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463
PLATE
217
INDICATIONS All femoral hernias should be repaired unless contraindi-
cated by the patient’s condition.
PREOPERATIVE PREPARATION e preoperative preparation is directed
by the patient’s general condition. When the contents of the hernia sac are
strangulated, the uid and electrolyte balance is restored by Ringer’s lactate solution administered intravenously. Antibiotics are instituted if the
examination indicates the possibility of nonviability of the bowel and consequent necessity for resection of intestine. Su cient time is taken to fully
resuscitate the patient. Constant gastric suction is instituted. A slowing of
the pulse and a good output of urine are signs favorable to early surgical
intervention. Uncomplicated femoral hernias may be repaired as ambulatory surgical procedures.
ANESTHESIA (See Plate .)
POSITION e patient is placed in a supine position with the knees slightly
exed to lessen the tension in the groin. e entire table is tilted slightly
with the patient’s head down.
OPERATIVE PREPARATION e skin is prepared in the routine manner.
A sterile transparent plastic drape may be used to cover the operative area.
INCISION AND EXPOSURE e surgeon should have in mind the rela-
tionship of the hernia sac to the deep femoral vessels and Poupart’s ligament (figure 1). e usual incision for inguinal hernia is made just above
Poupart’s ligament in the line of skin cleavage (figure 2). e incision
above Poupart’s ligament is preferred because it gives the best exposure of
the neck of the sac and provides better exposure if bowel resection and
anastomosis are necessary. e incision is made and carried down to the
external oblique fascia. A er the fascia has been dissected free of the subcutaneous fat, retractors are inserted in the wound. e external oblique
fascia is divided in the direction of its bers, as in the incision for inguinal hernia (Plate ). e round ligament or spermatic cord is retracted
upward along with the margin of the conjoined tendon (figure 3). e
peritoneum, covered by transversalis fascia, now bulges in the wound. e
neck of the hernia sac is freed from the surrounding tissues.
R F H
with forceps, while the operator applies counterpressure below Poupart’s
ligament through the hernial mass (figure 4). If the sac cannot be reduced
from beneath Poupart’s ligament by this maneuver, it becomes necessary to
dissect the subcutaneous tissue from the lower leaf of the external oblique
until the hernial sac is exposed as it appears in the femoral canal beneath
Poupart’s ligament (figure 5). Following this procedure, it is frequently
possible to withdraw the hernial sac from the femoral canal, converting the
femoral hernia to a diverticular type of direct hernia (figure 6).
If the contents of the hernial sac appear to be reduced so that it can be
opened without possible injury to incarcerated bowel, the sac is opened
(figure 7). A purse-string suture, which should include transversalis fascia as well as peritoneum, is placed at the junction of the sac and the peritoneal cavity so that when it is tied, no residual peritoneal pouch remains
(figures 8 and 9). Great care is taken that the suture closing the neck of
the sac does not include intestine or omentum.
CLOSURE ere are several methods of preventing recurrence of the her-
nia. e transversalis fascia and the aponeurotic margin of the transverse
abdominal muscle may be approximated from the spine of the pubis upward
along Cooper’s ligament (figure 10), as in the repair of a direct inguinal
hernia by the McVay technique (Plate ). It is essential to have adequate
exposure of the iliac vessels such that they are not injured when these interrupted sutures (figures 11 and 12) are placed. Several sutures are taken in
Cooper’s ligament and the lacunar ligament on the inferior edge of Poupart’s
ligament in order to close the femoral canal (figure 11). e iliac vessels
should not be constricted as the transition suture is placed near the medial
wall of the femoral vein. e repair then proceeds laterally in the McVay
manner, with interrupted sutures securing the conjoint tendon (internal
oblique muscle) to the shelving edge of the inguinal ligament (figure 12).
e round ligament in the female or the cord in the male is returned to normal position or transplanted as in other types of hernia repair. e external
oblique is closed without constriction about the cord or round ligament,
followed by the usual approximation of the subcutaneous tissue and skin. A
continuous subcutaneous absorbable suture is used to approximate the skin.
