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6 Laparoscopic Inguinal Hernia Repair: TEP
Fig. 6.1 Instruments in TEP technique
71
Fig. 6.2 PDB trocar
72
J.A. Bellido Luque and M. Sánchez Ramírez
Fig. 6.3 BTT trocar and 5-mm trocars
the rectus abdominis muscle homolateral to the hernia is exposed. A 2-cm opening
is made parallel to the direction of the muscle with the index fi nger and blunt dissection, and all of the rectus abdominis muscle is turned back, creating a retro muscular
tunnel. See Fig.
6.4 .
Creation of the Preperitoneal Space
Once this step has been carried out, the PDB balloon trocar is introduced and progressively infl ated, achieving the opening of the entire preperitoneal space at the
same time as the balloon is fi lled. The optic is introduced through the trocar in order
to confi rm the correct positioning of the balloon and begin structural identifi cation. With alternating lateral movements of the optic introduced in the trocar, an
opening in the Retzius space is achieved and more laterally in the Bogros’ space.
Subsequently, the balloon trocar is removed and the BTT trocar is put into place.
After the establishment of the pre-pneumoperitoneum, two 5-mm trocars are placed
on the infraumbilical midline separated by approximately 5 cm, under direct view.
See Figs. 6.5 , 6.6 , 6.7 , and 6.8 .
Identifi cation of Structures
It is necessary to identify the inferior epigastric vessels which are found in the most
cranial area of the working space and Cooper’s ligament. This ligament is easily
recognized as it is pearly white and in the medial zone above the bladder. Once these
structures have been identifi ed, we should also be able to view the inguinal cord and
the iliac vessels, which are found below and more medial to the cord.
6 Laparoscopic Inguinal Hernia Repair: TEP
73
Fig. 6.4 Port placement
Port placement
10–12 mm
5 mm
5 mm
Reduction of the Hernial Sac
In the case of a direct hernia occurring, the sac is generally completely reduced
when the preperitoneal space is created with the PDB trocar, with one being able
to see an orifi ce in the posterior wall of the inguinal region medial to the epigastric
vessels, which is the direct orifi ce. In the case of it not being reduced in this manner, with simple traction of the sac in an inferior direction, it will be completely
reduced, allowing a view of the transversalis fascia over the direct inguinal orifi ce. If the patient has an indirect hernia, the sac accompanies the elements of the
cord (gonadal vessels and the vas deferens) for its most cranial and media portions.
Using traction and contra-traction maneuvers, we will achieve the total reduction
of the indirect sac, making sure at all times that we do not traction over the gonadal
vessels or the vas deferens in order to avoid lesions.
74
J.A. Bellido Luque and M. Sánchez Ramírez
Fig. 6.5 Rome dissection with the fi nger until the Cooper’s ligament
Fig. 6.6 6 PDB balloon trocar makes the preperitoneal dissection
6 Laparoscopic Inguinal Hernia Repair: TEP
Fig. 6.7 BTT trocar and two infraumbilical 5-mm trocar
75
Fig. 6.8 Technique to open the Retzius space in TEP. 1 Opening the anterior fascia of rectus
muscle, 2 Dissection with the fi nger the preperitoneal space, 3 PDB trocar: epigastric vessels, 4
PDB trocar: Cooper’s ligament and epigastric vessels
76
The reduction of both direct and indirect sacs fi nalizes when we completely
skeletized the inguinal cord and we see the iliopsoas muscle, the caudal margin of
the dissection.
J.A. Bellido Luque and M. Sánchez Ramírez
Opening of the Bogros’ Space
Once the hernial sac has been reduced and the inguinal elements have been skeletonized, it is necessary to continue the lateral dissection, fi nalizing the opening of
the Bogros’ space. Laterally turning down the peritoneum, it is possible to reach the
anterior superior iliac spine, the lateral margin of the dissection. During this step,
it is common to observe nerve structures such as the femoral nerve and the femoral
branch of the genitofemoral nerve, which need to be avoided in order to rule out
chronic pain in the inguinal region.
