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408
12.7 Comments on Laparoscopic Colorectal Surgery
nally monitored trial. To gain this expertise, one must either be
a very skilled laparoscopic surgeon or a very high volume
colorectal surgeon with laparoscopic interest. I believe that because of the steepness of the learning curve it is inappropriate
for a surgeon performing only a few colectomies each month to
embark upon a laparoscopic program (Agachan et al. 1996). It
may be more prudent in such instances to refer appropriate
cases to a different member of the group who is facile and able
to execute the laparoscopic approach. The reader should remember that ultimately skill, experience, judgment, and case
volume can make the difference between a significant reduction in disability and a significant increase in morbidity.
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th
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410
13. Inguinal Hernia Repair
13.1 Videoendoscopic Preperitoneal Hernia Repair
E. Schippers, V. Schumpelick
Goals and Methods
Surgical intervention to reinforce the abdominal wall in the
plane of the transverse fascia is accepted as a standard procedure in treating an inguinal hernia. An important factor in this
has been the extremely low morbidity associated with the established conventional procedures described by Bassini, Shouldice, Stoppa, and many others.
With the advent of laparoscopic surgery and the application of
this technique to hernia repair these accepted procedures have
been challenged. The goal of laparoscopic hernia repair is to exploit the advantages of endoscopic surgery, i. e., reduced surgical trauma, reduced pain, early mobilization, and rapid reintegration into daily work and leisure activities, for the hernia
patient. Initial attemps at closing the hernia with clips or sutures, or occluding the hernia canal with a plug of plastic mesh
were plagued by a high incidence of early recurrence. These
methods have therefore been abandoned in favor of the preperitoneal implantation of mesh in a transformation of Stoppa’s
operation to an internal, minimally invasive procedure. Mesh
applied over a wide area with a technique similar to that de-
scribed by Stoppa covers all three potential types of hernia ori-
fices and insures a tension-free repair. Endoscopic access to the
plane of the transverse fascia permits the surgeon to dissect in
undisturbed tissue layers even in patients who have undergone
a previous conventional operation and now present with a recurrent hernia. These procedures pose less of a risk of injuring
the inguinal cord structures (vas deferens, testicular artery, and
pampiniform venous plexus). The fact that transperitoneal
access would have required converting a conventional, purely
preperitoneal procedure into an intraperitoneal operation with
all the associated risks of accidental organ injuries, formation of
adhesions and peritoneal infection led to the development of a
purely preperitoneal endoscopic technique.
Indications
From our point of view, the procedure is indicated solely in elective surgery to correct a recurrent hernia in adults. This restriction is due to the fact that this procedure (as opposed to conventional procedures) has the disadvantages of requiring general
anesthesia and implantation of foreign material.
increased and unrestricted respiratory effort in the postoperative phase to eliminate the carbon dioxide.
In the presence of coagulation disorders or anticoagulation
therapy, appropriate therapeutic measures or substitution
treatment should be undertaken; the procedure should begin
only after correction of the coagulation factors has been documented. Coagulation disorders that do not respond to treatment are absolute contraindications. Further contraindications
include infection of the abdominal wall and acute abdomen
with suspected bowel incarceration, ileus, or intestinal
ischemia. Regardless of the surgical approach chosen, the surgeon should make every effort to avoid the implantation of inelastic mesh in female patients of child-bearing age.
Relative Contraindications
Depending on the surgeon’s level of skill and experience, these
may include large scrotal hernias, patients who have undergone
previous intraperitoneal or preperitoneal lower abdominal
operations (i. e., prostate resection, bladder surgery, or
Caesarean section), and previous preperitoneal mesh implantation for hernia repair.
Surgical Risks and Patient Information
The general incidence of complications is low; complications
are comparable to those occurring with conventional operations. Studies cite an incidence ranging from 6.5 to 10%. Potential specific complications include transitory emphysema in the
abdominal wall or scrotum, hematoma in the abdominal wall or
scrotum, hydrocele formation, and transitory nerve irritation.
