laparoscopic hernia repair - semantic scholar · 2017-10-18 · acs surgery: principles and...

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ACS Surgery: Principles and Practice28 Laparoscopic Hernia Repair — 1

Since its first description in 1990,1 laparoscopic inguinal hernior-rhaphy has shown a great deal of promise; however, concurrentlywith its development, open anterior herniorrhaphy has evolvedinto a tension-free, mesh repair that is easily performed with thepatient under local anesthesia and that is also associated withrapid recovery and low recurrence rates [see 5:27 Open HerniaRepair].2,3Thus, the key question about laparoscopic inguinal her-nia repair at present is whether it provides a significant advantageover the tension-free open repair now in use.

The two most common techniques for laparoscopic inguinal her-nia repair involve the insertion of mesh into the preperitoneal space;one makes use of a transabdominal preperitoneal (TAPP) approach,the other a totally extraperitoneal (TEP) approach. Both approach-es would appear to offer potential advantages, such as reduced post-operative pain, shortened recovery, quicker and more accurate as-sessment and repair of bilateral groin hernias simultaneously, and, inthe case of recurrent hernia, avoidance of previously dissected andtechnically difficult scarred areas. In practice, however, the advan-tages are not invariably realized; a laparoscopic approach is not al-ways minimally invasive, and various disadvantages accrue from thecurrent requirement for general anesthesia, the need to traverse theabdominal cavity in the TAPP technique, and the increase in operat-ing room time and costs.4

Meticulous attention to surgical technique is essential. Becausesurgeons may be unfamiliar with inguinal anatomy as viewed frominside the abdomen and because the potential for complicationnecessitating laparotomy is increased with the laparoscopicapproach, surgeons must be proficient in laparoscopic techniquesand must have a precise knowledge of anatomic relations in theregion of the groin as seen from the peritoneal surface.

Since the late 1990s, laparoscopic video techniques have alsobeen increasingly applied to the repair of incisional hernias.5-9

Laparoscopic repair of large incisional hernias resembles openrepair in that mesh is inserted to cover the defect in the abdomi-nal wall fascia [see 5:27 Open Hernia Repair]. A laparoscopicapproach is theoretically attractive because an open approach usu-ally necessitates a large incision as well as extensive and tediouswide dissection to expose the abdominal wall defect, resulting inconsiderable postoperative pain and a risk of wound complica-tions—problems that a laparoscopic approach to the defect fromwithin might minimize.

It may be many more years before the true safety and efficacy oflaparoscopic herniorrhaphy can be determined and the correct indi-cations for its use established. In the meantime, every repair per-formed should be subjected to careful classification, documentation,and quality-of-life assessment. Surgeons should not perform laparo-scopic herniorrhaphy simply because it is relatively new or potential-ly economical; they should perform it only when convinced that it isanatomically and physiologically correct and logical.

In what follows, we discuss laparoscopic repair of both inguinaland incisional hernias. In addition to describing current operativetechniques, we address inguinal surgical anatomy, preoperativeplanning, and complications. Finally, we review selected trials

measuring the results of laparoscopic repair against those of openrepair and comparing the outcomes of TAPP repair with those ofTEP repair.

Laparoscopic Inguinal Hernia Repair

ANATOMIC CONSIDERATIONS

To most surgeons, inguinal anatomy as viewed through thelaparoscope appears unfamiliar. This is particularly true for theTEP approach, in which the preperitoneal space must be devel-oped. The surgical perspective on the pelvic anatomy from theintraperitoneal view has been elegantly described by Skandalakisand coworkers10 and has been elegantly demonstrated in cadaverdissections by Spaw and colleagues,11 whose work forms the basisof the descriptions we present in this chapter. Excellent descrip-tions of the preperitoneal space by Wantz12 and Condon13 are alsoworthy of review.

During laparoscopic herniorrhaphy, a number of structuresthat are usually visible during open herniorrhaphy (e.g. theinguinal ligament, the pubic tubercle, the lacunar ligament, andthe ilioinguinal and iliohypogastric nerves) are not seen initially.Conversely, a number of structures that are visible only after sig-nificant dissection in the open approach are easily viewed throughthe laparoscope [see Figure 1]. Identification of the iliopubic tract,Cooper’s ligament, and the transversus abdominis arch is manda-tory to ensure proper coverage by the prosthetic material used inthe repair.

During a TAPP repair, four important landmarks should beseen at initial laparoscopic inspection of the inguinal region [seeFigure 2]: the spermatic vessels, the obliterated umbilical artery(also referred to as the medial umbilical ligament or the bladderligament), the inferior epigastric vessels (also referred to as the lat-eral umbilical ligament), and the external iliac vessels. During aTEP repair, once the preperitoneal space has been established, thefirst easily identified landmarks are Cooper’s ligament and theinferior epigastric vessels; identification of these structures is help-ful in guiding early dissection.

Spermatic Vessels

The testicular artery and vein descend from the retroperitoneum,travel directly over and slightly lateral to the external iliac artery, andenter the internal spermatic ring posteriorly.These vessels are cov-ered only by the peritoneum and are usually well visualized as flatstructures in the abdominal cavity that assume a cordlike appear-ance when joined by the vas deferens immediately before enteringthe internal spermatic ring. If no hernia is present, a mere dimplewill be seen [see Figure 2]. In the TAPP approach, an indirect hernia,if present, will be immediately apparent and will have an obviousopening. In the TEP approach, the indirect sac will be seen later, af-ter dissection of the tissue on the anterior abdominal wall.The vasdeferens is best identified where it joins the spermatic vessels. Fromthere, the vas can be traced back medially as it courses over the

28 LAPAROSCOPIC HERNIA REPAIRLiane S. Feldman, M.D., F.A.C.S.,Marvin J.Wexler, M.D., F.A.C.S., and Shannon A. Fraser, M.D.

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pelvic brim and falls into the pelvis and behind the bladder.There isa small artery that runs with the vas deferens and is not well seen orknown. It is white and cordlike in appearance and can usually beseen just beneath the peritoneum.

Obliterated Umbilical Artery

The obliterated umbilical artery is an unfamiliar but sometimesprominent structure that is seen in the TAPP approach. It coursesalong the anterior abdominal wall toward the umbilicus, often withan apparent mesentery. It is most prominent in the region of themedial inguinal space.This ligament is most readily identified whenthe umbilical laparoscope is directed toward the pelvic midline,where the ligament’s bilateral structure is best seen as it is orientedtoward the umbilicus. Medial retraction of this structure is usuallynecessary for full exposure of the medial aspect of the inguinal canal.

Inferior Epigastric Vessels

The inferior epigastric artery and vein lie in the medial aspect ofthe internal inguinal ring and ascend the inferior surface of the rec-tus abdominis. In the TAPP approach, these vessels may be diffi-cult to visualize, particularly in obese patients.They are best iden-tified by locating the internal inguinal ring at the junction of the vasdeferens and the testicular artery and vein.At this location, the ves-sels exit the medial margin of the internal ring. However, they canquickly fade from view as they travel superiorly and medially alongthe anterior abdominal wall. In the TEP approach, early identifica-tion of the inferior epigastric vessels helps guide lateral dissection

and identification of the internal ring [see Figure 3]. However, dis-section in the incorrect plane when the preperitoneal space is ini-tially established may strip these vessels off the abdominal wall.

External Iliac Vessels

The lateral spermatic vessels and the medial vas deferens mergeat the internal inguinal ring and enter the inguinal canal, wherethey form the apex of the so-called triangle of doom [see Figure 4a,insert]. Beneath this triangle lie the external iliac artery and theexternal iliac vein. More laterally, the femoral nerve can be found.The external iliac vessels are often difficult to visualize, though inan elderly patient, a calcified pulsating artery may be prominent.Extreme care must be taken not to dissect within the triangle ofdoom, because such dissection can result in serious bleeding.

Cooper’s Ligament

Cooper’s ligament is a condensation of the transversalis fascia andthe periosteum of the superior pubic ramus lateral to the pubic tu-bercle. It can be seen only in the preperitoneal space and is the firstlandmark that should be identified during a TEP repair. In the initialstages of a TAPP repair, with the peritoneum intact, it is often easierto palpate the ligament than to see it, but once the ligament has beenidentified and cleaned, its glistening white fibers are apparent. Caremust be taken during dissection to avoid the tiny branches of the ob-turator vein that often run along the ligament’s surface.The iliopubictract inserts into the superior ramus of the pubis just lateral to Coop-er’s ligament, blending into it.

External Oblique MuscleInternal Oblique Muscle

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Figure 1 Laparoscopic inguinal hernia repair. Shown are (a) the anatomy of the left groin region as seenfrom the traditional anterior approach to herniorrhaphy and (b) the anatomy of the right groin from the pos-terior, or peritoneal, approach. The inguinal canal floor is covered by transverse fascia alone, and a largespace separates the transversus abdominis aponeurosis from the inguinal ligament (a). A preperitoneal viewof the groin region shows the distance between the transversus abdominis tendon and Cooper’s ligament, theiliopubic tract, and the inguinal ligament (b).



