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14 Tissue Repairs for Inguinal Hernia
249
7. Subperitoneal fat
8. Closure of the external oblique aponeurosis anterior to
the conjoint tendon
Shouldice Repair
In the Shouldice repair, the surgeon similarly divides the
transversalis fascia between the pubic tubercle and internal
ring. Medial and lateral fascial flaps are then mobilized by
bluntly dissecting the underlying preperitoneal tissue. The
layers are then reapproximated using a running, nonabsorbable monofilament suture from the lateral edge of the rectus
sheath to the iliopubic tract starting at the pubic tubercle. At
the internal ring, this suture includes the lateral cremaster
remnant and reverses back toward the pubic tubercle. The
medial transversalis fascia flap is approximated to the shelv-
ing edge of the inguinal ligament. The suture is tied down at
the pubic tubercle. A new running stitch starts at the internal
ring and approximates the conjoint tendon to the inguinal
ligament (Fig. 14.2c). At the tubercle, the stitch again
reverses to progress laterally through the same structures and
the lower end of the external oblique aponeurosis until it is
tied down at the internal ring (Fig. 14.2d). The external
oblique aponeurosis is then closed. An additional feature of
the Shouldice repair is the routine division of the genital
branch of the genitofemoral nerve during cord dissection.
McVay Repair
The McVay repair is primarily notable for addressing both the
inguinal and femoral defects. Once isolation of the spermatic
cord is achieved, the transversalis fascia is opened to access the
c
d
e
Fig. 14.2 Shouldice repair.
(Reproduced from [8])
250
ac
N.H. Carter and D.C. Chen
preperitoneal space. Cooper’s ligament is then exposed using
Desarda Repair
gentle blunt dissection. A relaxing incision is then made in the
anterior rectus sheath at the pubic tubercle (Fig. 14.3a). The
medial flap of the transversalis fascia is sutured to Cooper’s
ligament and runs laterally to occlude the femoral ring. A transition stitch approximates the transversalis fascia to the femoral
sheath and inguinal ligament lateral to the femoral ring. A
relaxing incision of the ipsilateral anterior rectus sheath reduces
tension on the reapproximated external oblique aponeurosis
and is considered a critical step of the McVay repair (Fig. 14.3d).
The Desarda repair, a modern variant of the historic
Halstead repair, entails reinforcement of the inguinal floor
with a laterally based pedicled strip of external oblique
aponeurosis [8]. An undetached portion of external oblique
aponeurosis is mobilized to the posterior wall of the inguinal canal with interrupted stitches securing it to the internal
oblique muscle superiorly and inguinal ligament inferiorly
(Fig. 14.4).
Fig. 14.3 McVay repair.
(Reproduced from [7])
bd
14 Tissue Repairs for Inguinal Hernia
Fig. 14.4 Desarda repair (Reproduced from [9]). (1) internal oblique
aponeurosis; (2) upper strip of the medial leaf of external oblique aponeurosis sutured to internal oblique aponeurosis; (3) medial leaf of
external oblique aponeurosis that is sutured to inguinal ligament
Closure
Each of these tissue repairs is completed with restoration of
the spermatic cord to its anatomic position followed by reapproximation of the external oblique aponeurosis. Scarpa’s
fascia and the skin can then be closed with running or interrupted sutures according to the surgeon’s preference. Drain
placement is not typically required or advised.
Postoperative Management
Postoperative management following tissue repair is similar to
open mesh-based techniques. If tissue repair was selected in
patients with infection, strangulated bowel, or other complicating factors, patients are typically observed in the hospital to
assure appropriate return of bowel function and resolution of
infection. In elective tissue-based repairs, patients may be discharged from the ambulatory setting once they have recovered
from anesthesia. Postoperative activity is typically restricted
for 3–4 weeks given that the strength of the repair is based
upon tissue scarring and wound healing properties rather than
mesh strength. In the longer term, surgeon- driven follow-up
regarding recurrence and chronic pain is encouraged to help
define the appropriate role for tissue repair and allow for tailoring of ideal technique for different patient cohorts.
