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Fig. 15.19 Slightly different view of the position of the Wantz prosthesis. Points D, E, and F are equivalent to 4, 5, and 6 in this fi gure
26515 Extraperitoneal or Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
Fig. 15.20 Final position of the prosthesis in unilateral GPRVS. The
prosthesis extends far beyond the borders of the dotted outline of the
MPO
Fig. 15.21 View from within the pelvis of the fi nal position of the
prosthesis in unilateral GPRVS. This is essentially the same as the position of the mesh in laparoscopic repair, extending far beyond the borders of the MPO
Fig. 15.22 Location of the small incision for the Kugel repair of inguinal hernia. The left and right dots denote the pubic tubercle and the
anterior iliac spine. The incision is positioned between these two
structures
through a small incision could be problematic. The presence of
even a small hematoma was likely to prevent the mesh from sitting properly and would compromise the repair. The learning
curve is possibly less than for laparoscopic repair, but most surgeons will still not wish to, or have the opportunity to, invest the
time in attaining technical pro fi ciency. The procedures have
ef fi cacy, but probably not much effectiveness, as can be seen from
some of the results below, and in this era of laparoscopic surgery,
one might question whether they have any use in the hands of
anyone apart from their original developers.
266 M. Kurzer
Fig. 15.24 Preperitoneal view showing fi nal position of the Kugel
patch (reprinted from Am J Surg. 1999;178:298–302 with permission)
Fig. 15.23 Insertion of the patch is simpli fi ed by using a malleable
retractor as a shoehorn
Fig. 15.25 The skin incision ( f ) for Ugahary’s operation. Surface anat-
omy: ( a ) inguinal ligament, ( b ) femoral artery, ( c ) lateral border of the
rectus muscle, ( d ) line perpendicular to the inguinal ligament from the
femoral artery, and ( e ) the deep or internal ring
Results
Nyhus, reporting his preperitoneal approach and prosthetic
buttress repair for recurrent hernia, assessed 203 operations
in 195 patients [
most patients, no perioperative antibiotics were given, and
9 ] . Regional anesthesia was used in
Fig. 15.26 Ugahary operation—insertion and positioning of the rolled
up prosthesis
long-term follow-up was available for 115 hernias (56%) in
102 patients (52%) over a period of 6 months to 10 years.
Eight patients had repeat recurrences at a mean of 30 months
after repair, but only two of these (1.7% of those who followed up) have recurred after sutured repair supplemented
with mesh buttress. The other six recurrences occurred in an
earlier experience when no mesh buttress was being used.
This was just before the start of the laparoscopic era, and the
authors felt strongly that the preperitoneal approach for
recurrent groin hernia with reinforcing mesh buttress should
be the procedure of choice for all recurrent groin hernias.
Stoppa et al. published an early report of the GPRVS
procedure in English in 1975 [ 22 ] , and more detailed reports
from the Amiens group appeared in 1984 and 1986 [
23, 24 ] .
The initial report was of 255 operated patients, with 218
(84.2%) having a completely uncomplicated postoperative
course. The hematoma rate was 7.9%, and the local sepsis
26715 Extraperitoneal or Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
Fig. 15.28 Final position of the mesh
Fig. 15.27 Use of both retractors to spread and position the mesh
rate was 5.8%. These were excellent results, especially for
that era, particularly when one realizes that many of these
early patients were elderly or poor risk and had undergone
multiple previous operations. Later results in a larger series,
with a follow-up of 91.3% at 2–10 years, revealed a recurrence rate of 2.5%. These fi gures were probably an order of
magnitude better than the general results obtained by general surgeons at that time. Stoppa’s reported recurrence rate
using this technique eventually fell to an amazing 1.4%
[ 25 ] . In general it seemed that the recurrences tended to
occur during the fi rst postoperative year, indicating that the
pattern of recurrence does not follow the same course as
anterior repairs, and is likely to be related to technical problems [ 26 ] . Very few of the infections were deep and related
to the prosthesis, and almost all resolved with antibiotics
without the need for mesh removal. Rignault, utilizing a
large piece of mesh without closure of hernial defects,
reported similar results; during a 14-year period, 767
patients, of which 239 were recurrent, underwent preperitoneal prosthetic inguinal hernia repair with a 2% sepsis rate
and a 1.2% recurrence rate [ 12 ] . Once again, most recur-
rences were seen within the fi rst postoperative year and
were related either to sepsis or to technical mistakes made
by inexperienced surgeons. Wantz’s results were equally
impressive. An early series of 358 patients with recurrent
hernias revealed a recurrence rate of 4.4% [ 13 ] . Wantz felt
that most of the recurrences were related to technical problems and inadequately sized mesh, and modi fi ed these
accordingly [
17 ] .
