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82
W.S. Cobb IV
Once the peritoneum is peeled away, the inferior epigastric vessels
are uncovered. These vessels are important landmarks, which lead
inferiorly to the iliac vessels. Medially, the prevesical space of Retzius is
entered anterior to the bladder. The pectineal ligament (Cooper’s) is
identi fi ed medially. Just superior to pectineal ligament courses the
“corona mortis” which is a direct branch of the iliacs. Frequently, an
accessory obturator vessel traverses the pectineal ligament. These vessels
must be appreciated and respected to avoid potential complications.
The iliopubic tract is a thickening of the inferior margin of the
transversalis fascia. It parallels the course of the more super fi cial inguinal
ligament, running from the pubic tubercle to the anterior superior iliac
spine. Fixation devices should not be placed below the iliopubic tract to
avoid damage to nerves and major vessels.
Preoperative Considerations
All patients with a groin hernia can be considered for a laparoscopic
repair. The laparoscopic approach is preferred in bilateral inguinal
defects, recurrent defects following an anterior repair, and inguinal
defects with concomitant pathology requiring laparoscopy. Larger
inguinoscrotal defects are certainly more challenging for a laparoscopic
approach and should be avoided early in one’s experience.
Candidates for a laparoscopic inguinal hernia repair should be
able to tolerate general anesthesia. Absolute contraindications include
Fig. 7.1. The anterior abdominal wall and inguinal region from the intra-abdominal
perspective.
83
7. Technique: Laparoscopic TAPP and IPOM
active intra-abdominal infection or peritonitis. Relative contraindications
include coagulopathy, ascites, and previous retropubic dissection.
The preoperative consultation should include discussion of potential
complications. Patients should be provided with the risks vs. bene fi ts of both
laparoscopic and open repairs and then allowed to choose. The purported
bene fi ts of the laparoscopic repair include earlier return to activity, the ability
to diagnose occult hernias, and potentially less chronic groin pain.
Intraoperative Setup
Equipment needs for a laparoscopic inguinal herniorrhaphy include a
standard laparoscopic instrument set. The Maryland dissector and blunt-
tipped fi ne-toothed graspers are all that are typically needed for dissection.
The endoshears are necessary and are attached to the electrocautery
cord.
The patient is asked to void his bladder prior to being brought back to
the operating suite. A urinary catheter is usually not necessary. The
intraoperative fl uids are held to less than one liter if possible to prevent
potential urinary retention.
Patients receive prophylaxis for deep venous thrombosis in the form
of sequential compression devices and subcutaneous heparin. A fi rst-
generation cephalosporin is given preoperatively.
The patient is prepped and draped for possible conversion to an open
repair. The patients’ arms are carefully padded and tucked at the sides
bilaterally. The surgeon stands on the side opposite the inguinal hernia.
The dissecting instrument is held in the hand of the same side as the
hernia (i.e., a right-sided defect is a right-handed repair and vice versa).
The video monitors are placed at the patients’ feet (Fig. 7.2 ).
Operative Technique: TAPP
Initial entry should be achieved per the surgeon’s comfort level.
Trocars are placed at the infraumbilical fold (12 mm) and just lateral to
the edge of the rectus muscle at the level of the umbilicus bilaterally
(5 mm). A long-acting local anesthetic is injected at the trocar sites prior
to making the incision. We prefer a cutdown, umbilical stalk technique
for initial entry at the umbilicus. A 5-mm 30° laparoscope is placed on
84
W.S. Cobb IV
the side of the hernia and held by the assistant. Inspection of the bilateral
inguinal regions is performed to assess for occult defects. The patient is
placed in Trendelenburg position to allow for the intra-abdominal
contents to “fall away.”
Dissection begins at the level of the medial umbilical ligament.
Beginning the dissection high on the abdominal wall just inferior to the
umbilicus allows for the creation of a sizable, preperitoneal pocket which
makes placement of mesh easier. The Maryland dissector is used to
retract posteriorly, and the shears are used to open up the peritoneum.
Ideally, the plane between the parietal peritoneum and the transversalis
fascia is developed. With continued gentle retraction posteriorly, the
endoshears can be used to bluntly open up the preperitoneal space with
countertraction. Medially, the space of Retzius is developed, and the
bladder fl ap is lowered. Laterally, the fat is carefully stripped off of the
peritoneum.