The incidence of recurrence after one year is 0.3−0.6%. No longterm data on the incidence of recurrence following this new
surgical technique are yet available. The issue of the biocompatibility of nonabsorbable plastic mesh has not yet been resolved.
In discussing these matters with the patient, the surgeon should
indicate that the final decision for or against an endoscopic procedure will be reached intraoperatively. The surgeon should expressly mention that conversion to an open procedure may become necessary. This should be interpreted as the standard of
care in managing the disorder at present.
Contraindications
Absolute Contraindications
These include risk factors that contraindicate general anesthe-
sia and severe respiratory disorders. The preperitoneal dissec-
tion with CO
that necessitates appropriate intraoperative ventilation and an
insufflation entails a high rate of CO2absorption
2
Special Preparations
Special preparations include determining patient tolerance of
anesthesia and excluding the risk factors mentioned in the previous sections. Further preparations include emptying the
bowel and bladder, and disinfecting the abdominal wall including the scrotum. An indwelling urinary catheter is mandatory.
Anesthesia
General anesthesia.
Patient Positioning
(Fig. 13.1.1).
Position of the Operating Team and
Equipment
(Fig. 13.1.2).
The surgeon stands opposite the hernia site. In the presence of a
bilateral hernia, the surgeon initially stands to the left of the
patient for dissection of the right inguinal region, after which he
or she moves to the right side. After the second, lateral instru-
ment trocar has been placed, the assistant (who stands opposite
the surgeon) assumes control of the laparoscope. The surgeon
continues the dissection and repair through the instrument tro-
cars, working with both hands. The operating room nurse
stands toward the patient’s feet. The monitor, video equipment,
pneumatic equipment, and light source are positioned at the
foot of the operating table. This gives the entire operating team
a good view of the surgical site and the instrument readings.
Trocar Placement
Fig. 13.1.1 Preperitoneal hernia repair.
The patient is placed in a 20−30° Trendelenburg position with both arms
adducted. Shoulder supports prevent the patient from sliding off the
operating table.
Assistant holding
the laparoscope
and camera
411
Surgeon
Trocar Placement
(Fig. 13.1.3).
Insert the laparoscope/camera trocar (T1; 11.5 mm, blunt-tip
stylet) paramedially, immediately inferior to the umbilicus be-
tween the rectus abdominis and the posterior layer of the rectus
sheath. To insert the trocar, make a 12-mm skin incision, open
the anterior layer of the rectus sheath, and separate the longi-
tudinal fibers of the rectus abdominis muscle from the midline
to the side of the planned operation under direct vision. Using
your little finger, dissect a space between the rectus abdominis
and the posterior rectus sheath to accommodate the blunt tro-
car. A rubber sleeve on the trocar or a pursestring suture is used
to seal the incision. The preperitoneal space is dissected bluntly
using a forward viewing laparoscope under permanent insuffla-
tion. Alternatively a balloon dissector is advanced towards the
pubis sliding onto the peritoneum. By insufflation of 700−
900 ml saline a preperitoneal space is created. After dissecting
and insufflating the preperitoneal space, place the first instrument trocar (T2; 12 mm, sharp pyramidal-tip stylet) directly to
the right of the linea alba halfway between the umbilicus and
the pubic bone under laparoscopic visualization. This trocar is
used to insert the dissector and grasper, which are controlled
with the left hand, and later to insert the mesh and stapler.
After continuing the dissection of preperitoneal space, place the
second instrument trocar (T3; 10.5 mm, sharp pyramidal-tip
stylet) under laparoscopic visualization in the right or left flank
(depending on the position of the hernia) laterally at the level of
T1. This trocar is used for introducing the scissors and dissecting
swab, which are controlled with the right hand. In the presence
of a bilateral hernia, the surgeon initially dissects the patient’s
right side from the left, and then switches to the right side and
inserts the laparoscope through T3. T1 and T2 then serve as instrument trocars for dissection of the left inguinal region and T3
as laparoscope/camera trocar.