Other groups have reported similar results. Mozingo and
colleagues treated 100 recurrent hernias in 84 men, with
three re-recurrences occurring within 6 months of surgery at
a follow-up of 6 months to 5 years. They reported few complications and no testicular complications [
26 ] . Two random-
ized trials have compared laparoscopic with open
preperitoneal mesh for bilateral [ 26 ] and a mixed group [ 27 ]
of groin hernias and found no signi fi cant difference in shortterm recurrence rates. Beets et al. [ 28 ] compared laparo-
scopic repair with open preperitoneal mesh for recurrent
hernia in 75 patients with 150 hernias (24 primary and 126
recurrent) using Marlex mesh. Recurrence rates were 2% for
open and 12% for laparoscopic, and the authors commented
that, of the two, they found the open repair an easier procedure with a shorter learning curve. Kurzer [ 20 ] reported the
results of its use in recurrent hernia only—101 consecutive
patients with 114 recurrent inguinal hernias—and reassessed
the patients 4 years postoperatively. There were fi ve recurrences in total, all occurring within 6 months of surgery. Four
of the recurrences were in the fi rst 20 cases, prompting a
modi fi cation of the technique. Hoffman [ 29 ] used the tech-
nique in 175 patients with 152 primary and 52 recurrent
inguinal hernias. There was one recurrence, and wound complications occurred in 12 patients (5.9%). It is important
however to carry out the operation correctly. One retrospective study of 112 patients found a recurrence rate of 32%
[ 30 ] . In the main, virtually all studies of the open preperitoneal mesh repair have con fi rmed the short learning curve and
excellent results of the open preperitoneal mesh repair.
Ugahary’s gridiron operation has not been widely adopted,
though the Kugel hernioplasty was supported by a number of
recent publications from other surgical groups (see below).
Ugahary himself reported on 427 hernia repairs in 364
patients operated over a 3-year period [
21 ] . There were seven
recurrences, though we are not told the length of follow-up,
and four of the recurrences were technical problems occurring in the fi rst week after surgery.
268 M. Kurzer
Kugel’s own results were excellent. As originally reported,
he had a recurrence rate of 0.62%, ( fi ve recurrences in 808
patients) though a later study gave an overall recurrence rate
of 0.4% [ 14 ] . In all cases recurrence was due to the lower
edge of the mesh lifting away from the posterior abdominal
wall allowing the hernia to recur underneath the patch, all
within the fi rst 6 months. Because of this, the prosthesis was
placed in a more posterolateral position. Other surgeons did
adopt this procedure and maintained that it was a safe and
effective operation, with short operative times, low complication rates, “minimal” post-op pain, and a rapid return to
normal activities [
31, 32 ] . Fenoglio reported a large retro-
spective series—a recurrence rate of 0.47% in 1,072 hernias
with a follow-up of 2–47 months—and van Nieuwenhove’s
was a multicenter prospective study in 450 patients with a
1.9% recurrence at a mean follow-up of 18 months. The
claimed advantages are a preperitoneal inguinal hernia repair
without the need for general anesthesia or expensive laparoscopic equipment [ 33 ] and possibly less discomfort than the
Lichtenstein repair [ 34 ] .
The Ugahary procedure is however a technically demanding procedure, and one study of 355 patients with six surgeons revealed an overall re-recurrence rate of 18%, almost
30% for recurrent hernias, and an estimated learning curve
of at least 36 cases [ 35 ] . The authors concluded, understand-
ably, that the recurrence rate was “unacceptably high” and
that the procedure “may not be suitable for repair of recurrent inguinal hernias or primary large direct inguinal
hernias.”
Conclusion
The open preperitoneal approach provides excellent access
to, and views of, the MPO. It thus permits inspection of all
potential groin hernia sites. It avoids reoperating through the
distorted anatomy and scar tissue that are present after a
failed anterior operation, and the risk of damage to the testicular vessels is minimized. Does it have a place in the laparoscopic era?
The learning curve is probably shorter than for laparo-•
scopic repair, and major vessel or visceral injury is less
likely.