Internal Inguinal Ring

In the TAPP approach, the internal inguinal ring is normallyidentified by a slight indentation of the peritoneum at the junctionof the vas deferens and the spermatic vessels.When an indirect her-nia is present, however, a true ring or opening is easily identified,and by rotating a 30° laparoscope, the surgeon can look directlyinto the hernial sac or insert the laparoscope into the sac, whichoften allows the external inguinal ring to be identified more medi-ally. An indirect hernial sac lies anterior and lateral to the sper-matic cord at this level, as opposed to the familiar medial cordposition seen in the classic exterior groin approach to openherniorrhaphy. The medial border of the internal inguinal ring isformed by the transversalis fascia and the inferior epigastric ves-sels.The inferior border is formed by the iliopubic tract, a distinctstructure that is the internal counterpart of the inguinal ligament.Anteriorly, the internal inguinal ring is bordered by the transversusabdominis arch, which passes laterally over the internal ring andforms a very well defined visible edge.The layers of the abdominalwall constituting the lateral border of the internal inguinal ringappear the same as when viewed from the exterior approach, andthis border, like all margins of the internal inguinal ring, is visibleonly when an indirect hernia is present.

Iliopubic Tract

The iliopubic tract originates laterally from the anterior superi-or spine of the ilium and courses medially, forming the inferiormargin of the internal inguinal ring and the roof of the femoralcanal before inserting medially into the superior pubic ramus.This tract is formed by the condensation of the transversalis fas-cia with the most inferior portion of the transversus abdominismuscle and aponeurosis, and it is usually sturdy along its entirecourse. All inguinal hernia defects lie above the iliopubic tract,either anterior or superior to it. Conversely, femoral hernias occurbelow the tract, either posterior or inferior to it. Fibers of the ilio-pubic tract extend into Cooper’s ligament medially, where theybecome the medial margin of the femoral canal. The iliopubictract is frequently confused with the inguinal ligament.This liga-ment, though nearby, is part of the superficial musculoaponeu-rotic layer, which is not seen laparoscopically, whereas the iliopu-bic tract is part of the deep layer.

Femoral Canal

The femoral canal is seen only in the presence of a femoral her-nia in the most medial aspect of the femoral triangle.The anteriorand medial borders are formed by the iliopubic tract, the posteri-or border is formed by the pectineal fascia, and the lateral borderis formed by the femoral sheath and vein.

Trapezoid of Disaster

Another area worthy of careful attention is the so-called trape-zoid of disaster, containing the genitofemoral, ilioinguinal, iliohy-pogastric, and lateral cutaneous nerves of the thigh, which inner-vate the spermatic cord, the testicle, the scrotum, and the upperand lateral thigh, respectively.A detailed knowledge of the anatom-ic courses of the nerves and careful avoidance of these structuresduring dissection are essential [see Figure 4].

Genitofemoral nerve The genitofemoral nerve arises fromthe first and second lumbar nerves; pierces the psoas muscle andfascia at its medial border opposite L3 or L4; descends under theperitoneum, on the psoas major; and divides into a medial genitaland a lateral femoral branch.The femoral branch descends lateralto the external iliac artery and spermatic cord, passing posteroinfe-rior to the iliopubic tract and into the femoral sheath to supply theskin over the femoral triangle.The genital branch crosses the lowerend of the external iliac artery and enters the inguinal canal throughthe internal inguinal ring with the testicular vessels. This branchsupplies the coverings of the spermatic cord down to the skin of thescrotum. The genitofemoral nerve is the most visible of the cuta-neous nerves and is sometimes confused with the testicular vesselsif the latter are not well appreciated in their more medial position.

Ilioinguinal and iliohypogastric nerves When dissectedfrom the anterior position, the ilioinguinal and iliohypogastricnerves lie between the external oblique and the internal obliquemuscles above the internal inguinal ring and descend with thespermatic cord. In the abdomen, the ilioinguinal and iliohypogas-tric nerves arise from the 12th thoracic and first lumbar nerveroots, are more laterally located, and run subperitoneally, emerg-ing from the lateral psoas border to pierce the transversus abdo-minis near the iliac crest, then piercing and coursing between the

Figure 2 Laparoscopic inguinal hernia repair. Shown is a laparo-scopic view of the anatomy of the left groin with the peritoneumintact in a patient without a hernia. (IEV—inferior epigastric ves-sels; IR—internal ring; MUL—medial umbilical ligament; TV—testicular vessels; VD—vas deferens)

Figure 3 Laparoscopic inguinal hernia repair: TEP approach.The significant anatomic landmarks are identified at the internalring: the inferior epigastric vessels, Cooper’s ligament, and thespermatic vessels and cord, as well as the potential indirect spaceseen lateral to the cord structures.



internal oblique and the external oblique muscles close to theinternal inguinal ring. Aberrant branches sometimes descend withthe genital nerve.The ilioinguinal nerve supplies a small cutaneousarea near the external genitals.

Lateral cutaneous nerve of thigh Supplying the front andlateral aspect of the thigh, the lateral cutaneous nerve of the thigharises from the second and third lumbar nerves and emerges at thelateral border of the psoas. There, it descends deep to the peri-

toneum on the iliac muscle and only comes to lie in a superficialposition 3 cm below the anterosuperior iliac spine.

PREOPERATIVE EVALUATION

History and Physical Examination

Preoperative assessment is necessary to determine whether apatient is a suitable candidate for laparoscopic herniorrhaphy. Acareful surgical history, including both previous hernia repairs and

Quadratus LumborumMuscle

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's

Figure 4 Laparoscopic inguinal hernia repair. Shown are the courses of the genitofemoral and ilioinguinalnerves of the right groin (a) and of the left groin (b). Inset shows the preperitoneal anatomy of the right groin, asseen by the laparoscopic surgeon.



other procedures (particularly those involving the lowerabdomen), should be elicited.A cardiovascular history should alsobe obtained and risk factors for general anesthesia determined.

Physical examination should confirm the presence of aninguinal hernia. If the patient reports a history of a bulge but nohernia is felt on physical examination, an occult hernia may bepresumed. Ultrasonography may be helpful for distinguishing anincarcerated groin hernia from other causes of inguinal swelling(e.g., lymphadenopathy or venous varix).

Selection of Patients

Indications With the evolution of the open anteriorapproach to tension-free prosthetic mesh repair, determiningwhich patients will benefit significantly from laparoscopic hernior-rhaphy has become increasingly important. In 2003, the CochraneDatabase of Systemic Reviews4 published an update to its original2000 report on laparoscopic versus open techniques for herniarepair, which indicated that whereas laparoscopic repairs (TAPPand TEP) generally took longer and had a higher rate of more seri-ous complications (bowel, bladder, and vascular injuries) thanopen repairs, they also were associated with shorter recovery timesand a lower incidence of persistent pain and numbness.14 Reducedhernia recurrence was related to the use of mesh rather than tooperative technique.The overall risk of recurrence with the laparo-scopic approach may be related to the surgeon’s level of experi-ence.15We believe that patients are best served when a surgeon hasseveral approaches at his or her command that can be applied toand, if necessary, modified for individual circumstances.

Currently, we treat primary unilateral hernias with an openanterior mesh repair, preferably with the patient under local orregional anesthesia; possible exceptions include manual laborersand athletes who desire a rapid return to vigorous physical activi-ty. We generally reserve laparoscopic inguinal herniorrhaphy forthe following clinical situations:

1. Recurrent hernia after previous anterior repair. In suchcases, a laparoscopic approach allows the surgeon to avoidthe scar tissue and distorted anatomy present in the anteri-or abdominal wall by performing the repair through unvio-lated tissue, thereby potentially reducing the risk of damageto the vas deferens or the testicular vessels.This is especial-ly true when mesh has previously been placed anteriorly.

2. Bilateral hernias or a unilateral hernia when the presence ofa contralateral hernia is strongly suspected. In such cases, alaparoscopic approach allows the surgeon to repair the twohernias simultaneously (and perhaps more rapidly) withouthaving to make additional incisions.

3. Repair of an inguinal hernia concurrent with another lap-aroscopic procedure, provided that there is no contamina-tion of the peritoneal cavity.

The choice of laparoscopic technique depends on the patient’shistory and on the type of hernia present. In general, we favor TEPrepair for most patients because it does not involve entry into theabdominal cavity. The TEP approach reduces the risk of compli-cations affecting intra-abdominal structures, theoretically decreas-es the risk of adhesions, maintains an intact peritoneal layerbetween the mesh and the intra-abdominal contents, and allowsthe mesh to be placed without the use of fixation. However, it hasa steeper learning curve than TAPP does, and it may not be feasi-ble in patients who have undergone lower abdominal procedures.

Contraindications We do not treat acutely incarcerated her-nias laparoscopically. In patients to whom general anesthesia may

pose an increased risk, we prefer open anterior repair using localor regional anesthesia. In infants and young children with indirecthernias, for whom repair of the posterior canal wall is unnecessary,we recommend high ligation of the sac via the anterior approach.

Previous lower abdominal surgery, though not an absolute con-traindication, may make laparoscopic dissection difficult. In par-ticular, with respect to TEP repair, previous lower abdominal wallincisions may make it impossible to safely separate the peritoneumfrom the abdominal parietes for entry into the extraperitonealplane, and conversion to a TAPP repair or an open repair may berequired. Previous surgery in the retropubic space of Retzius, as inprostatic procedures, is a relative contraindication that is associat-ed with an increased risk of bladder injury16 and other complica-tions.17 Similarly, previous pelvic irradiation may preclude safe dis-section of the peritoneum from the abdominal wall.18

OPERATIVE PLANNING

Preparation

General anesthesia is administered routinely. Prophylactic antibi-otics are unnecessary.19The patient is instructed to void before sur-gery, which renders bladder catheterization unnecessary.

