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13.2 Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair
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Fig. 13.2.1 Posterior aspect of the anterior abdominal wall, showing the
parietal peritoneum (left) and the transverse fascia (right) in part.
Hesselbach’s triangle is outlined in black. Medial border: lateral margin of
the rectus abdominis muscle. Lateral border: inferior epigastric vessels extending to the external iliac vessels. Distal border: superior margin of the
pubis (dashed line). The following structures are located inside the tri-
angle: medial inguinal fossa, supravesical fossa, and femoral canal.
1 Parietal peritoneum
2 Transversalis fascia (with borders of incision)
3 Posterior layer of the rectus abdominis fascia
4 Arcuate line (visible by transparency)
5 Rectus abdominis muscle
6 Iliacus muscle
7 Internal obturator muscle
8 Internal inguinal ring
9 Interfoveolar ligament
10 Conjoint tendon
11 Lateral inguinal fossa
12 Medial inguinal fossa
13 Supravesical fossa
14 Urinary bladder
15 Medial umbilical ligament
16 Right lateral umbilical ligament
17 Left lateral umbilical ligament
18 Peritoneal fold of the epigastric vessels
19 External iliac vessels
20 Inferior epigastric vessels
21 Testicular vessels
22 Ureter
23 Vas deferens
17
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2
4
5
8
23
9
19
22
23
7
1014
20
21
6
Fig. 13.2.2 Schematic diagram of the muscular and vascular lacunae and
femoral canal (Platzer).
1 Inguinal ligament
2 Iliopectineal arch
3 Lacunar ligament
4 Iliopsoas muscle
5 Pectineus muscle
6 Partorius muscle
7 Vascular lacuna
8 Muscular lacuna
9 Femoral canal with femoral septum
10 Femoral artery
11 Femoral vein
12 Deep inguinal lymph node
13 Lateral femoral cutaneous nerve
14 Femoral ner ve
Patient Positioning and Position of the
Operating Team
(Figs. 13.2.3 and 13.2.4).
Complications
Intraoperative Complications
− Arterial or venous bleeding caused by puncture from the
Veress needle or laparoscope/camera trocar.
− Perforation of hollow organs when inserting the Veress
Trocar Placement
(Fig. 13.2.5).
needle or laparoscope/camera trocar.
− Bleeding from the abdominal wall due to injur y of the epiga-
stric vessels during the dissection.
Fig. 13.2.3 Transabdominal preperitoneal hernia repair. Patient positioning.
Place the patient supine with the arm on the hernia side tucked in along-
side the body and the opposite arm extended to provide access for the anesthesiologist. Place the patient in a 20−30° Trendelenburg position so
that the small intestine falls into the upper abdomen.
Complications
419
Fig. 13.2.4 Transabdominal preperitoneal hernia repair. Position of the operating team and equipment.
The surgeon stands on the side harboring the inguinal
hernia; the assistant holding the laparoscope and
another assistant stand on the opposite side of the
patient. The surgeon works with both hands. The
monitor, light source, and insufflator are positioned at
the foot of the operating table. The operating room
nurse stands with the instrument table next to the
surgeon. The electrocautery unit and aspirator/irriga-
tor set can be positioned more or less as desired.
Surgeon
Instrument table
Assistant holding
the laparoscope
Assistant
Electrocautery
unit
Insufflator
Aspirator/
irrigator set
420
13.2 Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair
− Bleeding from the external iliac artery and vein.
− Perforation of the small intestine or colon.
Corrective action: Conversion to an open procedure.
Postoperative Complications
− Postoperative bleeding.
− Undetected intestinal injury with peritonitis and abscess.
− Swelling of the inguinal region due to hematoma or seroma.
T1
T3
− Early recurrence due to implant failure.
Corrective action: Intraabdominal complications must be
corrected immediately by laparotomy. A stable inguinal hematoma or seroma does not usually require treatment. Immediate correction of a recurring hernia is not necessarily
indicated; the time frame and method of the repair are decided on a case-by-case basis.
T2
Fig. 13.2.5 Transabdominal preperitoneal hernia repair. Trocar placement (for inguinal hernia on right side).
