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Minimally Invasive Inguinal Hernia Repair: TAPP, TEP, andeTEP Approaches
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4.2.4 Mesh Placement andClosure
Mesh placement continues in the standard fashion as above, positioned over the
myopectineal orice (Table1) and covering direct, indirect, femoral and obturator
spaces widely. Ports are removed as the space is de-sufated. The anterior fascia is
then closed with a 2-0 PDS and all skin incisions are closed with 4-0 Monocryl and
skin glue.
References
1. Gass M, Banz VM, Rosella L, Adamina M, Candinas D, Guller U.TAPP or TEP? Population-
based analysis of prospective data on 4,552 patients undergoing endoscopic inguinal hernia
repair. World J Surg. 2012;36(12):2782–6. https://doi.org/10.1007/s00268- 012- 1760- 4.
2. Kingsnorth A, LeBlanc K.Hernias: inguinal and incisional. Lancet. 2003;362(9395):1561–71.
https://doi.org/10.1016/S0140- 6736(03)14746- 0.
3. HerniaSurge G. International guidelines for groin hernia management. Hernia.
2018;22(1):1–165. https://doi.org/10.1007/s10029- 017- 1668- x.
4. Daes J, Felix E.Critical view of the myopectineal orice. Ann Surg. 2017;266(1):e1–2. https://
doi.org/10.1097/SLA.0000000000002104.
5. Aiol A, Cavalli M, Ferraro SD, etal. Treatment of inguinal hernia: systematic review and
updated network meta-analysis of randomized controlled trials. Ann Surg. 2021;274(6):954–61.
https://doi.org/10.1097/SLA.0000000000004735.
6. Ortenzi M, Williams S, Solanki N, Guerrieri M, Haji A.Laparoscopic repair of inguinal hernia:
retrospective comparison of TEP and TAPP procedures in a tertiary referral center. Minerva
Chir. 2020;75(5):279–85. https://doi.org/10.23736/S0026- 4733.20.08518- 1.
7. Bansal VK, Krishna A, Manek P, et al. A prospective randomized comparison of testicular
functions, sexual functions and quality of life following laparoscopic totally extra-peritoneal
(TEP) and trans-abdominal pre-peritoneal (TAPP) inguinal hernia repairs. Surg Endosc.
2017;31(3):1478–86. https://doi.org/10.1007/s00464- 016- 5142- 0.
Ventral Hernia Repair- Preperitoneal
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andUnderlay
PatrickMcCarty andAlisaM.Coker
1 Denitions
We dene the preperitoneal space as the anatomic space between the parietal peritoneum and the fascia. Underlay mesh placement for ventral hernia repair occurs in
either the preperitoneal space or the intraperitoneal space deep to the fascia and
peritoneum (Fig.1). Intraperitoneal mesh placement is historically referred to as
intraperitoneal onlay mesh (IPOM) [1]. Recently, some surgeons favor the term
intraperitoneal underlay mesh (IPUM), which we will use to more accurately reect
the mesh position.
A primary ventral hernia occurs at a location not associated with a previous surgical incision. These include, for example, umbilical and epigastric hernias.
Incisional hernias occur at the site of a prior fascial incision. Off-midline ventral
hernias, like Spigelian or ank hernias, will be covered in a separate chapter.
P. McCarty
General Surgery Medical Group of Ventura County, Oxnard, CA, USA
A. M. Coker (
Johns Hopkins University School of Medicine, Baltimore, MD, USA
e-mail: acoker5@jhmi.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_36
*)
423© The Author(s), under exclusive license to Springer Nature
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Rectus abdominis
b
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Peritoneum
a
Fig. 1 Mesh Positions: (a) Pre-peritoneal mesh and (b) Underlay
Abdominal cavity - could draw top of bowel
P. McCarty and A. M. Coker
2 Surgical Technique
VHR may involve primary suture repair of the hernia, the use of a bridging mesh
without defect closure, or repair of the hernia defect using prosthetic mesh.