Adhesive strips and a dry sterile dressing are then applied.
DETAILS OF PROCEDURE e operator must now choose one of two pro-
cedures. If the sac can be pulled upward through the femoral canal to the
surface, it may be unnecessary to open the abdominal cavity until the sac
itself is opened. is is facilitated by retracting the neck of the sac upward
POSTOPERATIVE CARE It is wise to keep the thigh slightly exed during
the immediate postoperative period. e patient is encouraged to ambulate
as soon as possible. Heavy manual labor, especially such as which greatly
increases intra-abdominal tension, should be avoided for about month. ■
464
1
Poupart’s ligament
Deep epigastric vessels
Iliohypogastric
nerve
2
Incision
3
Round ligament
Ilioinguinal
nerve
Ilioinguinal
nerve
Femoral
vein
Greater
saphenous vein
4
Femoral canal
7
Hernia sac
Peritoneum
Exploring sac
Round
ligament
Spine of pubis
Gimbernat’s
(lacunar) ligament
5
Neck of
hernial sac
Falciform
ligament
8
Femoral
vein
Hernia sac
Neck of sac
Round ligament
Deep epigastric
vessels
Lacunar
(Gimbernat’s)
ligament
Iliac vessels
Peritoneum and
transversalis fascia
6
9
Transversalis fascia
Poupart’s
ligament
Sac
Poupart’s
ligament
Femoral
canal
10
Aponeurosis of transversus
abdominis muscle
Cooper’s ligament
Femoral
canal
11
Femoral
canal
Aponeurosis
of transversus
abdominis
muscle
Poupart’s ligament
Lacunar ligament
Femoral
canal
Lacunar
ligament
12
Conjoined
tendon
Cooper’s
ligament
Spine of pubis
Round
ligament
465
PLATE
218
INDICATIONS All femoral hernias should be repaired unless contraindi-
cated by the physical or medical condition of the patient. Incarceration with
possible strangulation is a concern, as the femoral opening is small and its
boundaries are unyielding. Ultrasound imaging studies may be useful when
the diagnosis is di cult.
PREOPERATIVE PREPARATION e preoperative preparation is deter-
mined by the general condition of the patient. Uncomplicated femoral
hernias may be repaired in an ambulatory surgery setting. Incarcerated
femoral hernias without gastrointestinal signs or symptoms should be
repaired expeditiously, while symptomatic hernias are treated urgently.
Strangulation requires hospitalization and resuscitation of the patient with
nasogastric tube decompression, intravenous rehydration, and parenteral
antibiotics. Any general medical conditions are evaluated and su cient
time is allowed for volume and electrolyte stabilization. Improved vital
signs and a good urine output indicate readiness for surgery.
ANESTHESIA Deep sedation with in ltration of a local anesthetic as a
eld block may be used in elective cases, as can spinal or epidural anesthetic techniques. Patients with strangulation and obstruction should have
general anesthesia with an endotracheal tube and cu to lessen the threat
of tracheal aspiration.
POSITION e patient is placed in a supine position with the knees slightly
exed by a pillow so as to lessen the tension in the groin.
OPERATIVE PREPARATION e skin is shaved and prepared in the rou-
tine manner. Parenteral antibiotics appropriate for prophylaxis against the
usual skin bacteria are given immediately prior to the start of the procedure
and in su cient time to reach therapeutic tissue levels.
INCISION AND EXPOSURE It is important that the surgeon understand
the regional anatomy of the femoral space. is opening is approximately
to ½ cm in diameter and lies directly lateral to the pubic tubercle but inferior to the inguinal ligament (figure 1). e fascia overlying the pectineus
muscle forms the posterior wall, whereas the lateral aspect is bounded by the
slightly compressible femoral vein as it emerges under the inguinal ligament.