T1 10/12-mm laparoscope/camera trocar: inferior margin of umbilicus.
T2 Left instrument trocar (10/12-mm): left lower abdomen, a few centime-
ters inferior to the umbilicus, approximately at the lateral margin of the
rectus abdominis muscle.
T3 Right instrument trocar (10/12-mm): right upper abdomen, a few cen-
timeters superior to the level of the umbilicus, approximately at the
lateral margin of the rectus abdominis muscle.
Open trocar placement is an alternative.
Long-Term Results
Data regarding the incidence of recurrent hernia following laparoscopic repair are not yet available. The reliability of the
method should be assessed on the basis of multi-center studies.
Step-by-Step Procedure
1. Insert the trocars under laparoscopic visualization.
2. Explore the peritoneal cavity and confirm the diagnosis.
3. Make a curved peritoneal incision superior to the hernia orifice at the medial umbilical fold (= remainder of umbilical
cord) extending to a few centimeters lateral to the internal inguinal ring.
4. Completely dissect the peritoneal hernia sac out of the hernia
orifice and dissect the sac off the spermatic cords.
5. Expose the anatomic structures for fixation of the mesh.
6. Cut a polypropylene mesh to size (12 × 8−10 cm).
7. Introduce the rolled mesh into the abdomen through a trocar
reducing sleeve.
8. Roll out the mesh over the hernia orifices.
9. Fix the mesh to the ligaments using a hernia stapler.
10. Close the peritoneum with laparoscopic sutures and/or
staples.
Operative Technique
5
.
.
4
3
Long-Term Results
1
421
.
.
.
2
T2
Fig. 13.2.6 Transabdominal preperitoneal hernia repair. Exposing the
hernia orifice.
With the patient in Trendelenburg position, explore the abdomen with a
30-degree or 45-degree laparoscope. This provides good exposure of the
inguinal region and immediately reveals the location and extent of the
hernia. The anatomic landmarks for the dissection are the lateral umbilical
ligament, the epigastric vessels and their peritoneal fold, the peritoneal
fold over the vas deferens, the peritoneal fold of the spermatic vessels,
and Cooper’s ligament. Indirect inguinal hernias occur through disten-
sions of the internal inguinal ring, appearing as long and narrow to ample
pouches of the peritoneum that extend from lateral and posterior to me-
dial and anterior. The sac is located lateral to the epigastric vessels. The
vas deferens and the testicular artery and vein enter the inguinal canal to-
gether with the indirect hernia sac. Direct inguinal hernias appear as
dome-shaped pouches medial to the epigastric vessels. Femoral hernias
are rare and are located medial to the iliac vessels and superior to the linea
terminalis or Cooper’s ligaments.
1 Peritoneal fold of the epigastric vessels
2 Fold of the testicular artery and vein
3 Fold of the vas deferens
4 Linea terminalis
5 Iliopubic tract with peritoneal covering
Fig. 13.2.7 Transabdominal preperitoneal hernia repair. Incising the peritoneum and dissecting the hernia sac.
Begin the dissection by making a curved incision in the peritoneum superior to the hernia orifice. The peritoneal incision begins a few centimeters
lateral to the internal inguinal ring and courses medially to the lateral
umbilical ligament. Be careful to avoid injury to the epigastric vessels. The
preperitoneal fatty tissue can be dissected off the underlying anatomic
structures relatively easily. Completely removing the peritoneal hernia sac
from the hernia orifice and isolating the spermatic cords is more difficult,
especially in a recurring hernia. Despite this, the hernia sac must be dissected completely off the spermatic cords until it can be folded back into
the abdomen with the flap of incised peritoneum. If there is sufficient peritoneal tissue available for closing the peritoneum later, then part of the
hernia sac mayberesected (seeFig. 13.2.5 for key to instrument numbers).
422
13.2 Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair
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3
4
5
12 cm
8–10 cm
10
6
7
9
8
Fig. 13.2.8 Transabdominal preperitoneal hernia repair. Exposing loadbearing anatomic structures.