Patient Positioning

The patient is placed in the supine position with both armstucked against the sides. The anesthesia screen is placed as fartoward the head of the table as possible to allow the surgeon awide range of mobility with the laparoscope.The skin is preparedand draped so as to allow exposure of the entire lower abdomen,the genital region, and the upper thighs because manipulation ofthe hernial sac and the scrotum may be necessary. After thelaparoscope has been introduced, the patient is placed in a deepTrendelenburg position so that the viscera will fall away from theinguinal areas. Further bowel manipulation is rarely necessary,except to reduce hernial contents. Rotation of the table to elevatethe side of the hernia can provide additional exposure, if necessary.A single video monitor is placed at the foot of the bed, directly fac-ing the patient’s head.

The surgeon usually begins the repair while standing on theside contralateral to the defect; the assistant surgeon stands oppo-site the surgeon, and the nurse stands on the ipsilateral side [seeFigure 5]. A two-handed operating technique provides a distincttechnical advantage.

Equipment

Because inguinal hernias occur in the anterior abdominal wall,visualization through the umbilicus requires that the laparoscopebe angled close to the horizontal plane.The view is paralleled ante-riorly by the surface of the lower abdominal wall, which may makevisualization with a 0° laparoscope difficult. In addition, an indi-rect hernia is a three-dimensional tubular defect that can be wellvisualized in its entirety only with an angled lens. For these reasons,we recommend routine use of an oblique, forward-viewing 30° or45° laparoscope. Excellent laparoscopes are currently available in10 mm and 5 mm sizes. For the TAPP repair, one 10/12 mm andtwo 5 mm trocars are used.The dissection is performed with a dis-sector and scissors, to which an electrocautery may be attached.For mesh fixation, we currently use a spiral tacker (e.g.,TACKER;U.S. Surgical Inc., Norwalk, Connecticut).

In a TEP repair, besides the equipment needed for a TAPPrepair, a balloon-tipped blunt trocar is used to gain access to thepreperitoneal space. We usually develop the preperitoneal spacewith a balloon system [see Operative Technique,Totally Extraperi-



toneal Repair, below], but this can also be done with blunt dissec-tion if the surgeon prefers.Two additional 5 mm trocars are placed.The dissection is performed with two blunt-tipped dissectors.

OPERATIVE TECHNIQUE

Totally Extraperitoneal Repair

The extra-abdominal preperitoneal approach to laparoscopichernia repair, developed by McKernan,20,21 attempts to duplicatethe open preperitoneal repair described by Stoppa22-24 andWantz.12,25 In a TEP repair, the trocars are placed preperitoneallyin a space created between the fascia and the peritoneum. Ideally,the dissection remains in the extra-abdominal plane at all times,and the peritoneum is never penetrated.

Step 1: creation of preperitoneal space With the patientin the Trendelenburg position, the anterior rectus fascia is openedthrough a 1 cm infraumbilical transverse incision placed slightlytoward the side of the hernia, which helps prevent inadvertentopening of the peritoneum. An index finger is inserted on themedial aspect of the exposed rectus abdominis and slid over theposterior rectus sheath. In this plane, a preperitoneal tunnel be-tween the recti abdominis and the peritoneum is created in themidline by inserting a Kelly forceps (with the tips up) and per-forming gentle blunt dissection to the level of the symphysis pubis.A blunt 10/12 mm trocar is then secured in the preperitonealspace with fascial stay sutures.

A 30°or 45° operating laparoscope is inserted into the trocar forvisualization of the development of the correct plane while insuffla-tion of the preperitoneal space is begun, with the recti abdominisseen anteriorly and the peritoneum posteriorly. Maximal inflationpressure is 10 to 12 mm Hg to prevent disruption of the peritoneumor development of extensive subcutaneous emphysema. Blunt gentledissection with the laparoscope is employed to develop the space suf-ficiently to allow placement of additional trocars.

An alternative approach to dissection of the preperitonealspace—one that is especially helpful early in a surgeon’s experi-ence—is to employ a preperitoneal distention balloon system(e.g., PDB; U.S. Surgical Inc., Norwalk, Connecticut). This sys-tem consists of a trocar with an inflatable balloon at its tip, whichis used to develop the preperitoneal space by atraumatically sepa-rating the peritoneum from the abdominal wall. The balloon is

Anesthesia

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Figure 5 Laparoscopic inguinal hernia repair. Shown is one ofseveral possible OR setups. The surgeon stands on the side con-tralateral to the defect, with a nurse on the ipsilateral side. Theassistant surgeon stands opposite the surgeon. This positioningmay vary, depending on the surgeon’s preference and handed-ness, the visibility of the defect, and the type of defect present, aswell as on the prominence of the medial umbilical ligament andthe need for its retraction

a b c

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Figure 6 Laparoscopic inguinal hernia repair: TEP approach. Shown is the preperitoneal distention balloon(PDB) system. The PDB is introduced into the preperitoneal space (a). As it is tunneled inferiorly toward thepubis, the PDB is inflated under laparoscopic vision (b). Once the preperitoneal space is created, the PDB isremoved and replaced with a blunt-tip trocar. The preperitoneal space is insufflated under low pressure, addi-tional trocars are placed, and the repair is completed (c).



inserted into the preperitoneal space below the umbilicus bymeans of an open Hasson technique and is tunneled inferiorlytoward the pubis until the bone is felt with the tip of the balloontrocar.With the laparoscope in the trocar, the preperitoneal work-ing space is developed by gradual inflation of the balloon to a vol-ume of 1 L; the transparency of the balloon permits constantlaparoscopic visualization throughout the distention process. Oncethe working space is created, the PDB is removed and replacedwith a blunt sealing trocar. S-retractors are used to elevate the rec-tus and help ensure correct positioning of the trocar above theposterior fascia.The preperitoneal space is then reinsufflated to apressure of 10 to 12 mm Hg [see Figure 6].

Step 2: trocar placement After the peritoneum is dissectedaway from the rectus abdominis, a midline 5 mm trocar is insert-ed under direct vision three fingerbreadths below the infraumbili-cal port. A second 5 mm trocar is then inserted another three fin-gerbreadths below the first 5 mm trocar. Placement of the work-ing trocars away from the pubis facilitates mesh placement, in thatthe bottom port is not covered by the top of the mesh and there-by rendered nonfunctional [see Figure 7]. Care must be taken notto penetrate the peritoneum during trocar placement. If the peri-toneum is penetrated, the resulting pneumoperitoneum canreduce the already limited working space. If the working space iscompromised to the point where the repair cannot continue(which is not always the case), the surgeon can either try to repairthe rent with a suture or place a Veress needle in the upper abdom-inal peritoneal cavity. If such maneuvers are unsuccessful, the lossof working space may necessitate conversion to a TAPP approach.

Step 3: dissection of hernial sac Wide dissection of thepreperitoneal space is then undertaken with blunt graspers in atwo-handed technique by bluntly dividing the avascular areolartissue between the peritoneum and the abdominal wall [seeFigure 8].The pubis, Cooper’s ligament, and the inferior epigas-tric vessels are located first and used to orient the dissection. If

a direct hernia is present medial to the inferior epigastric vessels,it will often be reduced by the balloon dissector [see Figure 9]. Ifnot, the sac and the preperitoneal contents are carefully dissect-ed away from the fascial defect and swept cephalad as far as pos-sible. Gentle traction is applied to expose and dissect away theattachment of the peritoneum to the transversalis fascia [seeFigure 10].

The indirect space is then exposed by sweeping off the tissuelateral to the inferior epigastric vessels until the peritoneum isfound. If a lipoma of the cord is present, it will be lateral to andcovering the peritoneum and should be dissected out of the inter-nal ring in a cephalad direction to prevent it from displacing themesh.18 If there is no indirect hernia, the peritoneum will be foundcephalad to the internal ring. To ensure secure mesh placement,the peritoneum is bluntly dissected off the cord structures andplaced as far cephalad as possible.

Figure 8 Laparoscopic inguinal hernia repair: TEP approach.The edge of the peritoneum is identified lateral to the internalring and is dissected cephalad off the abdominal wall.

Figure 9 Laparoscopic inguinal hernia repair: TEP approach.Shown is a right-side direct hernia, with the inferior epigastricvessels lateral to the defect, as visualized after initial gas insuffla-tion and before dissection of preperitoneal fat.

Figure 7 Laparoscopic inguinal hernia repair: TEP approach.Shown is standard trocar placement for TEP repair. As in TAPPrepair, three trocar sites are used. One trocar is placed in theumbilicus; the second is placed in the midline, midway betweenthe umbilicus and the pubis; and the third is placed above thepubic arch. The trocars should not penetrate the peritoneum.

If an indirect hernia is present, the sac will be lateral and ante-rior to the cord structures. A small indirect hernial sac is bluntlydissected off the spermatic cord with a hand-over-hand techniqueand reduced until an area sufficient for mesh placement is created[see Figure 11].To prevent early recurrence, all attachments of theperitoneum should be dissected cephalad to where the inferioredge of the mesh will be. If a large indirect sac is not easily reducedfrom the scrotum, it may be transected in its superolateral edge,dissected off the cord structures, and closed with an endoscopicligating loop.The distal sac is then left in place and not ligated.

