Laparoscopic Trans Abdominal Pre Peritoneal Inguinal Hernia Re

8/14/2019 Laparoscopic Trans Abdominal Pre Peritoneal Inguinal Hernia Re

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Laparoscopic Transabdominal Preperitoneal

Inguinal Hernia RepairMichael J. Rosen, MD

When considering a laparoscopic approach for repairinginguinal hernias, the surgeon has several options. Ini-tially laparoscopic repairs involved an intraperitoneal onlaymesh. Using this technique, the surgeon placed a large piece ofmesh in an intraperitoneal position, similar to a laparoscopicventral hernia repair.Thisapproach has largely beenabandonedsecondary to high recurrence rates and the drawbacks of intra-peritonealmesh. The remaining two techniques includea totally

extraperitoneal (TEP) and a transabdominal preperitoneal(TAPP) approach. The main difference between these two tech-niques is the sequence of gaining access to the preperitonealspace. In the TEPapproach, the dissection begins in the preperi-toneal space with a balloon dissector. In the TAPP approach, thepreperitoneal space is accessed after initially entering the perito-neal cavity. Each approach has its own merits. Using the TEPapproach, the preperitoneal dissection is quicker, and the po-tential risks of intraperitoneal visceral damage are minimized.However, the use of dissection balloons can be costly, the work-ing space is more limited, and in the case of prior preperitonealsurgery or mesh the space may be impossible to create. Addi-tionally, if large tears in the peritoneal flap are created during a

TEP, the potential working space can become obliterated neces-sitating conversion to a transabdominal approach. For thesereasons, knowledge of a transabdominal technique is essentialwhen performing laparoscopic inguinal hernia repairs. Thetransabdominalapproach allows immediate identification of thegroin anatomy before extensive dissection and disruption ofnatural planes. The larger working space of the peritoneal cavitycan make early experience with the laparoscopic approach saferand easier. The TAPP is the preferredapproachof the author andwill be described herein.

There are no absolute contraindications to laparoscopicinguinal hernia repair other than the inability to tolerate gen-eral anesthesia. Patients who have had extensive prior lowerabdominal surgery can require significant adhesiolysis and

may be best approached anteriorly. In particular patientswho have had a radical retropubic prostatectomy with thepreperitoneal space previously dissected can make accuratesafe dissection challenging.

Preoperative

Routine use of Foley catheterization is not performed. Thepatients are instructed to empty their bladder before enteringthe operating room. A single dose of a first generation ceph-alosporin is given and sequential compression devices areapplied. The patient is placed under general anesthesia, botharms are tucked at the patients side, and the abdomen and

groin are sterilely prepped. The surgeon stands on the sideopposite the hernia and the first assistant stands on the ipsi-lateral side of the hernia along with the scrub nurse. The lapa-roscopic tower is positioned at the foot of the table (Fig. 1).

Trocar Positioning

The abdomen is accessed via an open Hasson techniquethrough an infraumbilical incision. The abdomen is insuf-flated to 15 mmHg. A 5 mm 30 degree laparoscope is theninserted and a general inspection of the abdominal cavity isperformed. The pelvic floor is evaluated and the pathology ofthe inguinal anatomy is examined (Fig. 2). Two additional

5-mm ports are placed in line with the umbilicus and justlateral to the inferior epigastric vessels. These trocars shouldremain above the umbilicus to avoid interference with thepreperitoneal flap dissection. Additionally, placing these tro-cars too far laterally can result in difficulty navigating instru-ments across the abdominal viscera (Fig. 3). Using an angled5-mm laparoscope, the surgeon can stand on the oppositesideof the hernia and use the middletrocaras a working port.The camera operator uses the lateral 5-mm port ipsilateral tothe defect for visualization.

Peritoneal Flap Dissection

The patient is placed in a slight Trendelenberg position. Thedissection begins at the ipsilateral medial umbilical fold. Thepreperitoneal flap is raised from a medial to lateral directionusing the curved scissors with monopolar cautery. It is impor-tant to begin this dissection rather cephalad on the abdominalwall to leaveenough spacefor reduction of the hernia and place-ment of an appropriately sized piece of mesh (Fig. 4). Addition-ally, as the initial incision is carried laterally, one should avoidthetemptation to drift inferiorly toward theinguinal canal, againcompromising the eventual space necessary for mesh place-ment. The proper incision carries transversely across the ab-

Department of Surgery, University Hospitals of Cleveland, Case Western

Reserve School of Medicine, Cleveland, OH.

Address reprint requests to Michael J. Rosen, Assistant Professor of Surgery,

Department of Surgery, University Hospitals of Cleveland, Euclid Ave,

Cleveland, OH 44106. E-mail: [email protected]

451524-153X/06/$-see front matter 2006 Elsevier Inc. All rights reserved.

doi:10.1053/j.optechgensurg.2006.04.008


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dominal wall toward the anterior superior iliac spine. Whentraversing across the plane, one must be cautious and avoid theepigastric vessels. Achieving the appropriate dissection plane iscriticalto the successof theoperation. Althoughthedissection is

typically below the arcuate line there tends to be an attenuated

transversalis fascia that is adherent to the rectus muscle. Theappropriateplane is justsuperficial to the peritoneum. By grasp-ing the inferior cut edge of the peritoneum and retracting ceph-alad the preperitoneal space is created by gently pushing away

anddividingtheloose filmy attachments(Fig. 5). The first struc-

Figure 1 Patient positioning andoperating roomsetupfor left inguinal hernia. Surgeon standson opposite side of hernia

using middle and lateral trocar working ports. First assistant stands on ipsilateral side of hernia with camera. Arms aretucked bilaterally at sides, with monitor at foot of bed.