OR nurse
Instrument table
Monitor and
laparoscope cart
Fig. 13.1.2 Preperitoneal hernia repair.
Position of the operating team and equipment.
412
13.1 Videoendoscopic Preperitoneal Hernia Repair
line incision in the lower abdomen is indicated. This also applies
to injuries of the iliac vascular structures and the testicular vessels. For this reason, the procedure should only be performed by
a surgeon who is able to continue the operation as a conventional open procedure should it become necessary.
Gas Leakage into the Peritoneal Cavity
Especially in patients who have undergone a previous lower
abdominal operation, penetration into the peritoneal cavity
may occur during the blunt dissection. This will result in gas
leakage into the peritoneal cavity, which diminishes the size of
the preperitoneal space.
Corrective action: The intraabdominal carbon dioxide can be removed by introducing a Veress needle into the peritoneum. This
relieves tension on the peritoneal membrane, which is then repaired with a laparoscopic clip or suture. If this is not possible,
the Veress needle may be left in place in the abdominal cavity to
permit the leaking carbon dioxide to escape from the peri-
T1
T3
T2
toneum. Continuing the endoscopic procedure requires that
you achieve a pressure equilibrium between the preperitoneal
and intraperitoneal spaces. This is best done by reducing the
flow of carbon dioxide into the preperitoneal space.
Note: If it is not possible to maintain sufficient exposure in the
preperitoneal space, conversion to a conventional procedure is
indicated.
Fig. 13.1.3 Preperitoneal hernia repair. Trocar placement.
T1 laparoscope/camera trocar: paramedially, inferior to the umbilicus.
T2 instrument trocar: To the right of the linea alba halfway between the la-
paroscope/camera trocar and the pubis.
T3 instrument trocar: on the right along the anterior axillary line at the same
level as the laparoscope/camera trocar.
Complications
Intraoperative Complications
Sudden Intraoperative Bleeding
This is usually caused by avulsion of the epigastric vessels
during blunt dissection of the preperitoneal space or by injuring
a vessel with an instrument. Take extreme care to ensure that
these vascular structures remain anterior to the plane of dissection.
Corrective action: If coagulating blood interferes with visualization of the surgical site, irrigate and identify the source of bleeding. Once the vessel is identified, control bleeding by applying a
clip or internal ligature.
Corrective action: If bleeding cannot be controlled or if the surgeon is in doubt or lacks the necessary experience, immediate
conversion to Stoppa’s conventional technique involving a mid-
Postoperative Complications
Emphysema in the abdominal wall and scrotum can be easily
and completely eliminated at the end of the procedure by applying manual pressure.
Minor hematomas at the trocar insertion sites are usually absorbed and may be aspirated if needed. Similarly, hematomas of
the scrotum will be resorbed spontaneously within one or two
weeks.
Seromas can occur as a reaction to the implant or in the transected distal hernia sac that is left in place. Repeated aspiration
under sterile conditions may be necessary before the seromas
are completely absorbed.
Neuralgia of the lateral femoral cutaneous nerve or the femoral
branch of the genitofemoral nerve may persist up to three
months postoperatively. This is due to irritation during the
lateral dissection or to excessive and unnecessary lateral fixation of the mesh affecting the nerve.
Late Complications
The major late complication is a recurrent hernia. The rate of recurrence after one year is 0.5%. Long-term data are not yet available. If the procedure is performed correctly, recurrence rates
similar to Stoppa’s open procedure may be expected. This incidence is cited as 1.4%. Possible causes include dislocation of the
mesh or using too small a mesh.
Corrective action: The extensive adhesions that develop in the
mesh region permit usually only open revision surgery.
Complications
413
Step-by-Step Propcedure
Preparations
1. Verify proper function of the laparoscopy unit:
− Light source
− Insufflator (select pressure level; 12−14 mm Hg).
− Laparoscope (white balance).
