to remove the loose areolar tissue from the pubic symphysis and Cooper’s ligament, and gentle dissection proceeds laterally toward the
28
J. Blank and M. I. Goldblatt
ASIS.Care is taken to ensure that the epigastric vessels remain anterior. In some
patients, the transversalis fascia continues inferiorly, and the plane posterior to the
transversalis fascia must be created starting inferiorly near the cord structures.
Once at the ASIS, the dissection is carried medially toward the internal ring,
which is skeletonized using blunt dissection to reveal the structures of the spermatic
cord: the vas deferens, pampiniform venous plexus, autonomic nerve bers, and
testicular artery. An indirect hernia or a cord lipoma may be found running with the
cord structures into the internal ring; this may be reduced with gentle traction, and
the peritoneum should be pushed posteriorly. A large indirect hernia sac can be
divided just distal to the internal ring and the remainder of the sac left in situ to
avoid trauma to the spermatic cord [1].
Dissection continues medially, where a direct inguinal hernia may be seen superior to the inguinal ligament, within Hesselbach’s triangle. This triangle is formed
by the inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the
lateral edge of the rectus sheath medially. Hernias found in this region may be gently reduced with a laparoscopic Kittner or blunt graspers. A femoral hernia may also
be visualized inferior to Hesselbach’s triangle and may be reduced by the same
technique. There is typically lymphatic tissue medial to the external iliac vein,
which should not be mistaken for a femoral hernia.
The dissection is now complete, and the following structures are clearly visualized: the pubic symphysis or tubercle medially; the ASIS laterally; the skeletonized internal ring with the vas deferens entering medially and the spermatic
vessels entering laterally; the epigastric vessels approximately halfway between
the pubic tubercle and ASIS, overlying the anterior abdominal wall; and the
peritoneum posteriorly. At this point, the surgeon may proceed with mesh
placement.
Access to the peritoneal cavity for a TAPP approach begins with inltration of
local anesthetic as above and placement of an optical trocar or Hasson trocar just
inferior to the umbilicus into the peritoneal cavity. The abdomen is insufated to
15mmHg pressure, and the abdominal contents are inspected for visceral injury or
other diseases. The patient may be placed in Trendelenburg position to allow the
bowel to fall cephalad out of the pelvis to aid in visualization of the inguinal region
[1]. Two additional 5-mm trocars are then placed under direct vision in the right and
left mid-abdomen, along the mid-clavicular line (Fig.3.1b).
The peritoneum is then scored using cautery or scissors approximately 6–7cm
cephalad from the pubic symphysis or 2cm above the superior edge of the hernia
defect [1]. The peritoneal ap is created by gently pulling the peritoneum posterior
toward the abdominal contents. This is performed in a medial to lateral fashion,
from the median umbilical ligament to the ASIS, preserving the medial umbilical
ligament to avoid inadvertent bleeding from a remnant umbilical artery [10]. The
preperitoneal space is developed using a laparoscopic Kittner or blunt graspers for
dissection in the avascular plane between the peritoneum and transversalis fascia
[10]. In some patients, the peritoneum does not separate from the transversalis fascia, and so in order to dissect laterally, the dissection must go to the pretransversalis
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29
plane. The surgeon should then identify the previously discussed structures: the
pubic tubercle and Cooper’s ligament medially, the ASIS laterally, and the internal
ring with the vas deferens and spermatic vessels. Indirect hernias will be visualized
with the spermatic cord and may be gently reduced. Direct hernias will again be
seen in Hesselbach’s triangle, and femoral hernias will be visible at the femoral
canal, inferior to the inguinal ligament. At this point, the surgeon may proceed with
mesh placement.
Mesh Placement
A variety of types of mesh may be used for inguinal hernia repairs and will be discussed in later chapters. Regardless of the type of mesh and operative approach, it
is imperative that the mesh cover the regions of indirect, direct, and femoral hernias.
The authors prefer a 2-cm overlap across the midline and under the pubic symphysis
to ensure proper mesh coverage.