Introduction of the Mesh
The prosthesis is rolled up and inserted through the BTT trocar and is unrolled in
the preperitoneal space. A consensus exists among the surgical community as to the
minimum size of the mesh to be used. This should be a minimum of 10 × 15 cm in
order to reinforce all the possible hernial orifi ces (direct, indirect, and femoral). The
positioning of the mesh in the said space is vital in order to avoid an early recurring
hernia, and for this reason we will give special attention to this step. It should totally
surpass Cooper’s ligament and the pubis (even more so in the case of direct hernias),
covering adequately the inguinal cord and the deep inguinal orifi ce and reaching the
most lateral area of the Bogros’ space. See Fig. 6.9 .
Prosthetic Fixation
For prosthetic fi xation in the preperitoneal space, we can use different methods:
absorbable or nonabsorbable tackers, glues, biological glues, or even no fi xation
method. The indication of one or another method will be discussed in another chapter.
Evacuation of the Pre-pneumoperitoneum and the Closure of Trocars
Evacuation of CO 2 must be done slowly, without moving the mesh during this stage,
at all times observing with the optic. Simultaneously, it is convenient at this time to
evacuate the CO 2 that could have been retained in both scrotal regions by diffusion
6 Laparoscopic Inguinal Hernia Repair: TEP
77
Fig. 6.9 Introducing the mesh. 1 Opening the Bogros space, 2 Reduction of the hernia (lipoma
and the sac), 3 Identify the structures, 4 Mesh placement: the lipoma and the hernia sac are placed
against the mesh
throughout this operation. Once the pre-pneumoperitoneum has been evacuated, the
surgery is completed with the closure of the superfi cial aponeurosis orifi ce and the
incisions in the skin.
Complications
The complications which can arise in a laparoscopic hernioplasty inguinal TEP procedure can be classifi ed into the categories discussed in the following sections.
Intraoperative
Hemorrhage
Few hemorrhages occur during a TEP procedure, and those which do are easily controlled with cauterization. Lesions on the inferior epigastric vessels, the obturator
78
J.A. Bellido Luque and M. Sánchez Ramírez
artery, or collateral arteries are produced by inadequate traction and are controlled
using metal clips. Hemorrhage from iliac vessels is incidental.
Damage to the Inguinal Cord
Lesions of the vas deferens are rare due to the easy identifi cation of this medial
structure to the inguinal cord, which appears as a pearly white cord. The gonadal
vessels are situated posterior and lateral to the inguinal cord, underneath the indirect
hernial sac. In order to avoid lesions to both structures, it is essential to achieve a
precise identifi cation, separating them from the indirect hernial sac with smooth
maneuvers, avoiding excessive tractions.
Peritoneal Rupture
This is the most frequent complication, with an incidence rate of between 13 and
24 %, and in 7 % of patients the tear is massive, losing the preperitoneal space and
therefore forcing a TAPP approach or open surgery. The surgeon’s experience is
vital in order to maintain a low conversion rate.
The best way of avoiding this complication is to identify at all times the peritoneum margin and the hernial sac, carrying out traction and contra-traction maneuvers in a smooth manner.
Although various studies with positive results have been published in which the
peritoneal small defect is not closed [ 4 ], we believe that in all of the cases in which
a peritoneal rupture is identifi ed, it is recommendable to close it in order to avoid the
loss of the CO 2 in the intraperitoneal cavity and the consequent diminishing of the
work space, as well as to reduce the probability of an introduction of a bowel loop
through the orifi ce and the immediate postoperative appearance of an obstruction.
There are several methods of peritoneal closure, such as continuous suturing, the
use of clips, or the use of preformed loops (Endoloops®, Ethicon endosurgery, Blue
Ash, OH, USA). This last option is the quickest and simplest. See Fig. 6.10 .
In the case of a loss of the pre-pneumoperitoneum in the intraperitoneal cavity
which produces a slight reduction of the working space, we can increase this space
with the introduction of a Veress needle in the left hypochondrium, facilitating the
exit of intraperitoneal CO 2 .
Postoperative
Seroma
This is the most common postoperative complication, above all in patients with
direct or medial hernias. It appears as a non-painful lump in the inguinal region,
from the 4th or 5th day post-operation, starting with a soft consistency and afterwards a hard consistency. During examination, it does not reduce or change with
6 Laparoscopic Inguinal Hernia Repair: TEP
Fig. 6.10 Closure of peritoneal tear with Endoloops (Endoloop®, Ethicon Endosurgery, Blue
Ash, OH, USA)
pressure or when lying down. It does not require treatment and usually disappears
approximately 1 month after the operation. Only in those symptomatic cases and
those in which it does not disappear can puncture aspiration be recommended.