Unlike a TAPP repair, in which any indirect hernia present isreadily apparent at first inspection, a TEP repair always requiresthat the space lateral to the inferior epigastric vessels be dissectedto make sure that there is no indirect component.This dissectionshould be done even if a direct or femoral hernia is identified.Themedial border of dissection is the iliac vein or its overlying fat, andthe lateral border of dissection is the psoas muscle. Superiorly, dis-section should reach the level of the umbilicus.

Step 4: placement of mesh As a rule, we use a large (10.8× 16 cm) piece of polypropylene mesh shaped to the contoursof the inguinal region. A number of different products can alsobe used for this purpose, including various forms of polypropy-lene and several types of polyester. A marking suture is placedat the superior edge of the mesh on the concave side, which isto be apposed to the peritoneum.The mesh is wrapped arounda grasper in a tubular fashion, then inserted through the umbil-ical trocar into the preperitoneal space. Once in the preperi-toneal space, the mesh is manipulated to cover the pubic tuber-cle, the internal ring, Cooper’s ligament, the femoral canal, andthe rectus abdominis superiorly [see Figure 12].Tacks or suturesare not usually needed for fixation, but if they are used, theyshould be placed into Cooper’s ligament and the anteriorabdominal wall; to prevent nerve injury, no tacks should beplaced inferior to the iliopubic tract lateral to the internal ring.Some surgeons believe that with direct hernias, there is a riskthat the mesh may migrate into a large defect.Accordingly, theyplace several tacks into Cooper’s ligament to prevent this occur-rence. For bilateral hernias, two identical repairs are done, and twomesh patches are used.

Step 5: closure The operative site is inspected for hemosta-sis. The trocars are removed under direct vision. The insufflatedCO2 is slowly released so that the mesh may be visualized as thepreperitoneal fat and contents collapse back onto the mesh. Thefascia at trocar sites 10 mm or larger is closed with 2-0 polydiox-anone sutures, and the skin is closed with subcuticular sutures.

Transabdominal Preperitoneal Repair

Step 1: placement of trocars Pneumoperitoneum is estab-lished through a small infraumbilical incision.We generally preferan open technique, in which a blunt-tipped 12 mm trocar isinserted into the peritoneal cavity under direct vision. CO2 is theninsufflated into the abdomen to a pressure of 12 to 15 mm Hg.The angled laparoscope is introduced, and both inguinal areas areinspected.Two 5 mm ports are placed, one at the lateral border ofeach rectus abdominis at the level of the umbilicus, to allow place-ment of the camera and the instruments [see Figure 13].The 5 mmlateral ports may be replaced with 10 mm ports if only a 10 mmlaparoscope is available.

Step 2: identification of anatomic landmarks The fourkey anatomic landmarks mentioned earlier [see LaparoscopicInguinal Hernia Repair, Anatomic Considerations, above]—thespermatic vessels, the obliterated umbilical artery (medial umbili-cal ligament), the inferior epigastric vessels (lateral umbilical liga-ment), and the external iliac vessels—are identified on each side.

In the presence of an indirect hernia, the internal inguinal ring iseasily identified by the presence of a discrete hole lateral to the junc-tion of the vas deferens, the testicular vessels, and the inferior epigas-tric vessels. Identification of a direct hernia can be more difficult.Sometimes, a direct hernia appears as a complete circle or hole; atother times, it appears as a cleft, medial to the vas deferens–vascularjunction; and at still other times, it is completely hidden by preperi-toneal fat and the bladder and umbilical ligaments.Visualization canbe particularly difficult in obese patients, who may have considerablelipomatous tissue between the peritoneum and the transversalis fas-cia, or in patients whose hernia consists of a weakness and bulging ofthe entire inguinal floor rather than a distinct sac. For adequate defi-nition of this type of hernia and deeper anatomic structures, the peri-toneum must be opened, a peritoneal flap developed, and the under-lying fatty layer dissected.26 Direct hernial defects are often situated



Figure 10 Laparoscopic inguinal hernia repair: TEP approach.The transversalis fascia is seen adherent to the hernial sac. Thesac must be separated from the fascia and dissected cephalad tothe level of the umbilicus.

Figure 11 Laparoscopic inguinal hernia repair: TEP approach.Shown is an indirect hernial sac retracted laterally, with cordstructures visualized medially.

medial to the ipsilateral umbilical ligament, and retraction or evendivision of this structure is sometimes necessary. Division of thisstructure has no negative sequelae; however, the surgeon should be aware that the obliterated umbilical artery may still be patent and that use of the electrocautery or clips may be necessary.Tractionon the ipsilateral testicle can demonstrate the vas deferens when visualization is obscured by overlying fat or pressure from the pneumoperitoneum.

Step 3: creation of peritoneal flap The curved scissors orthe hook cautery is used to create a peritoneal flap by making atransverse incision along the peritoneum, beginning 2 cm abovethe upper border of the internal inguinal ring and extending medi-ally above the pubic tubercle and laterally 5 cm beyond the inter-nal inguinal ring [see Figure 14]. Extreme care must be taken toavoid the inferior epigastric vessels. Bleeding from these vesselscan usually be controlled by cauterization, but application ofhemostatic clips may be necessary on occasion. Another solutionis to pass percutaneously placed sutures above and below thebleeding point while applying pressure to the bleeding vessel so asnot to obscure the field of vision. If the monopolar cautery is usedto create the peritoneal flap, the entire uninsulated portion of theinstrument must be visible at all times to ensure that inadvertentbowel injury does not occur.

The incised peritoneum is grasped along with the attachedpreperitoneal fat and the peritoneal sac and is dissected cephaladwith blunt and sharp instruments to create a lower peritoneal flap[see Figure 15]. Dissection must stay close to the abdominal wall.A significant amount of preperitoneal fat may be encountered,and this should remain with the peritoneal flap so that the abdom-inal wall is cleared. When the correct preperitoneal plane isentered, dissection is almost bloodless and is easily carried out.



Figure 12 Laparoscopic inguinal hernia repair: TEP approach.The mesh is oriented so as to cover the indirect, direct, andfemoral spaces (inguinal floor). The dissected hernial sac isplaced over the top of the mesh to reduce the risk that the sac willslide underneath the mesh and cause a recurrence of the hernia.

Figure 13 Laparoscopic inguinal hernia repair: TAPP approach.Shown is standard trocar placement for TAPP repair. Usually,three trocar sites are used. The laparoscope is inserted throughthe umbilical trocar, and two additional trocars are placed in theright and the left midabdomen. To ensure that the first trocar isnot placed too close to the surgical field, the first trocar should beplaced either in the umbilicus or immediately above it. The twolateral trocars should be placed lateral to the rectus sheath to pre-vent bleeding and postoperative muscle spasms. At least one tro-car must be 10/12 mm to allow insertion of the mesh.

Umbilicus

Figure 15 Laparoscopic inguinal hernia repair:TAPP approach. A flap of peritoneum is dissecteddownward, revealing a hernial defect and the inferiorepigastric vessels (arrow) on the left side.

Figure 14 Laparoscopic inguinal hernia repair:TAPP approach. Shown is dissection of a left directinguinal hernia. The hernial sac is inverted and theperitoneum incised superior to the sac.



Step 4: dissection of hernial sac The hernial sac, if pres-ent, is removed from Hesselbach’s triangle or the spermatic cordand surrounding muscle through inward traction, countertrac-tion, and blunt dissection with progressive inversion of the sacuntil the musculofascial boundary of the internal inguinal ringand the key deep anatomic structures are identified. In mostcases, the hernial sac can be slowly drawn away from the trans-versalis fascia or the spermatic cord. The sac is grasped at itsapex and pulled inward, thus being reduced by inversion. Theindirect sac may be visualized more easily if it is grasped andretracted medially; this step facilitates its dissection away fromthe cord structures.

Spermatic cord lipomas usually lie posterolaterally and are exten-sions of preperitoneal fat. In the presence of an indirect defect, suchlipomas should be dissected off the cord along with the peritonealflap to lie cephalad to the internal inguinal ring and the subsequentrepair so that prolapse through the ring can be prevented.

A large indirect hernial sac can be divided at the internal ring if it cannot be readily dissected away from the cord structures.This step may prevent the type of cord injury that can result fromextensive dissection of a large indirect sac. Division of a large in-direct sac is best accomplished by opening the sac on the side op-posite the spermatic cord, then completing the division from theinside.16

Step 5: reidentification and exposure of landmarks Oncethe peritoneal flap has been created, the key anatomic landmarksmentioned earlier [see Laparoscopic Inguinal Hernia Repair,Anatomic Considerations, above] must be reidentified andexposed so that neurovascular structures can be protected frominjury and the tissues required for reliable mesh fixation can belocated. The pubic tubercle is often more easily felt than seen.Cooper’s ligament is initially felt and subsequently seen along thepectineal prominence of the superior pubic ramus as dissectioncontinues laterally and fatty tissue is swept off to expose the glis-tening white structure. Care must be taken to avoid the numeroussmall veins that often run on the surface of the ligament, as wellas to avoid the occasional aberrant obturator artery.The iliopubictract is initially identified at the inferior margin of the internalinguinal ring, with the spermatic cord above, and is then followedin both a medial and a lateral direction. Minimal dissection is car-ried out inferior to the iliopubic tract so as not to injure the geni-tal femoral nerve, the femoral nerve, and the lateral cutaneousnerve of the thigh [see Figure 16].