2. Connect the aspirator/irrigator set.
3. Adjust the electrocautery unit to a medium setting.
4. Start the recording unit.
Endoscopic hernia repairs
5. Insert the laparoscope/camera trocar into the preperitoneal
space under direct vision.
6. Bluntly dissect the preperitoneal space under laparoscopic
visualization using a forward-viewing laparoscope. Alternatively use a balloon dissection device for opening the preperitoneal space.
7. Introduce the instrument trocars.
8. Dissect the anatomic landmarks in the inguinal region (internal inguinal ring, inferior epigastric artery and vein, external
iliac artery and vein, and Cooper’s ligament).
9. Dissect and reduce the hernia sac in the preperitoneal space
from the vas deferens, the testicular artery, and the testicular
vein. In case of a large scrotal component, the sac is dissected
off the cord structures and transected at the internal ring,
leaving the scrotal portion in place as tunica vaginalis. The
proximal sac is then reduced to the preperitoneal level.
10. In the presence of a bilateral hernia, proceed similarly on the
contralateral side.
11. Introduce a nonabsorbable mesh and place it so as to cover
direct, indirect, and femoral orifices.
12. Fix the mesh to Cooper’s ligament with staples or sutures.
13. Inspect the surgical site to verify hemostasis and correct positioning of the mesh.
14. Remove the instrument trocars under laparoscopic visualization and let the CO
15. Close the fascia at the incisions for the laparoscope/camera
trocar and midline instrument trocar (12 mm).
16. Close skin incisions.
out of the preperitoneal space.
2
Operative Technique
Fig. 13.1.4 Preperitoneal hernia repair. Incision of the anterior rectus
sheath.
Incise the skin inferior to the umbilicus, divide the subcutaneous tissue,
and open the anterior layer of the rectus sheath. After separating the
musculature parallel to the direction of its fibers from the linea alba in the
midline, dissect with your finger between the rectus abdominis and the
posterior layer of the rectus sheath. Place a blunt trocar in the space be-
tween the posterior wall of the rectus sheath and the transverse fascia.
Seal the incision with a rubber sleeve or, alternatively, by placing a purse-
string suture.
414
13.1 Videoendoscopic Preperitoneal Hernia Repair
Fig. 13.1.5 Preperitoneal hernia repair. Dissection of the preperitoneal
space.
Continue blunt dissection of the preperitoneal space under laparoscopic
visualization using the laparoscope (0-degree forward-viewing laparo-
scope) as a dissection instrument while insufflating with carbon dioxide
(12−14 mm Hg). The plane of dissection lies superior to the arcuate ligament, between the musculature and the posterior rectus sheath and inferiorly, between the rectus abdominis and the transversalis fascia. Dissect a
V-shaped area extending distally to the pubis and laterally to the epiga-
stric and iliac vessels. Make sure that the epigastric vessels lie anterior to
the plane of dissection. The peritoneum is pushed posteriorly.
Fig. 13.1.6 Preperitoneal hernia repair. Dissection of the preperitoneal
space.
As an alternative but more expensive, a balloon dissection device can be
inserted via the same incision. It is advanced towards the pubis such that
it slides off the arcuate line onto the peritoneum. The balloon is then inflated with 700−900 ml of saline depending on patient size and unilateral
versus bilateral repair. After removal of the balloon the cannula is advanced into the cavity and connected to CO
pressure of 8−10 mm Hg.
컅 Fig. 13.1.7 Preperitoneal hernia repair. Dissection of the preperitoneal
space.
After inserting an instrument trocar under laparoscopic visualization, continue the dissection laterally using an atraumatic dissector. Expose
Cooper’s ligament, and the epigastric and iliac vessels. Place the second
instrument trocar in the left or right flank (on the same side as the hernia)
laterally at the level of the laparoscope/camera trocar. In the presence of a
bilateral hernia, the laparoscope can later be inserted through this lateral
instrument trocar for dissecting the contralateral side.
. The cavity is inflated to a
2
Complications
415
Fig. 13.1.8 Preperitoneal hernia repair. Dissecting the hernia sac.