It requires no expensive specialized equipment and there-•
fore has signi fi cant economic advantages.
It can be used in patients un fi t for general anesthesia—•
Kugel or Ugahary.
It remains arguably the best operation for strangulated •
femoral hernia.
It is probably the best procedure for dealing with incar-•
cerated recurrent hernias and large sliding inguinal
hernias.
It is probably the best procedure for repairing large recur-•
rent inguinal hernias with tissue loss, for example, absent
inguinal ligament.
It serves as an excellent “stepping stone” to laparoscopic •
TEP repair, providing a means of familiarizing trainees
with the complex anatomy of the preperitoneal space.
While the majority of preperitoneal mesh hernia repairs
will admittedly be carried out laparoscopically, the open preperitoneal repair of groin hernia remains an important and useful technique and should have a place in the armamentarium
of every surgeon who professes an interest in hernia surgery.
References
1. Cheatle GL. An operation for radical cure of inguinal and femoral
hernia. Br Med J. 1920;2:68–9.
2. Henry AK. Operation for femoral hernia by a midline extraperito-
neal approach: with a preliminary note on the use of this route for
reducible inguinal hernia. Lancet. 1936;1:531–3.
3. Read RC. Use of the preperitoneal space in inguinofemoral hernior-
rhaphy. In: Bendavid R, et al., editors. Historical considerations.
Abdominal wall hernias. Principles and management. New York:
Springer-Verlag; 2001. p. 11–15.
4. Nyhus LM, Condon RE, Harkins HN. Clinical experience with pre-
peritoneal hernia repair for all type of hernia of the groin. Am J
Surg. 1960;100:234.
5. Read RC. Preperitoneal exposure of inguinal herniation. Am J Surg.
1968;116:653.
6. Rives J. Surgical treatment of the inguinal hernia with Dacron
patch: principles, indications, technique and results. Int Surg.
1967;47:360–2.
7. Stoppa RE, Petit J, Henry X. Unsutured Dacron prosthesis in groin
hernias. Int Surg. 1975;60:411–2.
8. Wantz GE. Testicular atrophy as a sequela of inguinal hernioplasty.
Int Surg. 1986;71:159–63.
9. Nyhus LM. Iliopubic tract repair of inguinal and femoral hernia: the
posterior preperitoneal approach. Surg Clin North Am. 1993;
73:487.
10. Arlt G, Schumpelick V. [Transinguinal preperitoneal mesh-plasty
(TIPP) in management of recurrent inguinal hernia]. Chirurg.
1997;68:1235–8.
11. Pelissier E, et al. Inguinal hernia: a patch covering only the myo-
pectineal ori fi ce is effective. Hernia. 2001;5:84–7.
12. Rignault DP. Properitoneal prosthetic inguinal hernioplasty through
a Pfanenstiel approach. Surg Gynecol Obstet. 1986;163:465–8.
13. Wantz GE. Giant prosthetic reinforcement of the visceral sac. Surg
Gynecol Obstet. 1989;169:408–17.
14. Kugel RD. Minimally invasive, nonlaparoscopic, preperitoneal, and
sutureless inguinal herniorrhaphy. Am J Surg. 1999;178:298–302.
15. Ugahary F, Simmermacher RKJ. Groin hernia repair via a gridiron
incision: an alternative technique for preperitoneal mesh insertion.
Hernia. 1998;2:123–5.
16. Fruchaud H. Anatomie chirurgicale des hernies de l’aine. Paris:
G. Doin; 1956.
17. Wantz GE. Prosthetic repair groin hernioplasties. In: Wantz GE,
editor. Atlas of hernia surgery. New York: Raven Press; 1991. p.
94–151.
18. Schumpelick VCJKU. [Preperitoneal mesh-plasty in incisional her-
nia repair. A comparative retrospective study of 272 operated incisional hernias] [German]. Chirurg. 1996;67:1028–35.
26915 Extraperitoneal or Preperitoneal Open Repair of Groin Hernias Using Prosthetic Reinforcement
19. Stoppa R, et al. The use of dacron in the repair of hernias of the
groin. Surg Clin North Am. 1984;64:269–85.
20. Kurzer M, Belsham PA, Kark AE. Prospective study of open preperitoneal mesh repair for recurrent inguinal hernia. Br J Surg.
2002;89:90–3.