Step 6: placement of mesh A 10 × 6 cm sheet ofpolypropylene mesh is rolled into a tubular shape and introducedinto the abdomen through the 10/12 mm umbilical trocar.Prolene is preferable to Marlex in this application because it is lessdense, conforms more easily to the posterior inguinal wall, and haslarger pores, which facilitate visualization and subsequent secur-ing with staples or tacks. The inherent elasticity and resiliency ofProlene mesh allow it to unroll easily while maintaining its form.The mesh is used to cover the direct space (Hesselbach’s triangle),the indirect space, and the femoral ring areas (i.e., the entireinguinal floor).We do not make a slit in the mesh for the cord.

It is our practice with the TAPP technique to tack the mesh toprevent any migration.We use an endoscopic multifire spiral tack-er to secure the mesh, beginning medially and proceeding lateral-ly. The upper margin is first tacked to the rectus abdominis andthe transversus abdominis fascia and arch, with care taken to stay1 to 2 cm above the level of the internal inguinal ring and to avoidthe inferior epigastric vessels, up to a point several centimeters lat-eral to the internal inguinal ring or the indirect hernial defect.Extending mesh fixation to the anterior iliac spine is neither nec-essary nor desirable.A two-handed technique is recommended fortack placement: one hand is on the tacker, and the other is on theabdominal wall, applying external pressure to place the wallagainst the tacker.The tacker itself is frequently pushed against thetissues and used as a spreader and palpator. However, it must notbe forced too deeply into the abdominal wall superolateral to thespermatic cord; doing so might lead to inadvertent entrapment of the sensory nerves. The tacker can be moved from the left to the right port, depending on which position more readily allowsplacement of the staples perpendicular to the mesh and the abdo-minal wall.

Once the superior margin is fixed, fixation of the inferior margin isaccomplished, beginning at the pubic tubercle and moving laterallyalong Cooper’s ligament.The mesh is lifted frequently to ensure ad-equate visualization of the spermatic cord. Care is taken to avoid theadjacent external iliac vessels, which lie inferiorly. Lateral to the cordstructures, all tacks are placed superior to the iliopubic tract to pre-vent subsequent neuralgias involving the lateral cutaneous nerve ofthe thigh or the branches of the genitofemoral nerve. If the surgeoncan palpate the tacker through the abdominal wall with the non-dominant hand, the tacker is above the iliopubic tract. The meshshould lie flat at the end of the procedure.

Step 7: closure of peritoneum The peritoneal flap, includ-ing the redundant inverted hernial sac, is placed over the mesh,and the peritoneum is reapproximated with the tacker [see Figure17]. Reduction of the intra-abdominal pressure to 8 mm Hg, cou-pled with external abdominal wall pressure, facilitates a tension-free reapproximation. Alternatively, the peritoneum may besutured over the mesh, but in most surgeons’ hands, this closuretakes longer.

Step 8: closure of fascia and skin The peritoneal repair isinspected to ensure that there are no major gaps that might resultin exposure of the mesh and subsequent formation of adhesions.The trocars are then removed under direct vision, and the pneu-moperitoneum is released.The fascia at the 10/12 mm port sitesis closed with 2-0 polydioxanone sutures to prevent incisional her-nias.The skin is closed with 4-0 absorbable subcuticular sutures.

POSTOPERATIVE CARE

Patients are observed in the recovery room until they are ableto ambulate unassisted and to void; if they are unable to void at

Direct Defect

Figure 16 Laparoscopic inguinal hernia repair: TAPP approach.Dissection of the preperitoneal space on the left side allows iden-tification of the anatomic landmarks. The dissector points to theiliopubic tract inferior to the direct hernial defect.



the time of discharge, in-and-out catheterization is performed. Pa-tients are advised to resume their usual activities as they see fit;driving a car is permitted when pain is minimal. Outpatient pre-scriptions for acetaminophen, naproxen, and oxycodone aregiven, and follow-up visits in the surgical clinic are scheduled forpostoperative day 7 to 14. Patients who live alone, have had intra-operative complications, have significant nausea or vomiting, orexperience unexplained or inordinate pain are admittedovernight.

DISADVANTAGES AND COMPLICATIONS

Disadvantages

Need for general anesthesia The need for pneumoperi-toneum and thus for general anesthesia in laparoscopic hernior-rhaphy is sometimes considered a major disadvantage. Nausea,dizziness, and headache are more common in the recovery roomafter TAPP repair than after Lichtenstein repair.27 It is not neces-sarily true, however, that local or regional anesthesia is safer thangeneral anesthesia.28 Anesthesiology studies critically appraisinganesthetic techniques for hernia surgery have shown the choice ofgeneral anesthesia over local or regional anesthesia to be safe and,in many cases, advantageous, particularly in patients who are inpoor health. Furthermore,TEP repair has been successfully donewith patients under epidural and local anesthesia.14,29,30

Lower cost-effectiveness A study comparing costs atNorth American teaching hospitals found that TEP repair costUS$852 more than Lichtenstein repair; however, this study couldnot quantify the cost savings arising from faster recuperation andearlier reentry into the workforce.31 Some studies have demon-strated economic savings with the use of a laparoscopic approach,in the form of fewer days of work missed and reduced worker’scompensation costs.32,33 Operating costs can also be reduced byavoiding the use of disposable instruments.34 In addition, operat-ing time has been shown to decrease as the surgeon’s experiencewith the procedure increases.15,35,36

Complications

Most randomized trials comparing laparoscopic repair withopen mesh repair have found the overall complication rate to becomparable between groups.14,15 In general, however, the rate ofserious perioperative complications, though still low, is increasedwith the laparoscopic approach.15

Complications of access to peritoneal cavity A TAPPrepair exposes the patient to several potentially serious risks relat-ed to the choice of the transabdominal route.Trocar injuries to thebowel, the bladder, and the vascular structures can occur duringthe creation of the initial pneumoperitoneum or the subsequentinsertion of the trocars.14,37 Visceral injury rates reported for thelaparoscopic approach, though quite low, are still about 10 timesthose reported for the open approach.14 Another complicationrelated to trocar placement is incisional hernia,14 which can leadto postoperative bowel obstruction14,15,38; however, this complica-tion can be minimized by using 5 mm trocars and a 5 mm laparo-scope instead of the larger 10/12 mm instruments.

Complications of dissection Injuries occurring during dis-section are often linked to inexperience with laparoscopic inguinalanatomy. If serious enough, they can necessitate laparotomy.Fortunately, such conversion is rare (< 3%).14 The most commonvascular injuries occurring during laparoscopic inguinal herniorrha-phy are those involving the inferior epigastric vessels and the sper-matic vessels.14 The external iliac, circumflex iliac, profunda, andobturator vessels are also at risk. A previous lower abdominal oper-ation is a risk factor.16 The source of any abnormal bleeding duringthe procedure must be quickly identified.All vessels in the groin canbe ligated except the external iliac vessels, which must be repaired.16

Injuries to the urinary tract may also occur. Four bladderinjuries necessitating repair were documented in a collected seriesof 762 laparoscopic repairs by different surgical groups.37,39,40

Bladder injuries are most likely to occur when the space of Retziushas been previously dissected (e.g., in a prostatectomy). Renal andureteral injuries identified intraoperatively should be repairedimmediately. Often, however, these injuries are not apparent untilthe postoperative period, when they present as lower abdominalpain, renal failure, ascites, dysuria, or hematuria—all of whichshould be investigated promptly. Although indwelling catheterdrainage may constitute sufficient treatment of a missed retroperi-toneal bladder injury, intraperitoneal injuries are best treated bydirect repair via either laparoscopy or laparotomy.

Complications related to mesh Complications related tothe use of mesh include infection, migration, adhesion formation,and erosion into intraperitoneal organs. Such complications usu-ally become apparent weeks to years after the initial repair, pre-senting as abscess, fistula, or small bowel obstruction.

Mesh infection is very rare. In the 2003 Cochrane review ofantibiotic prophylaxis for nonmesh hernia repairs,19 the overallinfection rate was 4.69% in the control group and 3.08% in thetreatment group. Thus, to prevent one infection in 30 days, 50patients would have to be treated, and these patients would thenbe at risk for antibiotic-associated complications. Laparoscopicrepairs were excluded from this review; however, in a meta-analy-sis comparing postoperative complications after laparoscopicinguinal hernia repair with those after open repair, superficialinfection was less frequent in the laparoscopic groups.14 Deepmesh infection was rare in both groups. Mesh infection usuallyresponds to conservative treatment with antibiotics and drainage.On rare occasions, the mesh must be removed; this may beaccomplished via an external approach. It is noteworthy thatremoval of the mesh does not always lead to recurrence of the her-nia, a finding that may be attributable to the resulting fibrosis.41

Mesh migration may lead to hernia recurrence. In a TAPPrepair, appropriate stapling of the mesh should reduce this possi-bility. In a TEP repair, stapling does not appear to be necessary toprevent migration.35,42

Figure 17 Laparoscopic inguinal hernia repair: TAPP approach.The peritoneum is stapled over the mesh.



The risk that adhesions to the mesh will form is augmented ifthe mesh is left exposed to the bowel. The long-term durabilityand effectiveness of the sometimes flimsy peritoneal coverageemployed in the TAPP approach have been questioned. Even inthe TEP approach, small tears in the peritoneum may expose thebowel to the mesh.