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ture identified is Coopersligament. By sweeping downthe blad-der staying high on the anterior abdominal wall one eventuallyencounters this white firm ligament. Even in unilateral hernias,I routinely sweep the bladder far medially past the midline toprovide adequate meshoverlap. Coopers ligamentis cleared offlaterally until a fairly constant crossing vessel is identified. Thisso-called aberrant obturator vessel is present in over 75% ofpatients. Next, the lateral dissection is begun. Unlike the medialdissection plane which typically canbe developed bluntlyallow-ingthepreperitoneal fatty tissue to divide in itsnaturalplane, the

appropriate plane for the lateral dissection is directly on theperitoneumwhich can typically be quite thin. The lateral dissec-tion is carried medially until the spermatic vessels and then thevas deferens are encountered. One must use extreme cautionwhen using electrocautery in the preperitoneal space, as a loopof intestine can be just below the peritoneal flap with energyeasily transmitted through the flap.

Dissection of Hernia Sac

At this point the hernia sac should be reduced (Fig. 6). If adirect defect is encountered, the hernia contents are graspedand the attenuated transversalis fascia is gently teased away.

If an indirect hernia is identified, the sac is likewise grasped

and retracted while bluntly sweeping off attachments to thecord structures. Large chronic indirect sacs can be particu-larly challenging. In cases where the hernia sac cannot becompletely reduced, it can be transected and either suturedor closed with an endoloop leaving the distal end open. Anycord lipoma typically located inferior and lateral to the cordstructures should be completely reduced to avoid potentialconfusion as a recurrence. These lipomas do not need to beresected and can be left in the preperitoneal space. Once thehernia sac is completely reduced, the peritoneal flap should

be dissectedat least 3 cm offthe vessels andcord structures toprevent any drag coefficient from allowing peritoneum tosneak under the mesh, predisposing to recurrence. The up-perflap of peritoneum is then grasped andretracted cephaladto develop a larger pocket for the mesh.

Placement of Mesh

At least a 1214 cm piece of polypropylene mesh is utilized.We do not place a slit for wrapping around the cord struc-tures as recurrences have occurred through these defects.The mesh is grasped at the medial aspect. We do not roll themesh tightly as this just makes unraveling more difficult once

inside the patient. The mesh is brought in through the

Figure 2 Inguinal anatomy of the right side. Location of indirect and direct space in relation to the inferior epigastricvessels.

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10-mm trocar and tucked medially into the pocket. The su-perior medial corner of the mesh is grasped and broughtanteriorly while the inferior instrument pushes the mesh

against the abdominal wall. While some groups advocate nomesh fixation, we currently believe some form of mesh fixa-tion is important to prevent migration. Once the mesh issituated we place one tack in Coopers ligament. By onlyplacing one tack, the mesh can still be rotated to obtain ideallateral placement. However, themesh will notmigrate duringlateral retraction. We then place a spiral tack at the superiorlateral aspectof the mesh. It is critical thatthe tip ofthe tackercan be palpated with the nondominant hand of the surgeonthrough the anterior abdominal wall before deploying anytacks. If the tacker can not be palpated it indicates that it islikely below the iliopubic tract and therefore the lateral fem-oral cutaneous, genital-femoral, or femoral nerve could be

entrapped. We then place one tack just lateral to the inferior

epigastric and one at the superior medial border of the mesh.Finally, another tack is placed in Coopers ligament (Fig. 7).

At the conclusion, the peritoneum is re-examined with par-

ticular concern over thevessels to ensureit is notencroachingunderneath the mesh. No tacks can be placed in the triangleof doom bordered by the vas deferens medially and thespermatic vessels laterally which contains the iliac artery andvein.

Peritoneal Closure

The peritoneal flap is then secured to the anterior abdominalwall. This can be completed with spiral tacks, staples, orsuturing. Any defects in the peritoneum should be closed.Occasionally, the reduced hernia sac can be used to closethese defects. If a large hole in the peritoneum is created,

several maneuvers can aid closure. The peritoneal flap dis-

Figure 3 Trocar positioning. Note two lateral ports are just lateral to the inferior epigastrics in line with the umbili-

cus.

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Figure 4 Dissection of peritoneal flap. The flap begins at the medial umbilical fold. Note the length above the inguinal

structures high on the anterior abdominal wall. Care is taken to avoid the epigastric vessels.

Figure 5 The inferior flap is grasped and retracted while the loose filmy attachments of the preperitoneal space are

dissected free. The medial dissection is completed clearly identifying Coopers ligament.



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Figure 7 The mesh is secured to the anterior abdominal wall with spiral tacks. No tacks are placed below the iliopubic

tract.

Figure 6 The indirect hernia sac is carefully reduced off of the cord structures.

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section should be extended inferiorly to gain laxity for clo-

sure, the pneumoperitoneum pressures can be reduced to 8

to 10 mmHg to decrease tension, andthe patient canbe taken

out of the Trendelenberg position. For left sided defects, the

sigmoid colon can be released from its peritoneal attach-

ments. The umbilical port is closed with a single figure of

eight resorbable suture and the abdomen is desufflated.

Special Considerations

In cases of bilateral hernias, we use two separate pieces of

mesh that are secured together in the midline. The mesh is

placed in the first hernia but the peritoneum is not closed

until the other side is completed in case the mesh is acciden-tally displaced.

In cases of prior preperitoneal hernia repairs, occasionallythe peritoneal flap is completely destroyed and in those casesone can consider an onlay technique.

Postoperative CareThe patients are typically discharged home from the recoveryroom. The patients must void before discharge as urinaryretention can be an issue especially in bilateral hernias. Thepatients are instructed to avoid heavy lifting forseveral weekspostoperatively. Patients are followed in the office at 2 and 6weeks.


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Laparoscopic Trans Abdominal Pre Peritoneal Inguinal Hernia Re