Secure fixation of the mesh to close the hernia orifices requires a clean ex-
posure of the load-bearing anatomic structures. Suitable structures me-
dial and superior to the hernia are the semilunar fold of the deep inguinal
ring and the interfoveolar ligament. The semilunar fold is the medial fold
of the transverse fascia into the internal spermatic fascia. The interfoveolar ligament (Hesselbach’s ligament) is a reinforcement of the transverse
fascia connected with the pectineal ligament and with the aponeurosis of
the internal oblique and transversalis muscles. It intersects the iliopubic
tract, a reinforcement of the transverse fascia along the inguinal ligament. Medial to the medial inguinal fossa lies a stronger structure that
may be used for mesh fixation: the conjoint tendon at the lateral margin
of the rectus abdominis muscle. Distal to the hernia site, the pubis and the
pectineal ligament (Cooper’s ligament) can be bluntly exposed with a
swab. Cutting the nonabsorbable mesh to size to fit over these structures
will cover all three possible hernia orifices and provide secure fixation.
1 Lateral umbilical ligament
2 Inferior epigastric artery and veins
3 Interfoveolar ligament
4 Distended internal inguinal ring, semilunar fold
5 Iliopubic tract
6 Testicular artery, pampiniform venous plexus
7 External iliac artery and vein
8 Vas deferens
9 Pectineal ligament
10 Conjoint tendon
Red dashed line indicates Hesselbach’s triangle.
T2
Fig. 13.2.9 Transabdominal preperitoneal hernia repair. Introducing the
mesh.
The polypropylene mesh should be cut to a width of 12 cm and a height of
8−10 cm to completely cover the hernia orifices. Round the corners of the
mesh to fit the anatomy. Then roll the mesh up and introduce it into the
abdomen through a 10-mm reducing sleeve (T2). Unroll the mesh with a
laparoscopic grasper and place it in the inguinal region over the hernia orifices (below).
Fig. 13.2.10 Transabdominal preperitoneal hernia repair. Placing the 컄
mesh.
Using fine laparoscopic graspers or a swab (T2, T3), place the mesh in
front of the potential hernia orifices so as to cover them completely. If the
mesh is too small, replace it with a larger one. The mesh should gener-
ously cover the entire inguinal region.
T2
T3
Long-Term Results
T2
423
Fig. 13.2.11 Transabdominal preperitoneal hernia repair. Attaching the
mesh.
Use a hernia stapler (T2) to attach the mesh. First attach the mesh to the
pectineal ligament, the conjoint tendon, and the semilunar fold by placing single staples. Then continue fixation of the superior and lateral parts
of the mesh, carefully avoiding damage to the epigastric vessels. Here,
the mesh is stapled to the interfoveolar ligament and the iliopubic tract.
Press the mesh against the transverse fascia with the hernia stapler well
applying counter pressure from the outside. Then fire the stapler. Verify
that each staple is properly positioned and seated. Laterally, fix the mesh
to the iliopubic tract and the inguinal ligament. Lift the mesh with forceps
to identify the exact position of the spermatic cord.
Note: The number of staples (or tacks) shown here should only
be used if the “load-bearing” anatomic structures can be clearly
exposed and the mesh can be attached under direct laparoscopic visualization. We have experienced no complications in
such cases. Other surgeons use significantly fewer staples for
fear of possible nerve lesions. This decision should be made in-
traoperatively according to the specific situation encountered
in each patients.
Editor’s note: From the drawings it would appear that the author
believes in the old adage, “two stiches are better than one.”
Most authors would presently feel secure with half or one-third
of the staples (or spiral tacks) shown, and none placed lateral to
the iliopubic tract and lateral to epigastric vessels, to protect the
nerves.
Fig. 13.2.12 Transabdominal preperitoneal hernia repair. Placing the
mesh under the spermatic cords.
An alternative technique is to laterally incise the mesh and pull it under
the spermatic cords and then close the incision with staples or sutures.
The “keyhole” opening in the mesh for the spermatic cord must not be
too narrow. The mesh must be carefully fixed laterally to reduce the risk of
it tearing out.
Fig. 13.2.13 Transabdominal preperitoneal hernia repair. Closing the 컄
peritoneum.