21. Ugahary F. The gridiron hernioplasty. In: Bendavid R, Abrahamson
J, Arregui M, et al., editors. Abdominal wall hernias. Principles and
management. New York: Springer-Verlag; 2001. p. 407–11.
22. Stoppa R, et al. Prosthetic repair in the treatment of groin hernias.
Int Surg. 1986;71:154–8.
23. Stoppa R. The preperitoneal approach and prosthetic repair of groin
hernias. In: Nyhus LM, Condon RE, editors. Hernia. Philadelphia:
Lippincott; 1995. p. 188–210.
24. Lowham A, et al. Mechanisms of hernia recurrence after preperitoneal mesh repair. Ann Surg. 1997;225:422–31.
25. Mozingo D, et al. Properitoneal synthetic mesh repair of recurrent
inguinal hernias. Surg Gynecol Obstet. 1992;174:33–5.
26. Velasco J. Preperitoneal bilateral inguinal herniorrhaphy; 1996.
27. Champault GG, Rizk N, Catheline J-M. Totally preperitoneal
laparoscopic approach versus Stoppa operation: randomized trial of
100 cases. Surg Laparosc Endosc. 1997;7:445–50.
28. Beets GL, et al. Open or laparoscopic preperitoneal mesh repair for
recurrent inguinal hernia? Surg Endosc. 1999;13:323–7.
29. Hoffman H, Traverso A. Preperitoneal prosthetic herniorrhaphy;
one Surgeon’s Successful Technique. Arch Surg. 1993;128:
964–70.
30. Schaap HM, van de Pavoordt HDWM, Bast TJ. The preperitoneal
approach in the repair of recurrent inguinal hernias. Gynecol Obstet.
1992;174:460–4.
31. Fenoglio ME, et al. Inguinal hernia repair: results using an open
preperitoneal approach. Hernia. 2005;9:160–1.
32. van Nieuwenhove Y, et al. Open, preperitoneal hernia repair with
the Kugel patch: a prospective, multicentre study of 450 repairs.
Hernia. 2007;11:9–13.
33. Baroody M, Bansal V, Maish G. The open preperitoneal approach
to recurrent inguinal hernias in high-risk patients. Hernia.
2004;8:373–5.
34. Nienhuijs S, et al. Pain after open preperitoneal repair versus lichtenstein repair: a randomized trial. World J Surg. 2007;9:1751–7.
35. Schroder D, et al. Inguinal hernia recurrence following preperitoneal Kugel patch repair. Am Surg. 2004;70:132–6.
36. Stoppa R. Reinforcement of the visceral sac by a preperitoneal
bilateral mesh prosthesis in groin hernia repair. In: Bendavid R,
Abrahamson J, Arregui ME, Flament JB, Phillips EH, editors.
Abdominal wall hernias: principles and management. New York:
Springer; 2001. p. 428–36.
Laparoscopic Inguinal Hernia Repair
Karl A. LeBlanc , Brent W. Allain Jr.,
and William C. Streetman
1 6
Introduction
The fi rst report of a hernia repair using laparoscopy was
made by Ralph Ger in 1982 [
rect 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 states that the
fi rst patient to be treated by laparoscopic closure of the neck
of the sac was under the care of Dr Fletcher of the University
of 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 all
potential hernia sites 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 fi brous 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 mini-
mal dissection by leaving the hernia sac in situ and covering the defect with mesh, which is stapled to the surrounding
1 ] . In a patient with right indi-
peritoneum. The major concerns with this repair are the
risk of injury to underlying structures from staples and of
obstruction or fi stula formation as a result of adhesions
between bowel and exposed mesh. These concerns had
resulted in this repair being performed in only a few centers.
Other materials, such as expanded polytetra fl uorethylene,
are thought less likely to cause adhesions and were also
being investigated with this repair [ 6, 7 ] . Currently, how-
ever, this technique is seldom utilized in inguinal hernia
repair.
The laparoscopic approach for the repair of inguinal hernias is achieving success and there are many 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 [ 8 ] and recurrent inguinal hernias after a
prior laparoscopic repair [ 9 ] . There seems to be a trend to
limit the use of this technique in those inguinal hernias that
are bilateral and/or recurrent. This trend, however, does not
take into account patient preference, surgical training, and
the need to maintain a good level of skill or performance for
those already undertaking the operation. Conversely, the
laparoscopic hernioplasty for incisional and ventral hernias
is increasing in popularity. It might possibly become the
standard of care for this problem given the results that have
been seen thus far.