251
ment. Rarely, pragmatic nerve ligation may be considered if
injury to one of the nerves is recognized intraoperatively or
if the course of the nerve predisposes it to injury. In these
cases, resection of the inguinal segment of the nerve with
proximal intramuscular reimplantation of the upstream segment into the internal oblique is recommended. Prophylactic
neurectomy of the inguinal nerves is not typically recommended as it may lead to unnecessary sensory disturbance
and the rates of chronic pain are not decreased versus a
“nerve-mindfulness” approach.
Inspection for femoral hernia: In the proper Bassini and
Shouldice procedures, incising the transversalis fascia at the
floor of the canal permits inspection for a femoral hernia. If a
femoral hernia is present, a McVay repair is indicated. The
Desarda repair does not require opening the canal floor, and
thus the surgeon could fail to identify a femoral hernia. We
suggest routinely creating a small opening in the floor of the
canal to expose the space of Bogros and evaluate for the presence of a femoral hernia or interrogating the femoral orifice
through the hernia sac.
Selecting a Tissue-Based Repair
Selection of a particular technique for tissue-based repair
depends on surgeon familiarity and comfort with each
approach. In experienced hands, the Shouldice repair is associated with recurrence rates that approach mesh repairs and
is considered the optimal tissue-based technique. Both
European Hernia Society and HerniaSurge guidelines recommend the Shouldice procedure for non-mesh repairs
although rates of recurrence are noted to be considerably
higher when performed by nonexpert surgeons [10, 11].
Evidence is lacking regarding the specific learning curves of
the various tissue-based repairs; however, the Shouldice
technique is considered notably challenging to master.
Indeed, the Shouldice Hospital is reported to require 300
operations prior to considering a surgeon qualified [4]. Thus,
it is reasonable to select a particular technique for tissuebased repair according to a combination of guidelines and
individual surgeon comfort and training.
Tips and Pitfalls
Nerve identification: As with all open anterior repairs, identification of nerves is crucial to minimize the risk of chronic
pain. Since each tissue-based repair includes placement of
numerous sutures, care must be taken to avoid nerve entrap-
References
1. McGillicuddy JE. Prospective randomized comparison of the
Shouldice and Lichtenstein hernia repair procedures. Arch Surg.
1998;133(9):974–8.
2. Danielsson P, Isacson S, Hansen MV. Randomised study of
Lichtenstein compared with Shouldice inguinal hernia repair by
surgeons in training. Eur J Surg. 1999;165(1):49–53. https://doi.
org/10.1080/110241599750007504.
252
N.H. Carter and D.C. Chen
3. Nordin P, Bartelmess P, Jansson C, Svensson C, Edlund
G. Randomized trial of Lichtenstein versus Shouldice hernia repair
in general surgical practice. Br J Surg. 2002;89(1):45–9. https://doi.
org/10.1046/j.0007-1323.2001.01960.x.
4. Evolution of Groin Hernia Surgery. World Guidelines for Groin
Hernia Management: The HerniaSurge Group; 2016.
5. Amid PK, Shulman AG, Lichtenstein IL. Local anesthesia
for inguinal hernia repair step-by-step procedure. Ann Surg.
1994;220(6):735–7.
6. Read RC, McLeod PC Jr. Influence of a relaxing incision on
suture tension in Bassini’s and McVay’s repairs. Arch Surg.
1981;116(4):440–5.
7. Stoppa R. Hernia of the abdominal wall. In: Chevrel J, editor. Hernias and surgery of the abdominal wall. 2nd ed. Berlin:
Springer; 1997.
8. Bendavid R. The shouldice operation. In: Chevrel J, editor. Hernias
and surgery of the abdominal wall. 2nd ed. Berlin: Springer; 1997.
9. Szopinski J, Dabrowiecki S, Pierscinski S, Jackowski M, Jaworski
M, Szuflet Z. Desarda versus Lichtenstein technique for primary
inguinal hernia treatment: 3-year results of a randomized clinical
trial. World J Surg. 2012;36(5):984–92. https://doi.org/10.1007/
s00268-012-1508-1.
10. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL,
Campanelli G, Conze J, et al. European hernia society guidelines on the treatment of inguinal hernia in adult patients. Hernia.
2009;13(4):343–403. https://doi.org/10.1007/s10029-009-0529-7.
11. Simons MP, Kleijnen J, van Geldere D, Hoitsma HF, Obertop
H. Role of the Shouldice technique in inguinal hernia repair: a systematic review of controlled trials and a meta-analysis. Br J Surg.
1996;83(6):734–8.
Laparoscopic Inguinal Hernia Repair
Ty Kirkpatrick, Brent W. Allain Jr., and Karl A. LeBlanc
15
Introduction
The first report of a hernia repair using laparoscopy was
made by Ralph Ger in 1982 [1]. In a patient with right indirect inguinal hernia, the neck of the sac was closed with a
series of staples using an operating laparoscope and a cannula placed in the right iliac fossa. Although this procedure
was carried out in November 1979, Ger stated that the first
patient to be treated by laparoscopic closure of the neck of
the sac was under the care of Dr. Fletcher of the University
of the West Indies, Jamaica.
The use of prosthetic material for laparoscopic repair of
an inguinal hernia was introduced by Corbitt and Schultz in
1991 [2, 3]. These repairs involved the use of a polypropylene plug, patch, or both to close the inguinal canal in a
tension- free manner. Because of unacceptably high early
recurrence rates, these approaches were abandoned in favor
of laparoscopic placement of a preperitoneal prosthetic biomaterial. This repair follows the same principles as the open
Stoppa repair [4]. After reducing the hernia sac, a large piece
of mesh is placed in the preperitoneal space covering the
entire myopectineal orifice in the inguinal region. The mesh
becomes sandwiched between the preperitoneal tissues and
the abdominal wall and, provided it is large enough, is held
there by intra-abdominal pressure until such time as it
becomes incorporated by fibrous tissue.
The intraperitoneal placement of mesh was introduced by
Fitzgibbons and colleagues as a method of laparoscopic hernia repair [5]. This operation is performed using minimal
dissection by leaving the hernia sac in situ and covering the
defect with mesh, which is stapled to the surrounding peritoneum. The major concerns with this repair are the risk of
injury to underlying structures from fixation devices and of
obstruction or fistula formation as a result of adhesions
T. Kirkpatrick (*) • B.W. Allain Jr. • K.A. LeBlanc
Surgeons Group of Baton Rouge/Our Lady of the Lake Physician
Group, Baton Rouge, LA, USA
e-mail: docmba2@yahoo.com
between bowel and exposed mesh. Currently, however, this
technique is rarely, if ever, utilized in inguinal hernia repair.
The laparoscopic approach for the repair of inguinal hernias is achieving success, and there are some areas of the
world where this is the preferred method of repair. However,
it does not seem that this methodology will become the standard of care for all inguinal hernias. In skilled hands, the
laparoscopic approach is also effective for incarcerated
inguinal hernias [6] and recurrent inguinal hernias after a
prior laparoscopic repair [7].
Extraperitoneal Operation
Anesthesia
Although totally extraperitoneal hernia repair can be performed using either local or epidural anesthesia, it is our
preference to use general anesthesia with complete muscle
relaxation and mechanical ventilation. This ensures that the
respiratory and cardiovascular changes that occur with extraperitoneal CO2 insufflation are minimized. These changes
are similar to or less than those observed with intraperitoneal
CO2 insufflation and may be related to the size of the space
created during the preperitoneal dissections [8]. All patients
undergoing totally extraperitoneal hernia repair receive DVT
prophylaxis. The use of antibiotic prophylaxis is controversial in this situation with little evidence for or against their
use; however, the authors prefer a preoperative dose of a
first-generation cephalosporin in most cases.