After identifying anatomic landmarks, begin dissection of the hernia sac
by reducing it into the peritoneal space. Grasp the hernia sac with an
atraumatic laparoscopic grasper, place tension on it and bluntly and
sharply dissect it out of the internal inguinal ring with scissors.
Fig. 13.1.10 Preperitoneal hernia repair. Overview.
The preperitoneal dissection to expose all potential hernia orifices ex- 컄
tends from the linea alba to the anterior superior iliac spine. Anteriorly,
the internal inguinal ring and the medial inguinal fossa are exposed. Posteriorly, the dissection exposes the iliopubic tract of the femoral canal.
Further anatomic landmarks to be identified during the dissection include
the epigastric vessels, the iliac vessels, the vas deferens, the testicular vessels, Cooper’s ligament, the lateral femoral cutaneous nerve coursing
lateral to the psoas major, and on it the femoral branch of the geni-
tofemoral nerve. The dissection is extensive enough to cover any hernia
orifice in the inguinal region with a sufficiently large mesh.
1 Inferior epigastric artery and vein
2 Cooper’s ligament
3 Vas deferens
4 External iliac artery and vein
5 Femoral branch of the genitofemoral nerve
6 Testicular artery and vein
7 Iliopubic tract
8 Area covered by mesh
9 Staple (see Fig. 13.1.12)
Hernia orifices:
A Direct inguinal hernia
B Indirect inguinal hernia
C Femoral hernia
Fig. 13.1.9 Preperitoneal hernia repair. Isolating the vas deferens and the
testicular vessels.
Using atraumatic graspers, dissector, and scissors, gradually separate the
vas deferens and testicular vessels from the hernia sac. Mobilize the sac as
far proximally as possible to complete the parietal dissection. A small
hernia sac may be left in place after the dissection and later placed on the
peritoneal side of the mesh. Large hernia sacs are ligated and resected. In
the presence of a large fixed scrotal hernia, transect the hernia sac and
leave the distal segment open to prevent hydrocele formation in situ.
1
A
B
C
2
9
6
5
4
3
8
7
416
Fig. 13.1.11
13.1 Videoendoscopic Preperitoneal Hernia Repair
Fig. 13.1.11 Preperitoneal hernia repair. Introducing the mesh.
Introduce a nonabsorbable mesh (12 × 17 cm) wrapped around a laparo-
scopic grasper. Beginning medially at the linea alba, unroll the mesh laterally to cover the potential hernia orifices. In the presence of a bilateral
hernia, a second mesh is placed in a similar position on the contralateral
side.
Bibliography
Arregui ME, Navarete J, Davis CJ, Castro D, Nagan RF. Laparoscopic inguinal
herniorraphy—techniques and controversies. Surg. Clin. N. Amer. 1993;
73:513.
Hourlay P. Extraperitoneal endoscopic inguinal hernia repair. In Schum-
pelick V, Wantz E. Hernia Surgery. Basel: Karger; 1994.
McFayden jr. BV, Arregui ME, Corbitt JD et al. Complications of laparoscopic
herniorraphy. Surg. Endosc. 1993; 7:155.
Schippers E. Complications of laparoscopic inguinal herniorrhaphy: Review
of the literature. In Schumpelick V, Wantz E. Hernia Surgery. Basel: Karger;
199 4.
Schumpelick V. Hernien. Stuttgart: Enke; 1993.
Stoppa RE, Warlaumont CR. The preperitoneal approach and prosthetic re-
pair of groin hernia. In Nyhus LM, Condon RE. Hernia, p. 199. Philadelphia:
Lippincott; 1989.
Fig. 13.1.12
Fig. 13.1.12 Preperitoneal hernia repair. Fixing the mesh.