Extraperitoneal Operation
Anesthesia
K. A. LeBlanc (*) • B.W. Allain Jr. • W.C. Streetman
Surgeons Group of Baton Rouge/
Our Lady of the Lake Physician Group ,
Baton Rouge , LA , USA
e-mail: Karl.LeBlanc@ololrmc.com
A.N. Kingsnorth and K.A. LeBlanc (eds.), Management of Abdominal Hernias,
DOI 10.1007/978-1-84882-877-3_16, © Springer Science+Business Media London 2013
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
271
272 K.A. LeBlanc et al.
respiratory and cardiovascular changes that occur with
extraperitoneal CO
insuf fl ation are minimized. These
2
changes are similar to or less than those observed with intraperitoneal CO
the space created during the preperitoneal dissections [
insuf fl ation, and may be related to the size of
2
10 ] .
All patients undergoing totally extraperitoneal hernia repair
receive DVT prophylaxis. 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 fi rst-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 theatre. Alternatively, a urinary catheter could be inserted but this is generally unnecessary. 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. 16.1 ). If two
monitors are being used, one should be placed at either side
of the lower end of the operating table.
Fig. 16.1 Position of operator, assistants, and television monitor at the
operating table for repair of a left inguinal hernia
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 should have built-in fi xation threads to
prevent them from moving in and out of the extraperitoneal
space as instruments are passed through. In addition, because
of the con fi ned 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. 16.2 ).
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.
Fig. 16.2 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
Fig. 16.3 ( a ) The de fl ated
PBD2 balloon for dissection
of the preperitoneal space.
( b ) The in fl ated PBD2
balloon for dissection of the
preperitoneal space.
( c ) Spacemaker Plus
Dissector System
27316 Laparoscopic Inguinal Hernia Repair
Laparoscope
Some surgeons substitute the 0° laparoscope for a 30 or 45°
laparoscope after developing the extraperitoneal space.
We fi nd 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 dif fi cult cases, the 5 mm laparoscope 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. The sheath is opened with a
#11 bladed scalpel through a small transverse incision. The
midline and rectus muscle are identi fi ed 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. Insuf fl ation with CO 2 can commence with
insuf fl ation pressure being kept between 10 and 12 mmHg.
A 0° laparoscope is then inserted through the 10 mm cannula and can be gently used as a blunt dissector to further
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 pubic arch 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 de fl ated balloon on the end of a cannula,
of which many different types are available (Fig. 16.3 ), is
placed in the preperitoneal space using the access described.
The balloon is then fi lled 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 is associated with bladder and bowel injury in patients who have had
previous lower abdominal surgery [ 11 ] . 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 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.
274 K.A. LeBlanc et al.
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 ordered fashion. The pectineal
(Cooper’s) ligament on the same side as the hernia should
be exposed fi rst. 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
insuf fl ation. Characteristic fi lamentous tissue, which
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 (it is not unusual to dissect this
far into the pelvis). The inferior epigastric vessels should
next be identi fi ed 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 fi eld
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. 16.4 ; see color insert) 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 [ 12 ] . 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
insuf fl ation 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.
2
Fig. 16.4 Laparoscopic appearance of the deep layer of fascia
transversalis
Fig. 16.5 Laparoscopic appearance of an right indirect hernia
Indirect Inguinal Hernias in Males
At this stage it should be possible to identify the sac of an
indirect inguinal hernia (Fig. 16.5 ; see color insert). 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
27516 Laparoscopic Inguinal Hernia Repair
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 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 identi fi ed
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 insuf fl ation 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 to 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.
16.6 ). This is to ensure complete exposure of the
myopectineal ori fi ce 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 identi fi ed in patients with little adipose tissue
(Fig. 16.7 ). Care should be taken not to damage these or a
small branch of the deep circum fl ex iliac artery, which lies
lateral to the cutaneous nerve of thigh. These structures all
lie beneath the iliopubic tract. Therefore, any fi xation 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 identi fi ed, 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
Fig. 16.6 Extent of dissection required with details of anatomy
observed at laparoscopy. A left direct inguinal hernia is seen as the right
inguinal hernia from Fig.
16.5
Fig. 16.7 Laparoscopic appearance of femoral branches of genitofemoral nerve and lateral cutaneous nerve of thigh
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
gentle separation of tissues using atraumatic dissecting forceps. If 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.