Primary repair of ventral hernias without the use of mesh has fallen out of favor,
apart from small, <1cm primary umbilical or epigastric hernias. Primary sutured
repair can be considered for small hernia defects, and in such a setting, a nonabsorbable or slowly resorbable suture should be used [2]. The placement of mesh
by either a minimally invasive or open technique decreases hernia recurrence compared to primary suture repair [3]. Given this decreased recurrence, surgeons routinely use mesh reinforcement with most hernia repairs [4, 5].
There are many described techniques for VHR which utilize the preperitoneal
space and underlay positions. Below we describe open, laparoscopic, and robotic
surgical modalities.
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2.1 Open
In open primary suture repair, the surgeon makes an incision over the hernia and
exposes the hernia sac and surrounding fascia. For an umbilical hernia, a curvilinear
incision is made either infraumbilical or supraumbilical, ideally in a position that
allows for dissection of the hernia sac away from the stalk without need to dissect and
transect the base of the stalk from the fascia to expose the hernia sac. For other midline
hernias, the incision is often oriented transversely to allow for elongation of the incision as needed. Soft tissue attachments are then divided. The anterior fascia is cleared
of soft tissue circumferentially around the hernia defect. The hernia sac is generally
maintained and reduced, taking down attachments to the fascia with cautery or scissors. Some surgeons favor excision of the sac. Opening the hernia sac may be necessary to inspect bowel in the setting of incarceration or strangulation, or to divide
incarcerated preperitoneal or omental fat. Once opened, the hernia sac should be closed
if possible. Protruding omental or pre-peritoneal fat can be reduced or ligated. The
preperitoneal space is developed bluntly and with limited cautery to small vessels to
allow for safe passage of suture, and the fascia is closed with non- adsorbable or slowly
resorbable sutures. These authors favor interrupted gure-of- eight sutures (Fig.2).
Mesh reinforcement in the open setting follows the same basic steps but the surgeon places prosthetic mesh into the preperitoneal space once dissected. The mesh
is attened into the space to avoid kinking, which can lead to recurrence. Suture is
passed through the fascia and back, in a mattress fashion, incorporating a small bite
of the mesh. Alternatively, interrupted sutures can be placed in close proximity,
often aided by “parachuting” the mesh into place. Types of mesh will be discussed
later. In short, if the peritoneum is not intact, then a coated mesh should be used. If
the peritoneum is intact, then the surgeon can deploy the mesh with which they feel
most comfortable. In addition to at mesh, there are several commercially available
mesh products designed for this space that have functions to assist with at deployment and securement. Once the mesh sits at in the preperitoneal space, the overlying fascia is closed. Some surgeons prefer to xate the tails of certain types of mesh
to the fascial defect, allowing for less tension on the repair. Others incorporate the
tails into the fascial closure [6]. Intraperitoneal mesh can also be placed, for instance,
if the peritoneum is obliterated by prior incision. Lysis of adhesions should precede
intraperitoneal mesh placement so that the mesh sits at.
2.2 Laparoscopic
Karl Leblanc described the rst laparoscopic ventral hernia repair in 1992 and
numerous techniques have since evolved [1]. These include hybrid approaches,
IPUM, IPUM with defect closure (“IPUM plus”), the “shoelace” technique, and
transabdominal preperitoneal (TAPP). Placement of mesh is integral to a sound
laparoscopic repair.
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c
d
e
Fig. 2 Open umbilical hernia repair technique: (a) Curvilinear incision, (b) Separation of hernia
sac from overlying umbilical skin, (c) Opening of sac to reduce incarcerated omental fat, (d)
Exposure of fascia around defect, and (e) Closure of defect
The hybrid approach involves the standard open approach as described above,
with placement of laparoscopic trocars to allow for tacking of the mesh to the peritoneum [7]. Both absorbable and permanent laparoscopic tacks exist. Based on data
from a systemic review and meta-analysis, there is no difference between the two in
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Fig. 3 Port placement for
laparoscopic
intraperitoneal underlay
mesh ventral hernia repair
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terms of recurrence, chronic pain, seroma, hematoma, ileus, or hospital length of
stay [8]. This technique allows for excellent defect approximation and a wide mesh
overlap that may be difcult to obtain from an open technique alone.