Position of the Patient on the Table
Before attempting totally extraperitoneal hernia repair, it is
important to ensure that the patient’s bladder is empty. This
can be achieved by asking the patient to micturate before
entering the operating theater. Alternatively, a urinary catheter could be inserted, but this is generally unnecessary
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_15
253
254
Camera operator
T. Kirkpatrick et al.
Assistant
Surgeon
Scrub nurse
Instrument
trolley
Fig. 15.1 Position of operator, assistants, and television monitor at the
operating table for repair of a left inguinal hernia
unless a prolonged operation is anticipated. The patient
should be placed on the operating table in the supine position
with a 15° Trendelenburg tilt. Ideally both hands should be
placed by the patient’s side to allow the operator and the
assistant to stand opposite each other at the patient’s epigastric level. Care must be taken to correctly pad all pressure
points. The operator stands on the side opposite of the hernia
being repaired. When bilateral repairs are to be done, the
operation can be started by standing on the side of the patient
opposite the larger hernia defect. The video monitor should
be placed at the foot of the table (Fig. 15.1). If two monitors
are being used, one should be placed at either side of the
lower end of the operating table.
Trocars and Trocar Position
One 10 mm cannula and two 5 mm cannulas are generally
used for this operation. The 10 mm cannula should have a
blunt-nosed trocar as it is inserted using an open technique.
The 5 mm cannulas that are preferred are those with some
method to prevent them from moving in and out of the extra-
TV monitor
Fig. 15.2 Sites of trocar placements for totally extraperitoneal hernia
repair. The mark on either side of the abdomen indicates the alternate
location for the 5 mm trocars
peritoneal space as instruments are passed through. In addition, because of the confined operating space, the 5 mm
cannulas should be short (60 mm). All the cannulas can be
placed in the lower midline. In this instance, the 10 mm cannula is placed in a sub-umbilical position; one of the two
5 mm cannulas is placed one-third of the way between the
symphysis pubis and the umbilicus and the other half way
between the symphysis pubis and the umbilicus (Fig. 15.2).
Alternatively, many physicians prefer the two smaller trocars to be placed laterally near the anterior axillary line above
the iliac crest on either side of the patient. These latter trocars
will usually be positioned after the dissection is nearly completed through the larger midline trocar. This will frequently
be accomplished with the use of the laparoscope itself.
Laparoscope
Some surgeons substitute the 0° laparoscope for a 30° laparoscope after developing the extraperitoneal space. We find
that this is not necessary and that the operation can be completed satisfactorily with a 0° laparoscope. Currently either
the 5 or 10 mm laparoscope can be used for the entire
procedure. In particularly difficult cases, the 5 mm laparo-
15 Laparoscopic Inguinal Hernia Repair
255
scope is preferred as this can be placed in the lateral ports to
visualize the anatomy from the contralateral aspect.
Developing the Extraperitoneal Space
A transverse incision of 1–1.5 cm, starting in the lower half
of the umbilicus and extending laterally, is made. The tissues
are then separated with scissors or hemostats and retracted
with two retractors to expose the anterior rectus sheath on the
side of the hernia to be repaired or more toward the larger
hernia in the bilateral situation. The sheath is opened with a
#11 blade scalpel through a small transverse incision. The
midline and rectus muscle are identified, and the space
between the rectus muscle and the posterior rectus sheath
space is developed using hemostats and blunt dissection. A
large right-angled retractor (to retract the rectus muscle anteriorly to allow the insertion of a blunt-nosed 10 mm trocar
and cannula) is then inserted into this space and moved
medially, laterally, and posteriorly to develop the preperitoneal space. Insufflation with CO
flation pressure being kept between 10 and 12 mmHg.
A 0° laparoscope is then inserted through the 10 mm can-
nula and can be gently used as a blunt dissector to further
can commence with insuf-
2
enlarge the space. It is important to feel the pubic symphysis
and stay in the midline and immediately posterior to the rectus
muscle with the laparoscope during this dissection. Once the
appropriate space is visible, two 5 mm cannulas are inserted
under direct vision in the positions previously described.
The preperitoneal space may also be developed using balloon dissection. A deflated balloon on the end of a cannula,
of which many different types are available (Fig. 15.3), is
placed in the preperitoneal space using the access described.