Clinically, the femoral herniation presents as a mass that may be confused
with super cial inguinal lymphadenopathy. In thin patients, the line of the
inguinal ligament from the anterior superior spine to the pubic tubercle can
be projected and the femoral herniation will clearly present below this, being
immediately lateral to the pubic tubercle and medial to the pulsation of the
femoral vessels. If the surgeon is certain of this diagnosis, which may be
aided by the use of ultrasonography, then the lower limited oblique incision
directly over the mass may be made (figure 2, b). If the diagnosis is in
doubt, the patient is obese, or the possibility of strangulation exists, then the
upper incision (figure 2, a) is made so as to provide maximum exposure
and exibility. is incision is slightly lower than that made for the usual
inguinal hernia. It is above and parallel in general to the inguinal ligament
R F H M
with a more transverse medial extension. e incision is made and carried
down to the external oblique fascia. e fascia over the canal is cleaned so
as to expose the external ring. e external oblique fascia is divided in the
direction of its bers in the manner used for exposure in inguinal hernias. A
pair of hemostats are placed on the superior and inferior leaves of the external oblique, which is then cleaned by blunt dissection down to the internal
oblique muscle superiorly and the shelving edge of the inguinal ligament
inferiorly. e round ligament or spermatic cord with attached ilioinguinal
nerve is dissected free and retracted superiorly either with a rubber Penrose
drain or a Richardson retractor (figure 3). e transversalis fascia constituting the oor of the canal is explored to rule out any direct herniation, and
therea er the region of the internal ring is explored to rule out the presence
of an indirect herniation.
DETAILS OF PROCEDURE e inferior leaf of the external oblique is
retracted superiorly and the femoral herniation becomes apparent as it
emerges just under the inguinal ligament lateral to the pubic tubercle. is
same exposure is obtained if the lower incision is made directly over the
hernia. e sac is grasped and, using a combination of sharp and blunt dissection, it is freed from the surrounding fat of the upper thigh (figure 4).
As the dissection proceeds, the herniation is found to occur through a narrow opening that is approximately the size of the surgeon’s h nger. Most
o en the sac contains preperitoneal fat or omentum, which can be reduced;
however, should strangulated gangrenous bowel be encountered, the surgeon must plan for resection with a synchronous laparotomy.
A er successful reduction in an uncomplicated case, it is not necessary to open the sac. is is usually invaginated back through the femoral opening, which now presents as a de ned hole (figure 5). A synthetic plug is made according to the method of Lichtenstein by rolling up
a piece of polypropylene mesh approximately by cm in length. is
spiral winding creates a cylinder of mesh that is grasped with a Babcock
clamp (figure 6) and then inserted into the femoral opening such that
a few millimeters protrude externally. ree quadrants of the cylinder
are secured with interrupted nonabsorbable sutures of polypropylene or
nylon. Each is anchored to the adjacent fascia with the suture extending
well into the center of the rolled cylinder so as to prevent an intussusception of the mesh. e superior suture attaches to the inguinal ligament, the
medial one to the lacunar ligament and fascia investing the pubic tubercle,
and the inferior one to the fascia over the pectineus muscle. No suture is
placed laterally, as this wall is the femoral vein (figure 7). e external
oblique fascia is reapproximated with either interrupted or running nonabsorbable sutures and the routine closure of Scarpa’s fascia and the skin is
performed. A small dressing is applied to cover the incision.