The peritoneum should be closed to eliminate the risk of formation of ad-
hesions between the small intestine and the mesh. A proven technique for
this is to reduce the pneumoperitoneum to 6−8 mm Hg. Using a hernia
stapler alone does not provide a sufficiently reliable closure. A proven
technique is to use laparoscopic sutures with extracorporeal knot-tying
and a knot pusher (T3). After placing several knots to bring the edges of
the peritoneal defect into opposition, staples may be placed with the
hernia stapler to complete the closure.
T3
424
13.3 Complicated Laparoscopic Hernia Repair
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Corbitt jr. JD. Laparoscopic herniorraphy. Surg. Endosc. 1993; 7:550.
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Fromont G, Leroy J. Laparoskopischer Leistenhernienverschluß durch sub-
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Ger R. Laparoskopische Hernienoperationen. Chirurg 1991; 62:266.
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13.3 Complicated Laparoscopic Hernia Repair: Avoiding Complications and Recurrence in Clinical Practice
R. Bittner, B. Leibl, and M. Butters
Transperitoneal laparoscopic hernia repair with preperitoneal
placement of polypropylene mesh is a procedure that can be
standardized and also used to treat large and complex inguinal
hernias. This also applies to large recurrent inguinal hernias extending far into the scrotal space, incarcerated hernias, and recurrent hernias following a previous laparoscopic operation.
Large, chronically irreducible hernias are the only exception for
which we recommend a conventional, open procedure.
The present chapter is concerned with systemic improvements
to overcome two critical features in the safety and performance
of the laparoscopic procedure in these situations:
1. The management of technical, intraoperative difficulties
during the laparoscopic procedure, and
2. The avoidance of complications and recurrences.
Intraoperative Technical Difficulties
Diff icult Access
In patients with short lower abdomens, i. e., a short distance between pubic symphysis and navel, as well as those with bilateral
hernias or a previous midline incision in the lower abdomen, we
place the laparoscope/camera trocar—in deviation from the infraumbilical standard position—superior to the umbilicus.
This technique avoids interference with instruments in the
working trocars. The latter are placed level with the umbilicus
in the midclavicular lines. In the presence of scarring and
possible adhesions an open method for trocar placement should
be employed. If unrestricted access to the abdominal cavity cannot be verified conversion to an open hernia procedure is recommended. If excessive adhesions are found in the regions
planned for the working trocars laparoscopic lysis (Fig. 13.3.1)is
performed prior to insertion of the working trocars.
Cord-like adhesions after local interventions and scarring of the
abdominal wall can usually be easily lysed and are rarely im-
Recurrent Inguinal Hernia
425
Fig. 13.3.1 Adhesions are only lysed as far as is necessary to introduce
the trocar or to gain access to the inguinal region and is easily possible. In
cases with scarred adhesions between stomach and inguinal region, e. g.,
after a perforated appendix, a conventional repair procedure is recom-
mended.
pediments to performing laparoscopic hernia repair. However,
if unusually broad and robust adhesions are present we convert
to an open procedure.
Direct adhesions between bowel loops and the hernia sac are
not lysed separately but are automatically mobilized when the
hernia sac is dissected off its bed.
Local Difficulties in Dissection
For complete dissection of the inguinal region, we generally use
monopolar electrocautery scissors (Metzenbaum type) and
curved laparoscopic scissors, supplemented by a combination
grasper and swab. The dissection is performed in an avascular
area (Fig. 13.3.2). Important anatomic landmarks are the anterior superior iliac spine, epigastric vessels, and the medial
umbilical ligament. The peritoneal incision is made in a wide
arc between the anterior superior iliac spine and the medial
umbilical ligament. The cranial arc is later undermined to ac-
cept the mesh. The medial umbilical ligament should not be
transected because of possible injury to vessels. If the operative
site is constricted and the fold projects anteriorly, the surgeon
can further incise the peritoneum superiorly or inferiorly parallelt to the fold. This improves the exposure of the symphysisand
the retrovesical space.