A standard intraperitoneal underlay mesh laparoscopic ventral hernia repair
(LVHR) occurs with the patient in the supine position, with arms tucked. Abdominal
access is gained using the surgeon’s preferred method, commonly at Palmer’s point
or away from prior incisions. Additional trocars are placed, generally through the
lateral abdominal wall, to allow triangulation of the hernia defect. Trocars are placed
on one or both sides of the abdomen (Fig.3). Placement on both sides of the abdomen allows for more facile tacking or suturing of the mesh at the expense of additional port sites. For larger hernias needing larger mesh pieces, having one 12mm
port allows for easier mesh introduction. All anterior abdominal wall adhesions to
the hernia should be taken down prior to hernia repair to allow for at mesh deployment directly on the fascia. Sharp dissection is preferred to reduce the risk of thermal injury to the bowel. Measurement of the hernia defect can be performed with a
ruler placed into the peritoneum, by use of an umbilical tape, or by passing a spinal
needle trans-abdominally. Ideally, mesh size will allow for overlap of the hernia
defect by 5 cm in all directions. Insertion of mesh usually requires a 12 mm or
15mm trocar. If a lateral trocar is up-sized for this purpose, the risk for incisional
hernia increases and the defect should be closed at end of case. Alternatively, placement of the larger trocar closer to the hernia defect is an option which will allow for
mesh to cover the trocar site as well. Various rolling techniques are employed by the
surgeon to insert the mesh into the abdomen and to maintain orientation of the mesh
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P. McCarty and A. M. Coker
a
b
c
Fig. 4 Laparoscopic IPUM technique: (a) Reduction of hernia contents, (b) Measurement of
defect using a ruler, (c) Use of a laparoscopic tacker to secure the mesh
once unrolled, while avoiding shearing off any anti-adhesion coating. Previously
placed sutures at the cardinal directions of the mesh allow for transabdominal passage of the sutures through stab incisions using a suture-passing device. Insufation
pressure can be lowered as the sutures are tied down to ensure the mesh is pulled
taught along the peritoneum. Alternatively, commercially available mesh positioning systems are available. Circumferential tacks are placed near the edge of the
mesh. More tacks, or additional transabdominal sutures, can be placed along the
interior of the mesh to ensure it does not migrate (Fig.4). Some authors advocate
for the “double crown” method of placing tacks as opposed to using tacks and transfacial suture, noting similar recurrence rates at 2years [9].
Eventration of the mesh is a concern in LVHR in the setting of bridging IPUM
without hernia defect closure [10, 11]. The incidence of mesh bulging eventration
after bridging IPUM is higher than after IPUM with defect closure [12]. The mechanism leading to mesh eventration is the Law of Laplace, where there is increased
wall tension across the thinner, nonfunctioning portion of the abdominal wall containing the hernia sac. This leads to the patient seeing a bulge and ultimately a poor
functional outcome as well. In addition to preventing eventration, some authors
advocate for routine closure of the hernia defect prior to mesh placement due to the
decreased risk of surgical site events, seroma and recurrence [13]. Longer-term data
is necessary to conrm the ndings of decrease recurrence, but we have observed
trends towards routine closure for larger defects.
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There are several methods to close the defect in LVHR.Running suture can be
used to close the hernia defect with laparoscopic suturing. The use of barbed sutures
facilitates reliable closure [14]. The Endostitch device (Covidien, Dublin, Ireland)
provides an alternative method of sutured fascial closure that some surgeons prefer.
The so-called “shoelace” closure technique allows for multiple transfascial sutures
to be placed during LVHR, both to close the hernia defect and for additional buttress
sutures [15]. The edges of the defect are marked on the patient’s skin using a spinal
needle. Starting at each end of the defect, suture is passed through a stab incision in
the middle of the hernia bulge and into the fascia. The surgeon grasps the suture
with a laparoscopic instrument, and the suture passer is brought through the fascia
on the contralateral side of the defect. The suture is grasped and pulled all the way
out through the stab incision. The suture is brought back through the same stab incision and through both sides of fascia again before pulling out through the incision
to complete a gure-of-eight suture. Additional gure-of-eight permanent suture
are passed through the fascia, at intervals of the surgeons choosing, until the hernia
is closed. Sutures are tied down at the end, ideally with reduced pneumoperitoneum,
under direct laparoscopic vision to avoid inadvertent injury to the underlying bowel
or omentum. Mesh placement follows the fascial closure, as described above, with
tacks or transfascial sutures. Buttressing U-stitches can be placed through the mesh,
adjacent to the fascial closure to ofoad tension if desired [16].