Fix the mesh to Cooper’s ligament medial to the iliac vessels with one or
two staples or with a suture. Verify proper position of the mesh. If desired,
a drain may be placed in the wound cavity for the first 24 hours postoperatively through the lateral trocar. Remove the instrument trocars
under laparoscopic dissection and let the CO
space.
out of the preperitoneal
2
Anesthesia
13.2 Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair
F. Köc kerling
417
Objectives and Methods
The goals of the surgical management of inguinal hernia are:
high ligation or control of the hernia sac, tightening or covering
the hernia orifices and repair or strengthening of the floor of the
inguinal canal. Proven conventional surgical techniques have
favorable long-term results with a five-year incidence of recurrence of 1−2%.
The goals and results of conventional hernia repairs can also be
achieved with laparoscopic techniques, adapted to the correc-
tion of a direct, indirect, or femoral hernia defect, while achieving the advantages of less pain, shorter hospital stay, and faster
return to normal activities recognized for minimally invasive laparoscopic techniques in general.
Laparoscopic hernia repair may be performed as a transabdominal preperitoneal or as a purely preperitoneal repair. The trans-
abdominal preperitoneal repair through a lower midline incision was first suggested by L. Tait in 1891. Later, this approach
was often used to correct a hernia during laparotomy performed for another indication, but it was also successfully used
in the specific treatment of a recurrent hernia. Laparoscopic repair is performed under general anesthesia. Initially there was a
broad range of techniques, some of which created a high inci-
dence of recurrence. In time, surgeons began to adapt the laparoscopic repair to the hernia defect, rather than to adjust the
defect to the existing inefficient laparoscopic techniques,
limited in concept and execution by a “laparoscopy at any price”
attitude. The recognition that surgical principles, in this case
ligation or control of the sac, narrowing of the inguinal ring, and
reinforcement or repair of the floor of the inguinal canal, have to
be satisfied by an operative procedure, rather than bending
these principles to fulfill a technical fancy, has led to the
development of two preperitoneal repairs. The transabdominal
preperitoneal repair may be especially useful in recurrent
hernias, where scarring and postoperative anatomical artifacts
may render a true preperitoneal approach more difficult.
Note: The operation involves a technique that requires working
with both hands. Initially it may prolong operating time, appear
to be tedious, and will be more costly. Long-term results are not
yet available. The technique awaits confirmation by careful
evaluation of long term results as they become available. These
issues are best left up to study groups with a research minded
staff and clinical experience in a wide variety of laparoscopic
operations.
Relative Indications
Primary laparoscopic management of an uncomplicated inguinal hernia is indicated under well defined conditions as part of a
clinical study. The same applies to recurrent reducible hernias.
With increasing global experience, these restrictions may be
lifted and laparoscopic hernia repairs will then b ecome a
routine experience for uncomplicated hernias, a concept that is
fast becoming a reality. Progressive technical sophistication will
allow surgeons to include some of the absolute indications for
conventional repair in the laparoscopy group.
Contraindications
− Anesthetic risks (see cahpter 2.5).
− Coagulation disorders that do not respond to treatment.
− Adhesions in the lower abdomen following lower abdominal
disorders or operations.
Surgical Risks and Patient Information
The surgeon should discuss in detail the current status of laparoscopic hernia repair with the patient. The patient should be
aware that long-term results are not yet available. The arguments for and against the laparoscopic technique should be
detailed enough to allow the patient to participate in a rational
decision that best addresses his or her circumstances. The
possible complications specifically associated with the
pneumoperitoneum and insertion of the trocars, the possibility
of recurrence, and the risks associated with implants should be
discussed. Patients with a recurrent hernia are “experienced”
patients and their questions should be answered precisely,
since they are usually disappointed with conventional surgical
techniques and tend to be receptive to alternative methods. The
surgeon should curb unrealistic expectations during such a discussion.
Special Preparations
As in every laparoscopic procedure, placement of a nasogastric
tube and indwelling urinary catheter is indicated.
Indications
Absolute Indications
Absolute indications include irreducible hernias. Incarcerated
hernias with peritonitis or suspected intestinal gangrene and
recurring incarceration are managed conventionally.
Anatomy
(Figs. 13.2.1 and 13.2.2).
Anesthesia
General anesthesia.