Urinary complications Injuries to the urinary tract aside [seeComplications of Dissection, above], urinary retention, urinary tractinfection, and hematuria are the most common complications.Avoidance of bladder catheterization reduces the incidence of thesecomplications,but urinary retention still occurs in 1.5% to 3% of pa-tients.15 General anesthesia and the administration of large volumesof I.V. fluids may also predispose to retention.

Vas deferens and testicular complications Wantz43 be-lieved that the most common cause of postoperative testicularswelling, orchitis, and ischemic atrophy is surgical trauma to thetesticular veins (i.e., venous congestion and subsequent thrombo-sis). Because spermatic cord dissection is minimized with thelaparoscopic approach, the risk of groin and testicular complica-tions resulting from injury to cord structures and adjacent nervesmay be reduced.15

Most testicular complications, such as swelling, pain and epi-didymitis, are self-limited. Testicular pain occurs in about 1% ofpatients after laparoscopic repair,33 an incidence comparable tothat seen after open repair.15,44 A similar number of patients expe-rience testicular atrophy,37 for which there is no specific treatment.

The risk of injury to the vas deferens appears to be much thesame in laparoscopic repair as in open repair.14 If fertility is anissue, the cut ends should be reapproximated if the injury is rec-ognized intraoperatively.

Postoperative groin and thigh pain Unlike patients whoundergo open anterior herniorrhaphy, in whom discomfort ornumbness is usually localized to the operative area, patients whoundergo laparoscopic repair occasionally describe unusual butspecific symptoms of deep discomfort that are usually positionaland are often of a transient, shooting nature suggestive of nerveirritation. The pain is frequently incited by stooping, twisting, ormovements causing extension of the hip and can be shocklike.Although these symptoms can frequently be elicited in the earlypostoperative period, they are usually transient. If tacks or stapleswere used and neuralgia is present in the recovery room, promptreexploration is the best approach.16

Persistent pain and burning sensations in the inguinal region,the upper medial thigh, or the spermatic cord and scrotal skinregion occur when the genitofemoral nerve or the ilioinguinalnerve is stimulated, entrapped, or unintentionally injured.Whenthese symptoms persist, they may result in severe morbidity.45 Amore worrisome symptom is lateral or central upper medialthigh numbness, which is reported in 1% to 2% of patients andoften lasts several months or longer. Whether this numbness isrelated to staple entrapment, fibrous adhesions, cicatricial neu-roma, or mesh irritation is unknown. Numbness and paresthesiaof the lateral thigh are less frequent and are related to theinvolvement of fibers of the lateral cutaneous nerve.These prob-lems can be prevented by paying careful attention to anatomicdetail and technique.46 Anatomic study, based on cadaveric dis-sections, suggests that both the genitofemoral nerve and the lat-eral cutaneous nerve of the thigh will be protected in all cases ifno staples are placed further than 1.5 cm lateral to the edge ofthe internal ring.47

A great deal of attention has rightly been focused on the risk ofnerve injury with laparoscopic hernia repair, as well as on ways ofpreventing it.At the same time, it is important to note that pain andnumbness, including thigh numbness, can also occur after openrepair and may in fact be more common in that setting than waspreviously realized. In one study, persistent groin pain was presentin 9.5% of patients after Lichtenstein repair versus 5.5% of patientsafter TAPP.48 In the Cochrane meta-analysis, persistent pain andnumbness 1 year after surgery were found to be significantlyreduced with either TEP or TAPP repair.14 This finding was con-firmed by a 2004 study that reported a 9.8% incidence of neuralgiaor other pain at 2 years in patients who underwent laparoscopicrepair, compared with a 14.3% incidence in open repair patients.15

Miscellaneous complications Laparoscopic repair appar-ently reduces the incidence of hematomas while increasing that ofseromas.14 Lipomas of the spermatic cord, if left unreduced inpatients with indirect hernias, may produce a persistent groinmass and a cough impulse that mimic recurrence, especially to anuninitiated examiner.These lipomas are always asymptomatic.

OUTCOME EVALUATION

Although there is a large body of literature on laparoscopicinguinal hernia repair—including a variety of randomized, con-trolled trials—the benefits of the laparoscopic approach have notyet been clearly defined or widely accepted. Given the low mor-bidity and relatively short recovery already associated with theconventional operation, demonstration of any significant differ-ences between the open mesh and laparoscopic techniquesrequires large study samples. The previously cited meta-analysisdone by the Cochrane collaboration addressed this question.14

Forty-one trials were included in this meta-analysis, ranging in sizefrom 38 to 994 randomized patients. The duration of follow-upranged from 6 weeks to 36 months.The results of the meta-analy-sis suggested that whereas operating times were longer and the riskof rare but serious complications higher in the laparoscopicgroups, recovery was quicker and persistent pain and numbnessless frequent. Recurrence rates did not differ significantly.

In addition, a large randomized, multicenter Veterans Affairs(VA) study published in 2004 compared open mesh repair with lap-aroscopic mesh repair (TEP, 90%; TAPP, 10%) in 2,164 patients.15

Patients with previous mesh repairs were excluded. In this study,the laparoscopic approach was associated with a higher risk of com-plications and, in contrast to the findings of the meta-analysis, ahigher overall recurrence rate at 2 years after operation. Pain wasreduced and recovery time shortened in the laparoscopic group.

Thus, there remains a degree of controversy regarding the idealapproach to and outcome for inguinal hernia repair. Accordingly,we will briefly review the salient outcomes of a number of studiesthat compare laparoscopic inguinal herniorrhaphy with openmesh repair.

Laparoscopic Repair versus Open Mesh Repair

Operating time The Cochrane meta-analysis suggested thatoverall, the average operating time was 15 minutes longer with thelaparoscopic approach; however, for bilateral hernias, laparoscop-ic repair required no more time than open repair.14 The surgeon’slevel of experience with laparoscopic technique was not explicitlystated in all of these studies, which made it difficult to assess theimpact of this variable on operating time. It has been shown thatwith more experience and greater specialization, the differences inoperating time between laparoscopic and open repair tend todecrease and become clinically unimportant.35,49



Recovery time The most significant short-term outcomemeasure after hernia repair is recovery time, defined as the timerequired for the patient to return to normal activities. One of themost frequently cited benefits of laparoscopic herniorrhaphy is the patient’s rapid return to unrestricted activity, including work.The Cochrane meta-analysis revealed that recovery time was significantly shorter after laparoscopic repair than after openmesh repair.14 In a cost comparison between TEP repair andLichtenstein repair, recovery time was 15 days after the former,compared with 34 days after the latter.31 In the 2004 VA study,laparoscopic repair patients returned to their normal activities 1day earlier.15

Postoperative pain After laparoscopic repair, mostpatients experience minimal immediate postoperative pain andhave little or no need for analgesics after postoperative day 1.Patients are able to perform some exercises better after laparo-scopic repair than after Lichtenstein repair.48 That patients expe-rience less postoperative pain after laparoscopic repair than afteropen mesh repair has been reported in several randomized stud-ies.27,32,40,44,50,51 In the Cochrane meta-analysis, persistent painand numbness 1 year after surgery was significantly less aftereither TEP or TAPP repair than after open repair.14 In a 2003report describing a 5-year follow-up of 400 patients treated witheither Lichtenstein open mesh repair or TAPP repair, the inci-dence of permanent paresthesia and groin pain was lower withthe TAPP approach.52 Moreover, all of the patients with pain andparesthesia significant enough to affect their daily lives were inthe open repair group. A later study that evaluated postoperativeneuralgia in 400 patients who underwent either TAPP repair orLichtenstein repair reported similar findings.48

Quality of life The studies that have assessed quality of lifeimmediately after hernia repair have tended to favor the laparo-scopic approach, albeit marginally. Using the SF-36 (a widelyaccepted general health-related quality-of-life questionnaire), onegroup found that at 1 month, greater improvements from baselinewere apparent in the laparoscopic group in every dimensionexcept general health; however, by 3 months, the differencesbetween the two groups were no longer significant.27 Anothergroup also found no differences in any SF-36 domains at 3months after operation.37 Yet another study, however, using theSickness Impact Profile, found some benefit to the laparoscopicapproach.53 In contrast, no postoperative differences in SF-36domains were found in the VA study.15

Bilateral hernias Laparoscopy allows simultaneous explo-ration of the abdominal cavity (TAPP) and diagnosis and treat-ment of bilateral groin hernias, as well as coexisting femoral her-nias (which are often unrecognized preoperatively), potentiallywithout added risk or disability. Bilateral hernias accounted for9% of the hernias reviewed in the Cochrane database.14 Operatingtime was longer in the laparoscopic groups than in the opengroups; however, recovery time, the incidence of persistent numb-ness, and the risk of wound infection were significantly reduced inthe former. These results are consistent with those of a prospec-tive, randomized, controlled trial from 2003 that compared TAPPrepair with open mesh repair for bilateral and recurrent hernias.54

In this study,TAPP repair not only was less painful and led to anearlier return to work but also was associated with a shorter oper-ating time. Further prospective, randomized trials designed tocompare simultaneous bilateral open tension-free repair withbilateral TEP laparoscopic repair should be undertaken.