Various techniques have been published in order to diminish the incidence of
seromas. In the case of direct hernias, we can invaginate the transversalis fascia, fi xing it to Cooper’s ligament with a helicoidal suture or by using an Endoloop. If we
come across large direct hernias, it would be recommendable to completely reduce
the hernial sac, as this has been shown to reduce the incidence of seromas. If it is
not possible to completely reduce it, once the sac is selected and bound to the nearest ending, we can fi x the distal end of the sac to the posterior wall of the inguinal
region in order to diminish the dead space which would remain if we were to leave
it without fi xing it.
79
Scrotal Hematoma
This complication is usually quite frequent in patients who have been operated
on for an inguinoscrotal hernia, with an incidence rate of between 4 and 22 %
according to publications. The treatment is conservative with relative rest and antiinfl ammatories. Only in those cases showing an organized hematoma, clinically
very symptomatic, should this be surgically drained.
To avoid this complication, it is necessary to carry out a careful dissection and
hemostasis during the surgical procedure, above all in those patients with inguinoscrotal hernias and those patients receiving an anticoagulant treatment. In these cases, the
use of aspirational drainage can help to diminish the incidence of scrotal hematomas.
Ischemic Orchitis
The appearance of pain or testicular infl ammation in the fi rst 5 days after the operation should make us consider ischemic orchitis. Its incidence varies between 0.05
and 0.1 %, above all in patients with inguinoscrotal hernias with a larger dissection
80
J.A. Bellido Luque and M. Sánchez Ramírez
of the hernial sac. It is believed that it is due to a thrombosis of the pampiniform
venous plexus more than an arterial lesion and should be differentiated from a scrotal hematoma or testicular torsion. A scrotal ultrasound helps with diagnosis, and
treatment is based on anti-infl ammatories, relative rest, and scrotal suspensory. The
majority of patients recover completely without developing testicular atrophy.
Chronic Pain
Chronic pain is that which persists for longer than the third month after surgery. The
following have been confi rmed through evidence-based medicine:
1. The laparoscopic approach to inguinal hernias produces less acute and chronic
pain than conventional surgery (1A).
2. There are no differences in terms of acute or chronic pain between TEP and
TAPP (1B).
3. The risk of acute and chronic pain after fi xation with helicoidal sutures is greater
when compared to fi xation with fi brin and non-fi xation (1B).
4. The risk of acute and chronic pain after a laparoscopic hernioplasty in a recurrent
inguinal hernia is less when compared to conventional surgery (1B).
5. There are no differences in chronic pain with the use of high- or low-weight
meshes in laparoscopic hernioplasty (1B).
In order to attempt to diminish the incidence of chronic pain, we should avoid
lesions of three nerve structures which are involved in the occurrence of chronic pain:
• Genital and femoral branches of the genitofemoral nerve
• Lateral cutaneous nerve of the muscle
• Cutaneous branch of the femoral nerve
Due to the mechanisms of the lesions not being well defi ned, diagnosis is usually imprecise and diffi cult. Therefore, the best treatment is usually prevention. The
best way to avoid this complication is to minimize the preperitoneal dissection in
the posterior pelvic wall and not place helicoidal sutures under the iliopubic tract.
The treatment of this complication is controversial, there being different methods. The initial treatment with nonsteroidal anti-infl ammatory drugs (NSAIDs) and
rest, together with an infi ltration of local anesthetics, is usually useful in controlling
this complication.
Faced with a persistent inguinodynia in spite of treatment, associated with motor
or sensorial defi cit, the most sensible solution would be another operation and
exploration of the whole inguinal area and removal of the helicoidal sutures.
Controversies in Laparoscopic Inguinal Hernia Repair
The development of polypropylene prosthetics revolutionized surgery in the repair
of abdominal wall hernias. A tension-free mesh technique has drastically reduced
recurrence rates for all hernias compared to tissue repairs and has made it possible