Transabdominal preperitoneal ventral hernia repair is feasible in the hands of a
highly skilled laparoscopic surgeon. This involves creation of a preperitoneal ap
and primary closure of the hernia defect. The adoption of this repair has been growing with the adaptation of robotic assisted surgery and we describe the technique below.
There are times when a LVHR will not be ideal. The Society of American
Gastrointestinal and Endoscopic Surgeons (SAGES) recommends against laparoscopic repair in the setting of loss of domain, presence of abdominal skin grafts,
active entero-cutaneous stulas, or need to remove previously placed prosthetic
mesh [17].
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2.3 Robotic
The robotic platform can be utilized to perform an IPUM repair similar to that of
LVHR.Port placement is typically on one side of the abdomen for centrally located
defects (Fig.5).
As with a laparoscopic repair, one of the trocars can be upsized to 12mm or an
assistant 12mm port can be placed to allow for easy mesh placement, but this isn’t
always necessary with smaller or light weight mesh. Most surgeons choose to close
the defect given it is a relatively easy task with the robotic assistance. This is accomplished with a running barbed suture. The mesh is then deployed such that the defect
has an overlap of 5 cm in all directions. The mesh needs to be held up to the
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Fig. 5 Port placement for
a robotic IPUM or TAPP
ventral hernia repair when
the defect is centrally
located
P. McCarty and A. M. Coker
Fig. 6 Robotic IPUM technique: (a) Measurement to determine mesh size for appropriate overlap,
(b) Suturing to close the defect, (c) Suturing to secure the mesh, (d) Final result with mesh in place
abdominal wall while suturing occurs. This can be accomplished with needles to
temporarily tack the mesh up, transfacial sutures, or a commercially available positioning device. Some surgeons prefer transfascial sutures, either in the center of the
mesh near the hernia defect, or near the edges at the cardinal directions, to distribute
the tension evenly. A running suture is then used to circumferentially secure the
mesh to the anterior abdominal wall (Fig.6).
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For surgeons that prefer to avoid intra-abdominal mesh placement and instead
utilize the pre-peritoneal space, the robotic platform can facilitate this. Here we
describe the standard transabdominal preperitoneal (TAPP) robotic ventral hernia
repair (rVHR).
Positioning is important to enable all arms to have sufcient room to work, while
also allowing for adequate intraabdominal space to operate. After induction of general anesthesia, the patient is placed with the top of the hip at the break in the bed
with arms tucked. Flexing the bed increases the distance between the costal margin
and iliac crest so that three robotic trocars can be placed along the lateral abdomen.
Tucking the arm in a way that it can hang slightly lower than the bed, while still
supported and padded, sometimes helps to prevent the robot from colliding with the
patient’s arms while working on the anterior abdominal wall. When planning a
robotic VHR approach, the trocars should be placed as far lateral as possible, taking
into consideration that a peritoneal ap will be 5cm from the hernia defect, and the
trocars should be 6–8 cm apart. Consider obtaining pneumoperitoneum prior to
trocar placement as the insufation pressure provides more space for trocar placement. A bariatric length trocar can be considered when near the iliac crest as the
extra length facilitates better range of motion up to the anterior abdominal wall
while avoiding collisions. Lateral trocar positioning is reasonable for most midline
ventral hernias. However, developing the peritoneal ap laterally may prove challenging in cases of thin peritoneum as you move further from midline. For this
reason, some surgeons prefer epigastric port placement, particularly for umbilical or
lower midline hernias (Fig.7). The preperitoneal space over the falciform ligament
Fig. 7 Epigastric
placement of robotic ports
for the repair of an
infraumbilical hernia
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