POSTOPERATIVE CARE In the uncomplicated case, the patient is quickly
discharged home with written instructions concerning activities, signs
of bleeding or infection, or any other unusual reaction. Most are able to
resume normal activities within a few days. ■
466
467
PLATE
219
L A
I R
is plate shows the key anatomic features of importance that the skilled
surgeon must know thoroughly during any type of laparoscopic operation
for inguinal and femoral hernia repair.
e rst concept is to recognize that the parietal peritoneum covers certain structures forming ve ligaments that are useful landmarks in identifying the hernia spaces when approaching the groin from the intraperitoneal
route as in the TAPP repair. ese ligaments include the median umbilical ligament () running from the bladder to the umbilicus, the medial
umbilical ligaments (), which are the remnants of the obliterated umbilical
arteries, and the lateral umbilical ligaments () formed by the peritoneum
covering the inferior epigastric vessels (). e spatial relationships of
these ligaments allow recognition of the various types of hernias. A direct
inguinal hernia () occurs in the medial space bounded by the inferior
epigastric vessels or lateral umbilical ligament, the iliopubic tract (),
the pubic tubercle () (the medial end of the muscular conjoined tendon
[internal oblique muscle]). An indirect inguinal hernia presents through
the internal ring () above the iliopubic tract and is lateral to the lateral
umbilical ligament containing the epigastric vessels () on the posterior
surface of the rectus muscle (). A view of the femoral hernia space () can
be seen below the iliopubic tract () and medial to the femoral vessels exiting through the femoral canal. During the laparoscopic repair, the direct,
indirect, and femoral spaces should all be covered with mesh.
e second important concept concerns the spaces that occur beneath
the peritoneal covering (). e preperitoneal space is the space bounded
by the peritoneum posteriorly and the transversalis fascia anteriorly. e
space of Retzius is that space between the pubis and the bladder. e lateral
extent of this space is named Bogro’s space. e transversalis fascia forms
the oor of the inguinal canal and the iliopectineal arch, iliopubic tract, and
crura of the deep inguinal ring. e iliopectineal arch divides the vascular
compartment (iliac vessels) from the neuromuscular compartment (iliopsoas muscle, femoral nerve, and the lateral femoral cutaneous nerve). e
iliopubic tract is an aponeurotic band that begins near the anterior superior
iliac spine and inserts on the pubic tubercle () medially. In its medial
extent, it contributes to the formation of Cooper’s ligament (). It forms
the inferior margin of the deep musculoaponeurotic layer made up of the
transversus abdominis muscle and aponeurosis and the transversalis fascia.
Laterally, it extends to the iliacus and psoas fascia. It forms with bers of
the transversalis fascia, the anterior margin of the femoral sheath and the
medial border of the femoral ring and canal. Its lower margin is attached to
the inguinal ligament. e iliopubic tract is an important landmark. Dissection or tacking of preperitoneal mesh should not take place inferior to the
iliopubic tract except in the limited region of Cooper’s ligament. Dissection
or tack placement centrally beneath the iliopubic tract will injure the femoral vein, artery, and nerve, whereas placement laterally may damage the
lumbar nerve branches. e superior and inferior crura of the deep inguinal ring are formed by the transversalis fascia. Cooper’s ligament is formed
by the periosteum of the superior pubic ramus and the iliopubic tract.
e inferior epigastric vessels give o two branches: the external spermatic vessel that travels in the spermatic cord and the iliopubic branch.
e latter may form a corona mortis. is vascular anomaly presents as a
branch of either the inferior epigastric or the external iliac that passes over
the pubic tubercle en route to the obturator system. Either the arterial or
the venous system may be involved in this “crown of death,” which may
cause signi cant hemorrhage during dissection and exposure of Cooper’s
ligament or mesh xation with penetrating tacks.