The mesh is rolled in a caudal to cranial orientation prior to placement into the
preperitoneal space. Once rolled up, the mesh is placed through the 10-mm/12-mm
trocar. It is then unrolled in a cranial to caudal fashion, ensuring a 2-cm overlap of
the midline, until the most inferior portion of the mesh covers the pubic symphysis
(Fig.3.4). The mesh must cover all three potential hernia spaces. A non-adherent
mesh may then be secured with tacks to the anterior abdominal wall, taking care to
avoid the epigastric vessels and the triangles of doom and pain. Tacks are placed at
the medial aspect of the pubic tubercle into Cooper’s ligament. Additional tacks can
be placed along the anterior abdominal wall, typically one medially and one laterally. Absorbable tacks are preferred by the authors. The assistant’s hand may be
placed on the abdominal wall to palpate the tacking device and ensure that all tacks
are placed superior to the iliopubic tract, to avoid the triangle of pain. Approximately
10mL of 0.5% bupivacaine is then instilled into the eld. The mesh is held in position and the eld is desufated. If a TAPP approach has been chosen, the peritoneum is now placed over the mesh and stapled or sewn in place.
Fig. 3.4 Left inguinal
hernia repair. Unrolling
mesh in a cranial to caudal
direction, ensuring at least
2-cm overlap of the pubic
tubercle. Shown here are
Cooper’s ligament (yellow
line), spermatic cord
(green line), and the pubic
tubercle (rectangle). Med
medial, Sup supercial, Lat
lateral
30
J. Blank and M. I. Goldblatt
Closure
The trocars are removed, and attention is directed to the 10-mm/12-mm trocar site.
The fascia is closed using a 0 Vicryl in a gure-of-eight fashion. The skin and the
remaining 5-mm port sites are closed using 4-0 Monocryl in a subcuticular fashion,
and incisions are covered with Steri-Strips. After sufcient recovery, the patient
may be discharged home on the same day.
Complications
Many surgeons still feel that placement of a urinary catheter is paramount to preventing bladder injury. This complication is rare, occurring in less than 1% of all
laparoscopic inguinal hernia repairs, and is more common in TAPP repairs than
TEP repairs [15, 16]. Still, patients who have undergone previous surgery in the
space of Retzius are at high risk for bladder injury [1]. An open repair should be
seriously considered for these patients. If a bladder injury does occur, it should be
repaired anteriorly to prevent mesh placement near the repair [1]. The authors
have their patients void immediately before going to the OR and have stopped
using urinary catheters, except in those patients with signicant benign prostatic
hypertrophy (BPH).
Urinary retention is also a recognized complication of laparoscopic inguinal
hernia repair, with a wide variation of incidence (1–22% [17]) in the literature.
The use of Foley catheterization has not been extensively studied in this instance,
and it is unknown whether this intervention would improve on the rate of postoperative urinary retention. In fact, a retrospective review by Patel and colleagues [18] suggested that Foley catheter placement may induce urinary
retention due to detrusor muscle injury during placement. This study also
described signicant variables that inuence the rate of postoperative urinary
retention, including age over 50years, bilateral hernia repair, and increased use
of postoperative narcotics [18].
Vascular injury usually involves the inferior epigastric and spermatic vessels, as
well as the iliac veins, and is more common in TEP than TAPP [1, 16, 19, 20].The
overall incidence of vascular injury during laparoscopic inguinal hernia repair is
low, at 0–3% [16, 19, 20]. The use of a Hasson trocar for entrance into the abdomen
as well as identication of vascular landmarks may help decrease the incidence of
these injuries [1]. Aberrant vasculature, specically the corona mortis, may also be
injured during dissection (Fig. 3.5). This vascular anomaly may be present as a
branch of the external iliac artery or the inferior epigastric artery and passes over the
pubic tubercle on the way to the obturator region [11]. The corona mortis is present
in approximately 15–40% of cases [20].
Chronic nerve pain is a common complaint after both open and laparoscopic
inguinal hernia repair. Patients may complain of burning pain or numbness to the
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Fig. 3.5 Aberrant branch
of the obturator artery, the
corona mortis (black line),
connects the inferior
epigastric artery (red line)
to the obturator artery. The
external iliac artery is deep
to the operative eld but
shown here for reference.