Attention is then directed to the hernia sac. Reduction of the hernia
sac depends on the type of defect. In direct defects, the peritoneal sac is
teased away from the attenuated transversalis fascia or “pseudosac.” The
pectineal ligament is uncovered medially until the femoral canal is
identi fi ed. The “corona mortis” and any accessory obturator vessels
should be visualized prior to placing tacks into Cooper’s ligament.
For indirect hernias, the sac dissection is more involved as it requires
identi fi cation and preservation of the vas deferens and gonadal vessels
Fig. 7.2. Operating room setup for a laparoscopic TAPP inguinal herniorrhaphy.
85
7. Technique: Laparoscopic TAPP and IPOM
(Fig. 7.3 ). In the female patient, this dissection is simpli fi ed by dividing
the round ligament. Smaller indirect sacs can be dissected free of the
cord structures and completely reduced. With large indirect sacs and
especially inguinoscrotal hernias, the sac can be dissected free of the
vas deferens and gonadal vessels and then divided. This maneuver may
result in postoperative seroma but does reduce the risk of ischemic
orchitis.
Once the sac is reduced, the cord structures are skeletonized off the
peritoneum to the level of the psoas muscle. This dissection provides for
a large peritoneal pocket for mesh placement and importantly reduces
the risk of an inferior recurrence. Development of the pocket inferiorly is
best achieved by grasping the peritoneum and retracting in inward while
teasing away the retroperitoneal attachments.
After an adequate-sized preperitoneal pocket has been developed, a
mesh is brought onto the fi eld for reinforcement of the myopectineal
ori fi ce. A tissue-separating or barrier-type mesh is not necessary because
of the protection provided by the peritoneum. A fl at, uncoated polyester
or polypropylene-based material works well in the groin. Macroporous,
lightweight materials are preferred for enhanced ingrowth and potential
reduction in pain. Typically, a mesh measuring 12 × 15 cm is utilized.
There is no need to slit the mesh. The blunt-tipped graspers are well-
suited to manipulate the mesh and avoid having the tips of the fi ner-
tipped Maryland grasper get caught in the interstices of the macroporous
meshes. The mesh should provide adequate coverage of the indirect and
direct inguinal spaces as well as the femoral space. The inferior edge of
the mesh should lie fl ush against the retroperitoneum and not curl under
when the peritoneum is elevated (Fig.
7.4 ).
Fig. 7.3. In direct defects, the sac is reduced while preserving the vas deferens
and gonadal vessels.
86
W.S. Cobb IV
Mesh fi xation can be achieved with mechanical devices (staples or
tacks) or fi brin sealants. Staples are placed on Cooper’s ligament at 2–3
points and to the anterior abdominal wall where the tip of the tacker can
be palpated in 2–3 additional spots. By palpating the tip of the fi xation
device, one avoids fi ring fi xation constructs below the iliopubic tract,
which can damage nerves or vessels (Fig. 7.5 ).
The repair is completed by re-approximating the peritoneal fl ap.
Closure is achieved with suture, staples, or tacks. Staples are preferred.
They are not driven into the abdominal wall, thereby minimizing trauma,
and they save time as compared to suturing. Hemostasis is con fi rmed and
the integrity of the peritoneal closure is assessed. Any additional tears in
the peritoneum that occurred during the dissection can be closed with the
Fig. 7.4. The inferior edge of the mesh should not move when the peritoneal fl ap
is elevated.
Fig. 7.5. Mesh covers the
myopectineal ori fi ce and is
secured with staples placed
above the iliopubic tract.
87
7. Technique: Laparoscopic TAPP and IPOM
stapler or suture. The trocars are removed under laparoscopic visualization
to ensure no injury or bleeding from the inferior epigastric vessels. The
fascial defect at the umbilicus is closed with an absorbable suture using
a suture-passer device.
Operative Technique: IPOM
The intraperitoneal onlay mesh (IPOM) procedure for inguinal
hernias is a transabdominal approach as well. The technique is similar to
the laparoscopic repair of ventral hernias and involves the placement of
a tissue-separating mesh against an intact peritoneum. The IPOM
technique of inguinal herniorrhaphy avoids the preperitoneal dissection
required with the TAPP repair and simpli fi es the transabdominal
placement of mesh in the groin. The IPOM repair of inguinal hernias was
initially described utilizing uncoated polypropylene mesh; however, with
the advances in mesh technology, a coated, barrier mesh is preferred.