Finally, there are two zones that must be avoided during preperitoneal
dissection and xation of mesh. e rst is the lateral zone that is bounded
on the medial side by the spermatic cord, superiorly by the iliopubic tract
and by the iliac crest laterally. is is known as the “triangle of pain.” (Plate
, figure 2.) is area contains the femoral (), lateral femoral cutaneous
(), anterior femoral cutaneous, and the femoral branch of the genitofemoral
nerves. Injury to these nerves may cause chronic neuralgia. e second is the
inferior zone bounded by the vas deferens () medially, the gonadal vessels
() laterally, and posteriorly by the peritoneal edge. is zone is known as the
“triangle of doom,” as it contains the external iliac vein (), the deep circum ex iliac vein, and the femoral artery (). (Plate , figure 2.) ■
468
469
PLATE
220
R I H, L
T P (TAPP)
INDICATIONS e indications for inguinal hernia repair have been
described in the preceding chapters. e techniques that will be described
include the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP). Laparoscopic repair may be applied to indirect, direct, or
femoral hernias. Laparoscopic inguinal herniorrhaphy is contraindicated
in the presence of intraperitoneal infection, irreversible coagulopathy, and
in patients who are poor risks for general anesthesia. Relative contraindications include large sliding hernias that contain colon, long-standing irreducible scrotal hernias, ascites, and previous suprapubic surgery. For TEP
repairs, speci c relative contraindications include incarceration and bowel
ischemia. A thorough knowledge of the anatomy of the inguinal region is
essential when it is approached posteriorly using a laparoscope. e view of
this area as seen from the intraperitoneal perspective in the TAPP repair, as
well as the one from the preperitoneal perspective in TEP, is shown on the
preceding Plate entitled Laparoscopic Anatomy of the Inguinal Region.
Additionally, pro ciency with laparoscopic skills or mentored experience
with this type of hernia repair is strongly recommended.
TRANSABDOMINAL PREPERITONEAL (TAPP)
PREOPERATIVE PREPARATION e patient must be a suitable candidate
for general anesthesia. Anticoagulation, aspirin, and antiplatelet drugs such
as Clopidogrel Bisulfate (Plavix) must be discontinued in advance of the
procedure in order to avoid postoperative hematoma formation. Preoperative antibiotics should be administered intravenously within one hour of
the incision.
EQUIPMANT AND SUPPLIES All laparoscopic repairs use some form of
prosthetic material. ese include synthetic mesh created from polypropylene (Marlex or Prolene), Dacron (Mersilene), or polyester (Parietex).
Expanded polytetra uoroethylene (e-PTFE) (Gortex) is supplied as an
extruded sheet. Mesh is generally preferred to e-PTFE because the structure allows brous in growth and hence greater xation to the surrounding
tissues. e-PTFE, composite mesh, or biologic materials are preferred in situations in which the prosthetic would be in touch with the intestine or other
intraabdominal organs, as it promotes less of a brous response and lessens
adhesions to these structures. In this regard, e-PTFE has been modi ed to
have polypropylene on one side. is so-called “dual mesh” might be useful
in cases in which the mesh cannot be completely covered by peritoneum.
Fixation of the mesh is necessary to prevent migration and the tendency
for the mesh to shrink overtime. ere are a variety of tacking devices that
may be used including helical coils, shaped like a key ring, and anchors.
ey may be absorbable or nonabsorbable metal. Most are delivered with
-mm disposable instruments.
ANESTHESIA General endotracheal anesthesia is required.
POSITION e patient is placed in the supine position, and the arms
are tucked. e operating room setup and port placements are shown in
figure 1.
OPERATIVE PREPARARTION Skin hair is removed with a clipper. A cath-
eter is placed in the bladder and removed at the end of the case.
INCISION AND EXPOSURE figure 1 shows the typical room setup for a
le inguinal hernia repair by either TAPP or TEP. e surgeon stands contralateral to the hernia. e camera operator is next to the surgeon and the
assistant directly across. One or two monitors may be positioned at the foot
of the operating table. In this Plate, a le indirect inguinal TAPP is shown
with the surgeon on the patient’s right side, whereas the TEP repair shown
in Plate demonstrates a right direct inguinal repair where the surgeon
would be positioned on the patient’s le side.
figures 3 through 7 illustrate a TAPP for a le indirect inguinal hernia.
e Hasson technique as described in Plate is used to gain access to the
peritoneal cavity. A supraumbilical incision is made for placement of the
Hasson trocar. e patient is placed in a gentle Trendelenburg position.