Dissection of the preperitoneal space is usually effected by a
subperitoneal inflow of CO
. This may be aided by the injection
2
Fig. 13.3.2 Dissection in an avascular region filled only with cobweb-like
adhesions with subtle hemostasis and particular sparing of sheathing fascia, especially spermatic fascia.
of physiological saline (described by Dunn as aqua- or hydrodissection); ultrasound is a further option.
The view revealed by preperitoneal dissection from dorsal to all
structures is unusual and must be learned and practiced.
Recurrent Inguinal Hernia
The particular advantages of the laparoscopic procedure are
clearly apparent in this situation. The dissection is shifted into
the scar-free preperitoneal space, allowing nearly the same
routine procedures as in the treatment of a primary hernia
(Figs. 13.3.3 and 13.3.4). This is also true for the time required
for the repair and its rate of complications.
Difficulties may occur following Lotheisen’s operation; significant scarring of Cooper’s ligament can often not be managed laparoscopically. This situation can still be mastered by using an
arc-like peritoneal incision of the medial and caudal area to
again reach scar-free preperitoneal tissue. The peritoneumcovered scar region is left intact for later use to anchor the propylene mesh.
A thick layer of scar tissue in the inner inguinal ring may surround the hernia sac and spermatic cord structures (Fig. 13.3.5).
This ring is transected right next to the epigastric vessels. The
hernia sac can then be easily dissected out of the inguinal canal
and off the spermatic cord and its vessels.
426
13.3 Complicated Laparoscopic Hernia Repair
Fig. 13.3.3 Laparoscopic view of a direct recurrent hernia before dissec-
tion of the peritoneal flaps. The scarring near the inner inguinal ring is
clearly visible.
Fig. 13.3.5 Scar tissue in the region of the inner inguinal ring in an in-
direct recurrent hernia.
Fig. 13.3.4 Same patient as in Fig. 13.3.3. After complete dissection of
the inguinal region and exposure of anatomic structures (direct hernial
canal, Cooper’s ligament, deferent duct, and testicular vessels as well as
the peritoneal reflexion).
Prior to this hernia sac dissection, complete exposure of the medial (symphysis, pubis, Cooper’s ligament, iliac vein; Fig. 13.3.6)
and lateral (iliopubic tract, psoas muscle, iliac artery; Fig. 13.3.7)
abdominal wall structures is recommended. Attention should
also be paid to the existing nerve structures (Fig. 13.3.8). Even in
obese patients all important and endangered structures, including the vas deferens and the testicular vessels can usually be exposed (Fig.13.3.9). Topographical displacements of the spermatic cord structures in particular may have resulted from previous operation. In addition, recurrent hernias can develop between the vas deferens and the testicular vessels and displace
these structures medially and laterally, respectively
(Fig. 13.3.10). In rare cases, the testicular vessels may also be
found twisted anteromedially around the spermatic cords
(Fig. 13.3.11).
All of these difficulties pertain almost exclusively to indirect re-
current inguinal hernias. The situation with direct recurrent
hernias is more simple since there are no structures that can be
injured in the immediate vicinity.
Scarring following transabdominal prostate surgery may present a particular problem. In this case, after precisely dissecting
the epigastric vessels, we recommend dissecting in the craniocaudal direction with curved scissors immediately anterior to
the transverse fascia and the rectus muscle.
Large (Scrotal) Hernia
The laparoscopic procedure is only recommended for hernias
that can be reduced. Possible adhesions between the contents
Large (Scrotal) Hernia
427
Fig. 13.3.6 Anatomic dissection of the medial compartment, exposing
the iliac vessels, epigastric vessels, and the anastomosing branch (corona
mortis) to the obturator vessels.
Fig. 13.3.7 Anatomic dissection of the lateral compartment, exposing
the inner inguinal ring, iliopubic tract, spermatic cord, and iliac vessels.
Fig. 13.3.8 Anatomic dissection of the lateral compartment below the
iliopubic tract, exposing the very variable nerve courses (lateral femoral
cutaneous nerve, genitofemoral nerve) and the peritoneal reflexion.
Fig. 13.3.9 Completed dissection of the inguinal region with the
detached peritoneal sac visible caudally (parietalization).