Patient preparation, operating room setup, and trocar positioning are
similar to the TAPP repair. A urinary catheter is routinely placed for
bladder decompression.
The bilateral myopectineal ori fi ces are examined for the presence of
inguinal and femoral defects. The sac in direct or indirect defects is
inverted with gentle external pressure. The peritoneum is then excised
approximately 1–2 cm from the base of the defect. The peritoneum is
excised circumferentially to reduce the sac. The gonadal vessels and vas
deferens are identi fi ed to avoid injury during this portion of the dissection.
Dissection of the sac allows for removal of cord lipomas as well. Just as
with the TAPP technique, large inguinoscrotal sacs are left intact after
removing the peritoneum from the base of the defect (i.e., “ringing the
neck” of the hernia sac).
A coated, barrier mesh measuring 12 × 15 cm is selected. The mesh is
introduced through the 12-mm umbilical trocar. The mesh is oriented in
the groin to provide coverage of both inguinal and femoral spaces with at
least 3 cm of overlap of the hernia defect. The suture passer is then
utilized to pass transabdominal sutures through the midpoint of the upper
edge of the mesh and in each of the superior corners of the mesh. These
three sutures are secured to fi xate the mesh. The hernia stapler is then
used to fi xate the lateral and inferior aspects of the prosthesis. Medially,
the mesh is fi xated to the pectineal (Cooper’s) ligament. The lateral side
of the mesh is fi xated by palpating the tip of the stapler externally during
88
W.S. Cobb IV
deployment. Fixation constructs are placed approximately 1 cm apart.
Inferiorly, the staples are placed lightly and approximately 2 cm apart to
minimize potential damage to nerves and vessels. Here, the staples
should be fi red in a vertical orientation to avoid nerve entrapment.
Fixation constructs should not be placed just inferior to the internal ring
to avoid damage to the cord structures.
Complications
Similar to open inguinal herniorrhaphy, complications following
transabdominal, laparoscopic inguinal repair are typically rare and minor
when they do occur. Nevertheless, a transabdominal approach does create
the possibility of more serious complications that are typically not of
concern with an anterior groin approach.
Urinary retention can occur following any inguinal repair. Patients
with benign prostatic hypertrophy and bilateral repairs result in a higher
incidence of urinary retention. Bladder decompression with a urinary
catheter is usually all that is required.
Seromas can occur particularly with larger defects and when the sac
is not completely reduced. They are almost always painless and self-
limiting. Rarely aspiration is required for excessively large fl uid
collections.
Wound and mesh infections are almost unheard of following
laparoscopic inguinal hernia repair and typically imply a break in surgical
technique. Ecchymosis of the groin and testicle can occur following the
repair; however, erythema raises the concern for potential staphylococcal
contamination. If concern for a mesh infection is present, computed
tomography of the pelvis is indicated.
Early postoperative small bowel obstruction can occur if the peritoneal
closure breaks down and bowel herniation occurs. Any patient with
persistent postoperative nausea and vomiting should raise concern, and
appropriate radiographic studies should be obtained.
Serious complications can arise during and after laparoscopic inguinal
herniorrhaphy. Major vascular and visceral injuries can occur with trocar
placement or during dissection. The best management of such injuries
depends on the comfort level of the surgeon. The patient’s lower abdomen
and thighs should be prepped and draped as if performing an open
inguinal hernia repair to allow for rapid conversion to a groin incision or
lower midline incision if such complications occur. For bowel or bladder
89
7. Technique: Laparoscopic TAPP and IPOM
injuries, the repair can be performed either laparoscopically or open.
Bladder injuries are repaired with an absorbable suture in two layers.
A urinary catheter is placed and left in place for 7 days. A contrast study
of the bladder is obtained prior to removal of the catheter. The decision
to place a synthetic mesh in the face of bowel or bladder injury depends
on the degree of contamination. The literature supports the use of a
lightweight, macroporous synthetic mesh with minimal contamination
of urine or enteric contents. Biologic and bioresorbable materials can be
utilized if a synthetic mesh is not desired.
Long-term complications following laparoscopic inguinal hernia
repair consist of recurrence and trocar site hernias. The recurrence rates
following the laparoscopic approach as compared to the open technique
have been long debated in the literature and are dif fi cult to interpret.
What is clear is that the laparoscopic TAPP repair can provide recurrence
rates comparable to open mesh-based repairs in the hands of experts.