A -mm -degree laparoscope is passed. Two -mm trocars are placed
under direct laparoscopic vision in the right and le mid abdomen at the
level of the umbilicus (figure 1). A diagnostic laparoscopy is performed
and the hernia spaces inspected for additional hernias. Utilizing the two
lateral trocars, a peritoneal ap is created using laparoscopic scissors and
electrocautery. e incision is begun lateral to the medial umbilical ligament, which should not be divided, as this may cause bleeding from a vestigial umbilical artery. An incision is made in the peritoneum to cm
above the hernia sac and carried laterally to the anterior iliac spine. e
preperitoneal space is entered and blunt dissection is carried out with a laparoscopic Kittner dissector in the avascular plane between the peritoneum
and the transversalis fascia. For a direct hernia, the dissection is begun laterally to expose the cord structures and epigastric vessels. As the ap is
dissected, the critical anatomic landmarks from medial to lateral include
Cooper’s ligament, the inferior epigastric vessels, the vas deferens, and the
lateral zone or fossa (figure 2). e sites of an indirect and direct hernia
are shown. Care should be to avoid dissection in the area labeled the Triangle of Pain which contains sensory nerves (figure 2), injury to which
may cause chronic pain in the inguinal region, testicle, or thigh. Likewise
care is exercised to avoid dissection in the Triangle of Doom (figure 2),
the area which contains the major vascular structures. A corona mortis, a
branch of the inferior epigastric may be seen on the lateral edge of Cooper’s
ligament in of patients (Plate ). is must be avoided when dissecting Cooper’s ligament or tacking the mesh in order to prevent troublesome
bleeding. e le indirect sac is carefully teased and dissected away from
the cord structures as it is brought back into the preperitoneal space. A
small indirect sac may be completely reduced, but a larger sac that extends
into the scrotum may need to be divided. Downward traction on the cord
structures facilitates dissection of fatty tissue in the spermatic cord (cord
lipoma). e iliopubic tract is identi ed (figure 3). e peritoneal ap is
developed inferiorly. Care is taken to avoid injury to the genital branch of
the genitofemoral nerve and the lateral femoral cutaneous nerve (Plate ).
A er an inferior ap is created, the following structures are identi ed: the
inferior epigastric vessels, the symphysis pubis, and the rectus abdominis.
Dissection is then carried medially to the contralateral pubic tubercle to
allow su cient overlap for the mesh placement to cover all of the potential
hernia spaces. figure 3 demonstrates the nal peritoneal ap and space.
For bilateral hernias, the space of Retzius is dissected through two lateral incisions avoiding division of the urachus. is creates a large common
space connecting the two sides.
e mesh is introduced through the -mm trocar (figure 4). For a
unilateral repair, it should be preformed or at least × cm. Although
not shown in the illustrations for a bilateral repair, two similar sheets of
mesh or one large ( × cm) may be employed. For the unilateral repair,
the mesh is placed over the peritoneal opening so that it covers all of the
hernia spaces (direct, indirect, and femoral). A wide overlap is necessary
and extends from the contralateral pubic tubercle medially to the ipsilateral anterior iliac spine. e mesh is unrolled and positioned with generous overlap in all directions. A slit may be made for the cord structures.
Tacking devices are applied medially to the superior edge and inferior one
edge. is is facilitated by direct counter-pressure by the surgeon’s nondominant hand. e lateral edge aspect of the mesh is usually generally
not tacked into place because of potential nerve injury (lateral femoral
cutaneous and the femoral branch of the genitofemoral nerve). e mesh
is secured medially to the tissues immediately adjacent to the contralateral
and the ipsilateral pubic tubercle and Cooper’s ligament (figure 6). Any
redundancy in the inferior edge of the mesh should be trimmed in order
to avoid rolling up.
e next step is to close the redundant peritoneum over the mesh.
e mesh needs to be completely covered. Once the mesh is in place, the
patient is taken out of the reverse Trendelenburg position. Desu ation to
mmHg is accomplished.
abdominal wall or sutured closed (figure 7). ■
e peritoneal ap is then tacked to the anterior
470
471
PLATE
221
R I H, L,
T E (TEP)
Total extraperitoneal (TEP) approach avoids entering the peritoneal cavity;
hence, there is the theoretical advantage of less probability for visceral injury
or incisional hernias. In addition, it avoids the problem of closure of the
peritoneal ap. It is more di cult than TAPP because the operative space
is tight. e preoperative preparation, anesthesia considerations, patient
position, and operating room setup are the same as those for TAPP.