The balloon is then filled with air and the space developed
under direct vision using a 0° laparoscope. This method is
helpful in the learning period when surgeons are still unfamiliar with the preperitoneal anatomy. While balloon dissection is slightly more rapid, it has the disadvantage of adding
additional expense to the operation. In addition, it can be
associated with bladder and bowel injury in patients who
have had previous lower abdominal surgery [9]. In those
patients that have had prior lower abdominal surgery or prostatectomy, it is preferred to either perform the entire operation without the use of a balloon dissector or performing a
transabdominal preperitoneal operation. Some surgeons will
occasionally merge the two techniques. In these cases, the
surgeon will enter the abdomen above the umbilicus with a
5 mm port and inspect the lower abdominal contents. If there
Fig. 15.3 (a) The deflated
PBD2 balloon for dissection
of the preperitoneal space. (b)
The inflated PBD2 balloon for
dissection of the preperitoneal
space. (c) Spacemaker Plus
Dissector System
a
c
b
256
T. Kirkpatrick et al.
are no adhesions, which occur frequently, the dissection can
be converted to the totally extraperitoneal operation either
with or without the use of the balloon dissection.
Dissection
Two atraumatic dissectors, which will grasp but not tear the
peritoneum, are important for this part of the procedure. A
sharp pair of scissors will sometimes be used but is seldom
necessary. It is important to identify the anatomical landmarks
in an orderly fashion. The pectineal (Cooper’s) ligament on
the same side as the hernia should be exposed first. At this
stage, in thin patients, you may see the external iliac vein laterally, and accessory obturator vessels, if present, will be found
crossing the pectineal ligament. Separation of the perivascular
and extraperitoneal fat is performed in the avascular plane
between both using gentle blunt dissection and is aided by the
CO
insufflation. Characteristic filamentous tissue, which
2
breaks down easily, will be observed between the two planes.
The retropubic space can now be developed in the midline
and on the side of the hernia to above the level of the obturator nerve and vessels. The inferior epigastric vessels should
next be identified and the space between them and the extraperitoneal fat developed. During this part of the dissection, it
is important to keep the epigastric vessels up against the rectus muscle using one dissector, while the other is used to
separate the tissues. If this is not done, the epigastric vessels
will come down into the operating field, and small branches
between them and the rectus muscles will be torn, giving rise
to troublesome bleeding. Between the inferior epigastric vessels and extraperitoneal fat, a fascial layer is encountered.
This represents the deep layer of the fascia transversalis
(Fig. 15.4) and should be divided using a combination of
blunt and sharp dissection to open up the space lateral to it.
This may not always be necessary if the dissection allows the
complete separation of these structures.
Much of this will be accomplished with the dissection
balloon if this is the chosen technique. The choice of the use
of the balloon or blunt dissection has been shown to be
equally effective in creating the space necessary to perform
this operation [10]. The attention to the epigastric vessels is
limited when this is used because the unfurling of the balloon will sometimes pull these vessels down rather than leaving them in situ. This may limit the insufflation of the balloon
whereupon the surgeon must complete the dissection manually. Also, for those surgeons that prefer the lateral location
of the 5 mm trocars, some of the dissection will usually be
necessary with the laparoscope and/or one of the dissection
graspers that would be inserted through one of the lateral or
midline trocars.