Additionally, the learning curve for the laparoscopic approach to inguinal
hernias is much greater than for open repairs. Some authors suggest that
the learning experience may be as high as 250 cases. The growing number
of advanced laparoscopic training programs and proper instruction of the
technique have probably reduced this number, but it is still a more
dif fi cult repair to grasp than the open repair.
Further Reading
1. Colburn GL, Brick WG, Gadacz TR, et al. Inguinal anatomy for laparoscopic
herniorrhaphy, part I: the normal anatomy. Surg Rounds. 1995;18:189–98.
2. Franklin ME, Diaz-Elizondo JA. The intraperitoneal onlay mesh procedure for groin
hernias. In: Fitzgibbon’s Jr RJ, Greenburg AG, editors. Nyhus & condon’s hernia. 5th
ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002. p. 269–76.
3. Neumeyer LA, Gawande AA, Wang J, et al. Pro fi ciency of surgeons in inguinal hernia
repair: effect of experience and age. Ann Surg. 2005;242:344–52.
4. Wauschkuhn CA, Schwarz J, Boekeler U, Bittner R. Laparoscopic inguinal hernia
repair: gold standard in bilateral hernia repair? Results of more than 2800 patients in
comparison to literature. Surg Endosc. 2010;24:3026–30.
91
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_8,
© Springer Science+Business Media New York 2013
8. Strangulated Inguinal Hernia
Jonathan P. Pearl and E. Matthew Ritter
Strangulated inguinal hernias occur when the contents of a hernia are
deprived of adequate blood supply. This may occur in both acutely and
chronically incarcerated hernias. Strangulation is quite rare, but when it
occurs, it is a true hernia emergency necessitating immediate operation. The
mortality rate in strangulated inguinal hernias may be as high as 30%.
Pathophysiology
Strangulation represents a continuum from incarceration of hernia
contents to vascular compromise to tissue necrosis if the condition goes
untreated. Hernia contents become incarcerated within the hernia ring
with resulting tissue edema. Increasing edema and interstitial pressure
cause venous stasis with concomitant impairment of perfusion across the
capillaries. This can lead to necrosis and eventual perforation. One study
showed that risk of strangulation increased signi fi cantly if symptoms had
persisted for more than 6 h prior to presentation for medical care.
All groin hernias are susceptible to strangulation, with most series
reporting a preponderance of right-sided indirect hernias. Strangulation
might occur in femoral hernias in greater proportion to their incidence
because of the lack of elasticity of the femoral canal. Similarly, obturator
hernias also carry an increased risk of incarceration and strangulation as
evidence by the fact that as many as 90% of patients with obturator
hernias present with a small bowel obstruction due to incarceration.
Small bowel and greater omentum are the most commonly strangulated
organs, but there are reports of strangulated vermiform appendixes
(Amyand’s hernia), colon, bladder, ovary, and uterus (Fig. 8.1 ).
92
J.P. Pearl and E.M. Ritter
Presentation and Diagnosis
Men vastly outnumber women with strangulated hernias, likely
because of the higher incidence of hernias in men. Strangulated femoral
hernias are more common in women. The median age of patients with
strangulated hernias is approximately 60 years, although strangulation
has been reported in all ages from pediatric patients to nonagenarians.
The most common presenting symptom is acute groin pain with an
accompanying bulge. Patients with strangulated bowel may also present
with nausea or vomiting, fevers, chills, or malaise. Neglected strangulated
hernias may lead to bowel perforation with attendant hemodynamic
instability. In rare cases, bowel perforation may result in scrotal fecal
fi stula.
On examination, the hernia bulge is usually evident on inspection.
The overlying skin may be erythematous. A tender mass will be palpable
either cephalad or caudad to the inguinal ligament, depending on the
type of hernia.
A thorough history and physical examination are usually suf fi cient to
establish the diagnosis of incarcerated inguinal hernia, and strangulation
may be suspected based on tenderness, skin erythema, fever, or
leukocytosis. Extrapolating from data from strangulated bowel
obstructions, it may be dif fi cult to discern incarceration from strangulation
based on clinical fi ndings alone.
When the diagnosis is uncertain from the history and physical
examination, radiologic imaging may be useful. Plain abdominal
radiographs may show evidence of a bowel obstruction. Computed
tomography will clearly delineate the incarcerated organ and establish
the diagnosis (Fig. 8.2 ). Vascular compromise of the hernia contents
Fig. 8.1. Necrotic appendix
secondary to a strangulated
right-sided obturator hernia.