EQUIPMENT AND SUPPLIES A three-component dissecting balloon
should be used to do the initial dissection of the preperitoneal space
(figure 2a, b, c).
INCISION AND EXPOSURE A cm incision is made just lateral and infe-
rior to the umbilicus on the same side as the hernia. e muscle is retracted
laterally so as to expose the posterior rectus fascia. Blunt dissection with the
s-retractors or nger opens the preperitoneal space. (figure 1b). e dis-
section of this space is facilitated by the use of a three-component dissecting
balloon. is is inserted into the space via the umbilical incision. e bulb
insu ator device is used to expand the balloon. During the insu ation, the
surgeon monitors the dissection process with the laparoscope (figures 2a
and b). e expansion is gradual. It is important to have all the creases in
the dissecting balloon atten out. e balloon is desu ated and removed.
e smaller stay balloon is then inserted (figure 2c) and lled with mL
of air. It is used to hold traction on the fascia by being retracted back and
locked. is is attached to the CO insu ator, which is set to a pressure of
mmHg. e patient is placed in a slight Trendelenburg position to avoid
external compression of the preperitoneal space by the abdominal viscera.
e hernia spaces are examined. Two -mm trocars are placed in the midline inferior to the umbilicus (figure 1a): e rst is two ngerbreadths
above the pubic tubercle and the second ve ngerbreadths above the pubic
tubercle just below the camera port. figure 3 shows the anatomy of the
region which is explained in detail in Plate . A right direct inguinal is
identi ed and the area is cleared (figure 4). e pubic tubercle is iden-
ti ed and slight lateral dissection is continued until the obturator vein is
visualized. Blunt dissection with laparoscopic Kittner is used to open the
preperitoneal space. Small tears in the peritoneum should be repaired in
order to prevent competing pneumoperitoneum. If this becomes problematic, a Veress needle or -mm trocar can be placed in the peritoneal cavity
to release the CO pressure. e spermatic cord is then skeletonized and the
preperitoneal space dissected to the same extent as the TAPP. Although the
orientation is di erent, the dissection and the mesh placement are similar
to the TAPP. e mesh is cut to the size and shape shown in figure 5. It is
then rolled and inserted under direct vision through the -mm trocar used
for the camera (figure 6). e mesh is unrolled and positioned in order to
cover all three hernia areas—indirect, direct, and femoral (figure 7a). It
may be tacked medially in place, as described in the TAPP section, avoiding the danger points previously discussed (figure 7a). Alternatively, some
surgeons prefer to use a brin-based glue to secure xation, while others
use no xation while relying upon the de ated peritoneum to anchor the
mesh. e trocars are removed under direct vision. e CO is slowly vented
such that the mesh does not move. e mesh and collapsing peritoneum are
observed as the videoscope is removed. e nal position of the mesh in the
preperitoneal space is shown in figure 7a.
CLOSURE e fascia is closed with absorbable interrupted suture. e
skin is closed with subcuticular absorbable suture. e bladder catheter is
removed prior to leaving the operating room.
POSTOPERATIVE CONSIDERATIONS Local anesthetic may be injected
into the incision sites or instilled into the preperitoneal space to facilitate
pain management. If the patient is able to void urine, then he is discharged
the day of the surgery if there are no immediate complications. e patient
is also advised not li greater than pounds (about two gallons of milk) for
the rst week. Return to work is dictated by pain tolerance. Many patients
are back to work in to days. ■
472
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