Again shown are Cooper’s
ligament (yellow line), the
spermatic cord (green
line), and the iliopubic
tract (blue line)
31
inguinal region, testicle, or thigh. Delayed onset of symptoms usually signies a
self-limiting condition. However, if symptoms occur in the recovery room, immediate return and re-exploration should be considered, especially if tacks were
used [1]. Violation of the triangle of pain greatly increases the risk of chronic
nerve pain.
Recurrence of inguinal hernia after both open and laparoscopic repair is another
recognized complication. A meta-analysis of over 6000 patients who underwent
either open or laparoscopic inguinal hernia repair found a signicantly increased
risk of recurrence for laparoscopic inguinal hernia repair (RR=2.06). Subgroup
analysis revealed no difference between TAPP and open inguinal hernia repairs, but
TEP repairs were associated with a signicantly increased risk of recurrence when
compared to open (RR=3.72) [21]. Another meta-analysis conrms these results,
with a recurrence rate of 2.7% for open repairs and 5.5% for laparoscopic repairs
[22]. Many surgeons agree that the learning curve for TEP repairs is high and the
number of cases to achieve mastery may be over 250.
Conclusion
We have presented our preferred operative technique for laparoscopic TEP and
TAPP inguinal hernia repairs. Laparoscopic inguinal hernia repair is a viable
alternative to open inguinal hernia repair, and the complex anatomy of the region
requires intraoperative vigilance in order to avoid morbidity and mortality for
our patients.
32
J. Blank and M. I. Goldblatt
References
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operative strategy in general surgery. NewYork: Springer; 2014.
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3. Koch A, Edwards A, Haapaniemi S, Nordin P, Kald A.Prospective evaluation of 6895 groin
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4. Antoniou SA, Antoniou GA, Bartsch DK, Fendrich V, Koch OO, Pointner R, Granderath
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6. Bansal VK, Misra MC, Babu D, Victor J, Kumar S, Sagar R, Rajeshwari S, Krishna A, Rewari
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7. Richardson WS, Hamad GG, Stefanidis D, Guidelines Committee SAGES.SAGES VTE pro-
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8. Ellison EC, Zollinger RM. Repair of inguinal hernia, laparoscopic totally extraperitoneal
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Pollock (Eds.), Schwartz’s principles of surgery, 10e. NewYork: McGraw-Hill Education.
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11. Ellison EC, Zollinger RM.Laparoscopic anatomy of the inguinal region. In: Zollinger’s Atlas
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12. Fruchaud H.Anatomie chirurgicale des hernies de l’aine. Doin, Paris, 299–303 and 336–342;
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13. Kang JS, Qiao F, Nie L, Wang Y, He SW, Wu B. Preperitoneal femoral hernioplasty: an
“umbrella” technique. Hernia. 2015;19(5):805–8.
14. Bathla L, Fitzgibbons RJ Jr. Perspective on hernias: laparoscopic inguinal hernia repair. In:
Zinner MJ, Ashley SW, editors. Maingot’s abdominal operations, 12e. NewYork: McGrawHill; 2013.
15. Kocot A, Gerharz EW, Riedmiller H.Urological complications of laparoscopic inguinal hernia
repair: a case series. Hernia. 2011;15(5):583–6.
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for inguinal hernia repair: systematic review of effectiveness and economic evaluation. Health
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33
19. Sharma D, Yadav K, Hazrah P, Borgharia S, Lal R, Thomas S.Prospective randomized trial
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Hernia Materials: Fundamentals
ofProsthetic Characteristics
CoreyR.Deeken andSpencerP.Lake
For nearly 80 years, biomaterials have been utilized to reinforce hernia repairs,
beginning with silver and tantalum meshes in the early 1940s [1, 2] and progressing
to permanent synthetic polymer meshes in the late 1950s [3]. In more recent years,
advancements in biomaterial technology have led to rapid expansion of this eld
with nearly 150 hernia repair materials now available [4]. This seemingly everexpanding array of biomaterials has recently been classied by our group in a hierarchical fashion (Fig. 4.1) [4] that better reects the nuances of recent designs
compared to previous classication schemes [5, 6].