Recurrent hernias Approximately 10% of patients under-going hernia repair present with recurrent inguinal hernia.54

Patients with recurrent hernias may potentially derive greater ben-efits from a laparoscopic approach through an undisturbed planeof dissection, rather than a second groin exploration via an opentechnique, dissecting through scar tissue and potentially causingsignificant tissue trauma. This is especially true when mesh wasused for the previous open repair.

Open mesh repair has been associated with long-term recur-rence rates of 1% or less, even when not performed by hernia spe-cialists.2, 55 If the laparoscopic approach is to be a viable alternativeto open repair, it should have comparable results.With respect toshort-term results, prospective, randomized trials suggest that her-nia recurrence rates are comparable in laparoscopic repair andopen mesh repair groups.14 However, the Cochrane meta-analysisfound that reductions in hernia recurrence were effected primari-ly by the use of mesh rather than by any specific placement tech-nique.14 This finding is consistent with the Cochrane meta-analy-sis of open mesh inguinal hernia repair versus open nonmeshrepair, which indicated that tension-free mesh repair led to a sig-nificant reduction in hernia recurrence.3 In a 5-year follow-upstudy from 2004, the recurrence rate after laparoscopic meshrepair still was not significantly different from that after open meshrepair.34 In the VA study, the hernia recurrence rate at 2 years washigher in the laparoscopic group (10%) than in the open mesh re-pair group (4%) for primary, unilateral hernias.15 In both groups,the recurrence rates were higher than generally expected. How-ever, these rates were found to be affected by the surgeon’s level ofexperience: those who had performed more than 250 laparoscop-ic repairs reported a recurrence rate of 5%.

Most reported recurrences after laparoscopic herniorrhaphycome at an early stage in the surgeon’s experience with these pro-cedures and arise soon after operation.56 The majority can beattributed to (1) inadequate preperitoneal dissection; (2) use of aninadequately sized patch, which may migrate or fail to support theentire inguinal area, including direct, indirect, and femoral spaces;or (3) staple failure with TAPP repair.

Transabdominal Preperitoneal Repair (TAPP) versus Totally Extraperitoneal Repair (TEP)

The TAPP approach is easier to learn and perform than theTEP approach, and even experienced laparoscopic hernia sur-geons report more technical difficulties with the latter.15,57

Nonetheless, there is a growing body of literature to suggest thatTEP repair, by avoiding entry into the peritoneal cavity, has sig-nificant advantages over TAPP repair.4 In particular, the TEPapproach should reduce the risk of trocar site hernias, small bowelinjury and obstruction, and intraperitoneal adhesions to the mesh.In a study that included 426 patients, TAPP repairs were per-formed in 339 and TEP repairs in 87, and the patients were fol-lowed for a mean of 23 and 7 months, respectively.58 Time offwork was shorter after TEP. A total of 15 major complicationswere noted, including one death, two bowel obstructions, onesevere neuralgia, three trocar site hernias, one epigastric arteryhemorrhage, and seven recurrences.With the exception of the epi-gastric artery hemorrhage, all of these complications occurred inthe TAPP group. It is possible, however, that these results can bepartly explained by the learning curve, in that the TAPP repairswere all done before the TEP repairs.That six TAPP recurrencesoccurred in the first 31 cases, whereas only one occurred in thesubsequent 395 cases, lends support to this possibility.

In a study comparing 733 TAPP repairs with 382 TEP repairs,11 major complications occurred in the TAPP group (two recur-



rences, six trocar site hernias, one small bowel obstruction, andtwo small bowel injuries), whereas only one recurrence and nointraperitoneal complications occurred in the TEP group.59 SevenTEP procedures were converted to TAPP procedures. Time offwork was equal in the two groups but was prolonged in patientsreceiving compensation. As in the study cited above,58 the TAPPpatients were followed longer than the TEP patients, and theTAPP cases occupied the first part of the learning curve.To avoidthis type of selection bias would require a randomized study.

Not all surgeons are convinced that TEP repair is the laparo-scopic procedure of choice. A 1998 study compared 108 TAPPrepairs with 100 TEP repairs.57 Although the TEP repairs weredone only by surgeons who were already familiar with TAPPrepair, many of the surgeons still encountered technical difficultiesand problems with landmark identification. Overall, complicationsdid not occur significantly more frequently in either group, butthey seemed more severe in the TAPP group: four trocar site her-nias, one bladder injury, and six seromas were noted in the TAPPgroup, compared with one cellulitis and six seromas in the TEPgroup.The authors concluded that because TAPP repair is easierand does not increase complications significantly, it is an “ade-quate” procedure. The sample size may have been too small topermit detection of small differences in complication rates.

Regardless of any individual preference for one technique or theother, laparoscopic hernia surgeons ideally should be capable ofperforming both TEP and TAPP well. For example, a plannedTEP repair may have to be converted to a TAPP repair, or a TAPPapproach may be required if the surgeon is doing another intra-peritoneal diagnostic or therapeutic procedure.

Laparoscopic Incisional Hernia Repair

Incisional hernias develop in approximately 2% to 11% ofpatients undergoing laparotomy.60,61 It has been estimated that90,000 ventral hernia repairs are done in the United States everyyear.5 When prosthetic mesh is not used, repair of large incisionalhernias is associated with recurrence rates as high as 63% after 10years, compared with 32% when mesh is used.62 In addition tothese high recurrence rates, even with the use of mesh, open inci-sional hernia repair may be associated with significant complica-tions and a substantial hospital stay.

Initially described in 1992,9 laparoscopic repair of incisionalhernias has evolved from an investigational procedure to one thatcan safely and successfully be used to repair ventral hernias.Takinga laparoscopic approach allows the surgeon to minimize abdomi-nal wall incisions, avoid extensive flap dissection and muscle mobi-lization, and eliminate the need for drains in proximity to themesh, thereby potentially achieving reductions in pain, recoverytime, and duration of hospitalization, as well as lower rates of sur-gical site infection (SSI).8,63,64 In addition, the improved visualiza-tion of the abdominal wall associated with the laparoscopic viewmay result in better definition of the defect, the discovery of unrec-ognized hernia sites, and improved adhesiolysis. Improved visual-ization permits more precise and accurate placement and tailoringof the mesh, as is suggested by the reduced recurrence rates (9%to 12%) reported up to 5 years after laparoscopic incisionalherniorrhaphy.64-66

PREOPERATIVE EVALUATION

Selection of Patients

Laparoscopic incisional hernia repair may be considered for anyventral hernia in which mesh will be used for the repair.This cat-

egory includes virtually all incisional hernias, in that even small 0000(< 10 0cm2) de0f000ects are known to carry a significant riskof recurrence.62 Both upper abdominal and lower abdominal inci-sions are amenable to a laparoscopic approach, although herniasat the extremes of the abdominal wall—abutting the pubis, thexiphoid, or the costal margins—pose a technical challenge foreffective mesh fixation.The so-called Swiss cheese hernia, whichcomprises multiple small defects, is particularly well suited to thisapproach; open repair would necessitate a large incision for accessto the multiple fascial defects, and small defects might not beappreciated. Incarcerated hernias can also be approached laparo-scopically; however, the suspected presence of compromisedbowel is a contraindication. An abdomen that has undergonemultiple operations and contains dense adhesions presents achallenge in terms of both access to the abdominal cavity andaccess to the hernia site. If the surgeon cannot obtain safe accessto the peritoneal cavity for insufflation, a laparoscopic approachis contraindicated.

Contraindications Laparoscopic incisional herniorrhaphy iscontraindicated in patients with suspected strangulated bowel orloss of domain. Hernias in which the fascial edges extend lateral to

Manufacturer

Gore

Bard/Davol

Genzyme

Sofradim

Brennen Medical

Ethicon Endo-Surgery

Cook

Table 1 Meshes Used for Incisional Hernia Repair

Product Name

DualmeshDualmesh Plus

ComposixComposix E/XComposix KugelVisilexDulexReconix

Sepramesh

Parietex

GlucameshGlucatex

Proceed

SurgisisSurgisis Gold

Composition

Dual-sided ePTFEDual-sided ePTFE, antibiotic-

impregnated

Polypropylene/ePTFE laminatePolypropylene/ePTFE laminatePolypropylene/ePTFE laminatePolypropyleneDual-sided ePTFEDual-sided ePTFE

Polypropylene/HA/CMC laminate

Polyester/type I collagen hydrophilicfilm laminate

Polypropylene/β-glucan laminatePolyester/β-glucan laminate

Polypropylene/oxidized regeneratedcellulose

Porcine intestinal submucosa

ePTFE—expanded polytetrafluoroethylene HA/CMC—hyaluronate/carboxymethyl-cellulose

Manufacturer

U.S. Surgical (AutoSuture)

Ethicon Endo-Surgery

Sofradim

Onux Medical

Table 2 Devices Used for Mesh Fixation in Incisional Hernia Repair

Device Name

TACKER

EndoANCHOR

Pariefix

Salute

Fixation Method

Steel spiral tacks

Nitinol anchors

Polyglycolic T-fasteners

Wire loop deployment



the midclavicular line may make trocar placement lateral to thedefect impossible. Defects in close proximity to the bony marginsof the abdomen, especially those near the xiphoid, pose significantchallenges for mesh fixation, though this is also true with openincisional herniorrhaphy. Patients who have undergone multipleprevious operations, with or without mesh, may have dense adhe-sions. Patients in whom polypropylene mesh has previously beenplaced in an intra-abdominal position may have dense adhesionsto the underlying viscera. Whether such patients are approachedlaparoscopically should be determined by the surgeon’s expertise.