Indirect Inguinal Hernias in Males
At this stage, it should be possible to identify the sac of an
indirect inguinal hernia (Fig. 15.5). The sac will be found
immediately lateral to the inferior epigastric vessels as it
enters the internal ring. The sac should be grasped at the
internal ring and reduced by retracting and dissecting the
adhesions between it and the inguinal canal. Tension needs
to be kept on the sac during this part of the dissection by
using both dissectors in a stepwise fashion; otherwise, as the
sac is released to regrip it, it will return to the inguinal canal
because of its elasticity and inguinal attachments. It is
important to dissect all the tissues around the sac down to
the peritoneum. These tissues represent attenuated transversalis fascia (see Chap. 2) which invests the cord and indirect
sac as it enters the internal ring. Once this has been achieved,
the sac can be lifted up, and the vas deferens will be visible
at its posterior border and may be dissected off it along with
Fig. 15.4 Laparoscopic appearance of the deep layer of fascia
transversalis
Fig. 15.5 Laparoscopic appearance of a right indirect hernia
15 Laparoscopic Inguinal Hernia Repair
the testicular vessels. The vas runs medially and crosses
over the iliac vessels as it descends into the pelvis, while the
testicular vessels take a course slightly lateral to the iliac
vessels. In small to moderately sized indirect inguinal hernias, the apex of the sac can be identified and the sac completely reduced into the extraperitoneal space. If the sac is
large and entering the scrotum, it may be wise to divide and
ligate it at a convenient point as one would do with open
hernia repair. This, of course, will be done with intracorporeal suturing. The testicular vessels and vas deferens should
be completely skeletonized of any lipomatous material that
may be in the inguinal canal. Not infrequently, a small hole
may be made in the sac during its reduction. This should not
impair the ability to complete the dissection, and such
defects can usually be ignored. However, it should be noted
that great care must be exercised to avoid a large tear of the
peritoneal sac during these maneuvers. This will result in
the insufflation of the intra-abdominal space, which will
limit the available preperitoneal space and subsequent
“working room” for the operation to continue. Additionally,
this could expose the patch material to the intestinal contents of the abdomen with resulting adhesions. If a large tear
occurs and cannot be closed with sutures, there are two
options. One may convert to the transabdominal preperitoneal technique and use a tissue separating prosthesis as used
in the incisional hernia repair or abandon the laparoscopic
approach altogether.
Posteriorly the peritoneal dissection should be taken back
until the vas can be seen descending into the pelvis. Laterally
it should go at least to the level of the anterior superior iliac
spine, while medially dissection should cross the midline
and go well below the pectineal ligament (Fig. 15.6). This is
to ensure complete exposure of the myopectineal orifice and
that there is adequate space for insertion of the mesh.
Lateral to the testicular vessels, the femoral branch of the
genitofemoral nerve and the lateral cutaneous nerve of the
thigh can be identified in patients with little adipose tissue
(Fig. 15.7). Care should be taken not to damage these or a
small branch of the deep circumflex iliac artery, which lies
laterally to the cutaneous nerve of the thigh. These structures
all lie beneath the iliopubic tract. Therefore, any fixation of
the meshes must be placed above this line to assure that these
nerves are not in harm’s way. Also in thin patients, the external iliac vessels will be easily identified, the artery appearing
between the testicular vessels and the vas and the vein lying
medial to the artery. In all patients, the characteristic pulsation from the external iliac vessels will be observed in this
position. Small peritoneal branches arising from the iliac
artery may also be noted during the dissection, and as these
are usually at the posterior limit of the dissection, they can be
preserved. As all dissection is carried out in an avascular
plane, there should be only a limited need to use electrocautery during the operation. Most dissection is performed by
257
Fig. 15.6 Extent of dissection required with details of anatomy
observed at laparoscopy. A left direct inguinal hernia is seen as is the
right inguinal hernia from Fig. 15.5
Fig. 15.7 Laparoscopic appearance of femoral branches of genitofemoral nerve and lateral cutaneous nerve of the thigh
gentle separation of tissues using atraumatic dissecting forceps. If there is an injury to larger vessels such as the epigastric artery or vein, then the use of hemostatic clips or suture
ligation will be necessary. If this fails, then one could place
transfascial absorbable sutures to maintain hemostasis of
these vessels.
Indirect Inguinal Hernias in Females
The approach to these hernias is similar to that of the indirect inguinal hernias in the male patient. Once the sac is
reduced, the round ligament can be left in situ or divided
and ligated at the internal ring depending on the surgeon’s
preference. Generally it is very difficult to avoid division of
this structure due to the dense adherence of the peritoneum.
Separation of the peritoneum and round ligament very often
results in a tear in the peritoneum. Early division avoids this
issue.
258
T. Kirkpatrick et al.
Direct Inguinal Hernias
A direct inguinal hernia will be encountered during the dissection to expose the pectineal ligament (Fig. 15.6). The
defect lies laterally to the border of the rectus muscle and is
medial to the inferior epigastric vessels except when a combined direct and indirect hernia is present. Sometimes a
direct defect can appear to encroach on the femoral canal and
in this circumstance may be confused with a femoral hernia.