In the Deeken & Lake Mesh Classication System [4], hernia repair materials
are rst grouped according to the composition of the underlying structural scaffold
material, forming three broad groups: permanent synthetic polymers, resorbable
polymers, and biological tissue-derived materials (Fig.4.1). Hernia repair materials
are then further subdivided based on the presence of a coating, barrier layer, or reinforcing material. Coatings and barriers are used to minimize tissue attachment by
separating the abdominal viscera from the mesh when utilized in the intraperitoneal
position. Coatings are applied to the surface of the individual mesh bers and do not
span across the pores of the mesh, while a barrier layer is applied continuously
across the surface of the mesh, spanning the pores and creating a distinct layer.
Barrier layers are additionally characterized as composite or noncomposite.
Composite barrier layers are constructed of a distinct anti-adhesion layer that is
4
C. R. Deeken (*)
Covalent Bio, LLC, St. Louis, MO, USA
e-mail: deekenc@covalentbiollc.com
S. P. Lake
Department of Mechanical Engineering and Materials Science, Washington University,
St. Louis, MO, USA
e-mail: lake.s@wustl.edu
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_4
35
36
eB
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C. R. Deeken and S. P. Lake
Bare
PP
PET
PTFE
PVDF
Permanent
Synthetic
Barriers &
Coatings
Permanent
Barrier
Permanent
Coating
Resorbable
Barrier
Resorbable
Coating
Biological
Tissue
Barrier
Reinforced ReinforcedBar
Resorbable
Fibers
P4HB
Silk
PGA
PLGA
TMC
Resorbable
Synthetic
Barriers &
Coatings
Resorbable
Barrier
Biological
Tissue-Derived
Barriers &
are
Coatings
Non-crosslinked
Crosslinked
HumanPorcineBovineOvine
Antimicrobial
Permanent
Fibers
Permanent
Barrier
Resorbable
Fibers
Resorbable
Barrier
Fig. 4.1 Deeken & Lake Mesh Classication System hierarchy encompassing three main categories that are further distinguished by the presence, type, and composition of complementary barriers, coatings, or reinforcing materials. Terms of Use: This gure was adapted from the original
gure licensed under a Creative Commons Attribution 4.0 License (https://creativecommons.org/
licenses/by/4.0/) attributed to Corey Deeken and Spencer Lake. The original version can be found
here: https://doi.org/10.1016/j.jmbbm.2017.05.008. The content of the gure is reprinted with
minor modications to the original work [4]
sewn or vacuum-pressed onto the structural mesh component. Noncomposite barriers are formed from a single sheet of scaffold material that possesses side-specic
features: anti-adhesive (e.g., smooth surface or smaller pores) or tissue attachment
properties on the sides of the biomaterial intended to be placed in contact with the
viscera and the abdominal wall, respectively. Reinforcing materials, which can be
permanent or resorbable, are often included to optimize initial mechanical support
of the defect and facilitate handling during implantation. To date, both permanent
synthetic and biological tissue-derived scaffold designs have incorporated reinforcing materials, creating many unique combinations in which part or all of the scaffold resorbs over time, gradually transferring the load back to the host tissue in the
process.
The rst broad category of hernia repair materials in the Deeken & Lake Mesh
Classication System [4] consists of permanent synthetic polymers such as polypropylene (PP), polyester (PET), polytetrauoroethylene (PTFE), polyvinylidene
uoride (PVDF), and various combinations of these polymers (Table4.1). Many of
the products in this category are available as bare meshes, without coatings, barriers, or reinforcements (Table4.1, column 1). However, several designs contain antiadhesion barriers that may be classied as permanent, resorbable, or biological
tissue derived. These barriers are further subdivided into noncomposite or composite barriers (Table4.1, column 2). In the permanent barrier, noncomposite group, the
anti-adhesion barriers of all current designs are comprised of expanded PTFE
(ePTFE). In the permanent barrier, composite group, the anti-adhesion barriers of
all current designs are also comprised of ePTFE, except for one design comprised
of silicone (Surgimesh
®
XB, Aspide/BG Medical, Barrington, IL). In the permanent
coating group, the anti-adhesion coatings of all current designs are comprised of
titanium (TIMESH product line, Biomet Biologics/GfE Med. GmbH).
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