Patients with a direct hernia will also occasionally be found
to have a femoral hernia. The direct hernia sac and preperitoneal fat are usually easy to reduce by grasping the sac with
atraumatic forceps and simple pulling gently. While the hernia is being reduced, the characteristic appearance of a pseudosac, which is attenuated transversalis fascia, will be
displayed. This should be allowed to retract into the defect.
As with indirect hernias, the sac is reduced into the extraperitoneal space, and no attempt is made to open or ligate it. The
vas deferens and testicular vessels need to be exposed to
exclude a synchronous indirect hernia. The extent of the dissection should be identical to that of the indirect hernia
repair. It is important to be careful during this part of the
operation as the peritoneum is easily torn at the internal ring
in patients with a direct hernia. It is generally best if the peritoneum is pushed with the laparoscopic forceps rather than
pulled at this location so that this tear may be avoided.
Femoral Hernias
As the pectineal ligament is exposed as far lateral as the
external iliac vein in all patients, a femoral hernia should not
be missed during totally extraperitoneal hernia repair. This
can be reduced in the same manner as for direct hernias. One
should be attentive to the possibility of the inclusion of an
organ such as the bladder or ovary into the hernia contents.
When found, these structures should be carefully reduced to
avoid injury. Once this has been done, dissection should proceed as for other groin hernias.
Recurrent Hernias
A reasonable amount of experience with totally extraperitoneal hernia repair is required before dealing with recurrent
hernias following an open repair and even more if subsequent to a laparoscopic approach. This is because the anatomical landmarks are often distorted due to the previous
surgical dissection and the associated mesh implantation.
The inferior epigastric vessels may have been divided and
thus be in part absent or visible as a much smaller vessel.
Dense adhesions form between the neck of the recurrent sac
and the previous repair, and because of this, it is wise to use
careful sharp dissection to free it from these adhesions.
Elsewhere the peritoneum is often very thin and easily torn,
as stitches may have gone through it from the previous repair.
Because of the frequent use of a prosthetic biomaterial in the
prior repair, the occurrence of a tear in the peritoneum should
be expected during the dissection.
Because of these reasons, it is probably best to use a transabdominal approach (TAPP) if mesh material resides in the
preperitoneal space. This will allow the surgeon the ability to
dissect the peritoneum under direct vision and allows the
assurance that there are no adhesions from an intra- abdominal
organ.
Bilateral Hernias
Bilateral hernias can be repaired using the same access as for
unilateral hernias, and additional trocars are not required.
Once dissection has been completed on one side, the operator simply switches to the other side and reduces the contralateral hernia. Although one large piece of mesh can be used
for bilateral hernia repair, it is our preference to use two different meshes that are at least 10 cm by 15 cm in size. In this
circumstance, it is helpful to fixate one to the pectineal ligament before the contralateral mesh is placed into position (if
fixation is to be done at all). Larger hernias will require even
larger meshes of 15 × 15 cm.
For all indirect hernias and most direct hernias, a heavyweight mesh generally does not need to be tacked, stapled, or
sutured in place. If, however, a large direct defect encroaches
upon the femoral canal or there is a femoral hernia, it may be
advisable that the mesh be stapled or sutured to the pectineal
ligament to prevent the inferior border of the mesh from slipping upward and into the defect. The mesh does not need to
be divided to fit around the cord or, indeed, sutured or tacked
around the cord.
An exception to the above statement has come about in
the last several years. The lighter-weight macroporous
meshes are very supple and soft, an advantage in their use.
However, this characteristic makes fixation necessary so that
the product does not protrude into the hernia defect. The type
of device and method chosen for fixation will vary according
to surgeon preference.
On desufflating the extraperitoneal space, it is important
to ensure that the inferior fold of the mesh does not roll up
with the peritoneum. If an adequate dissection has been carried out, this will be unlikely to occur. After desufflation, all
cannulas are removed, and the rectus sheath at the subumbilical incision is closed with 2/0 or 0 Vicryl, while the
skin is closed with interrupted absorbable subcuticular
stitches and/or adhesive tapes.