OPERATIVE PLANNING

Preparation

The procedure is performed with the patient under generalanesthesia. Mechanical bowel preparation is not routinely used;however, it may be considered if incarcerated colon is suspected.If the defect is in the lower abdomen, a three-way Foley catheteris placed in the bladder. Sequential compression stockings areapplied. Patients are routinely given heparin, 5,000 U subcuta-neously, and prophylactic antibiotics.67

Positioning

The patient is placed in the supine position with both armstucked. If the hernia is in the midline, the surgeon can stand oneither side of the patient, with the monitor directly opposite. If thehernia extends significantly to one side, initial trocar placement isdone on the opposite side. Initially, the assistant stands on thesame side as the surgeon; however, he or she may later have tomove to the opposite side to help with dissection and stapling. Asecond monitor on the opposite side of the table is useful. If thedefect is subcostal, the surgeon may prefer to operate frombetween the patient’s legs, with a monitor at the head of the bed.

Equipment

As the wide variety of mesh materials currently available sug-gests, there is no one ideal mesh. Meshes may be divided into twocategories: (1) polymeric meshes and (2) meshes made of special-ly prepared connective tissue (animal or human) [see Table 1].Thepolymeric meshes are biocompatible materials made of eitherpolypropylene, polyester, expanded polytetrafluoroethylene(ePTFE), or laminates of these. Most ePTFE meshes are engi-neered so that one side is porous to encourage tissue ingrowth andthe other is smooth to resist adhesion formation.They may also becoated with an adhesion-resisting absorbable material.

Because laparoscopic incisional hernia repair leaves the meshexposed to the intraperitoneal cavity, concerns have beenexpressed about the risk of adhesion formation and fistulization ifpolypropylene mesh is used. Polytetrafluoroethylene (PTFE)mesh has been demonstrated to have a reduced propensity foradhesion formation.

Additional special equipment used for incisional hernia repairincludes a suture passer, a 5 mm spiral tacker (or other tackingdevice), and 2-0 monofilament sutures. Several tacking devicesand suture placement devices have been developed to facilitatemesh fixation [see Table 2]. All work in essentially the same man-ner. A Keith or similar needle may also be used. Atraumatic bowelinstruments are required to manipulate the bowel if lysis of adhe-sions is needed.

OPERATIVE TECHNIQUE

In essence, the repair consists of the intraperitoneal placementof a large piece of mesh so that it overlaps the defect in the fascia

and the abdominal wall. The defect is not closed. The mesh isanchored with a minimum of four subcutaneously tied transfascialsutures placed at the four corners and is further secured betweenthe sutures with intraperitoneally placed tacks and additionalsutures as needed.

Step 1: placement of trocars Because of the probability ofextensive intra-abdominal adhesions, we begin with open inser-tion of a blunt 12 mm trocar.Although open insertion necessitatesan often tedious dissection through several layers of the abdomi-nal wall, it has the advantage of allowing early diagnosis and repairof any iatrogenic bowel injury. Nevertheless, good results have alsobeen reported with insertion of a Veress needle, usually in the leftupper quadrant (where adhesions are presumed to be minimal).Ultimately, trocar position is determined by the location of thehernia. For midline hernias, we usually begin on the left side of thepatient and insert the first trocar lateral to the edges of the defect,about midway between the costal margin and the iliac crest.

CO2 is then insufflated to a pressure of 12 to 15 mm Hg, and a5 mm 30° scope is inserted. As in laparoscopic inguinal herniarepair, an angled scope is essential because dissection and repairare done on the undersurface of the anterior abdominal wall,which cannot be adequately visualized with a 0° scope. The her-nial defect is visually identified, and two additional 5 mm trocarsare placed on the same side under direct vision, with their preciseplacement dependent on the size and contours of the defect andon the locations of any adhesions. If possible, these trocars areplaced superior and inferior to the initial trocar, as far laterally aspossible, with care taken to ensure that the downward movementof the instruments is not limited by the iliac crest or the thigh.Lateral placement is necessary to optimize exposure of theabdominal wall [see Figure 18].

Step 2: exposure of hernial defect The edges of the her-nial defect are exposed by reducing the contents of the hernia intothe abdominal cavity.All adhesions from bowel or omentum to theabdominal wall in the vicinity of the defect and along the fulllength of the previous incision should be divided. Complete adhe-siolysis of abdominal wall adhesions facilitates the identification of

Figure 18 Laparoscopic incisional hernia repair. Shown is anexternal view of incisional hernia trocar site placement. Openinsertion of a blunt 10/12 mm trocar at the left lateral midab-domen site is performed, with subsequent placement under directvision of two 5 mm trocars above and below the initial trocar.



Swiss cheese defects [see Figure 19]. Starting in the upper abdomenmay be easier, in that bowel adhesions are less likely to be encoun-tered. External pressure may also help reduce hernial contents andfacilitate identification of the hernial sac. Placing the patient headdown or head up and rotating the table will also aid in exposure.

If dense adhesions are present, it is preferable to divide the sacor the fascia, so as not to risk bowel injury [see Figure 20]. Sharpdissection with scissors is recommended to prevent thermal injuryto the bowel, which may not be immediately recognized. If incar-cerated bowel cannot be reduced with laparoscopic techniques, anincision is made over the area of concern, and the bowel is freedunder direct vision. Once this incision is closed, laparoscopic meshplacement can proceed, and there may be no need for full conver-sion to an open operation. Strategies for avoidance and treatmentof bowel injury are discussed in more detail elsewhere [seeComplications, Bowel Injury, below].

Step 3: selection of mesh The contours of the hernialdefect are marked as accurately as possible on the exterior abdom-inal wall; the edges may be delineated with a combination of pal-pation and visualization. All Swiss cheese defects are marked.Thedefect is measured after pneumoperitoneum is released to ensure

that its size is not overestimated [see Figure 21]. Ideally, the pros-thesis should overlap the defect by at least 3 cm on all sides.Coverage of all of the defects with a single sheet of mesh is pre-ferred, but more than one sheet may be needed, depending on thelocations of the defects and the size of the patient.The mesh sheetis laid on the abdominal wall in a position that approximates itseventual intra-abdominal position, and its four corners and thoseof its representation on the abdominal wall are numbered clock-wise from 1 through 4 for later orientation [see Figure 22]. A markis made on the inner side of the mesh sheet so that the surgeon caneasily determine which side is to face the peritoneum once themesh is inserted into the peritoneal cavity. If a dual-sided mesh isbeing used, the smooth side must be the one facing the bowel. A2-0 monofilament suture is tied in each corner of the mesh, andboth ends of each suture are left about 15 cm long.

The mesh swatch is rolled as tightly as possible around a grasp-ing forceps and introduced into the peritoneal cavity. Smallswatches can be inserted through a 12 mm trocar; for largerpieces, we remove a large trocar and insert the mesh directly intothe abdomen. The trocar is then repositioned and insufflation ofCO2 recommenced.

Step 4: fixation of mesh Once the mesh swatch has beenintroduced into the abdomen, it is unfurled and spread out, withthe previously placed corner sutures facing the fascia and orient-ed so that the four numbered corners are aligned with the num-bers marked on the abdominal wall. Small skin incisions are thenmade with a No. 11 blade.Through each of these incisions, a suturepasser is inserted to grasp one tail of the previously placed anchor-ing suture and pull it out through the abdominal wall, then rein-troduced through the incision at a slightly different angle to pullout the second tail. This is done for each of the four anchoringsutures, and the mesh is unfurled under appropriate tension (withcare taken to avoid excessive tension and stretching). Initially, thecorner sutures are held with hemostats and not tied; some adjust-ment to achieve optimal positioning of the mesh is often required,especially early in the surgeon’s experience.

Once the mesh is in a satisfactory position, each suture is tiedand buried in the subcutaneous tissue to anchor the mesh swatchto the fascia and maintain its proper orientation [see Figure 23].With large defects, it is usually necessary to place one or moreadditional 5 mm trocars contralateral to the initial ports to aid inmesh fixation. A tacker is then employed to tack the mesh cir-cumferentially at 1 cm intervals along its edge.A two-handed tech-nique is used, in which the second hand applies external pressureto the abdominal wall to ensure that the tacks obtain the best pos-sible purchase on the mesh and the abdominal wall [see Figure 24].Care should be taken to place the tacks flush because they cancause bowel injury if left protruding.68 Additional sutures are thenpassed at 5 cm intervals directly through the mesh with either thesuture passer and a free suture or a suture on a Keith needle.Sutures should be tied taut but not tight, so as not to cause necro-sis of the intervening tissue.

Step 5: closure The pneumoperitoneum is released.The fas-cia at any trocar site 10 mm in diameter or larger is closed. Carefulclosure of the site used for open insertion of the first trocar ismandatory to prevent trocar site hernia. The skin is then closedwith subcuticular sutures.

POSTOPERATIVE CARE

The Foley catheter is removed at the end of the procedure.Unless adhesiolysis was minimal, patients are admitted to the hos-

Figure 20 Laparoscopic incisional hernia repair. Shown is dis-section of incarcerated small bowel and omentum from an inci-sional hernia.

Figure 19 Laparoscopic incisional hernia repair. Multiple smallhernial defects (so-called Swiss cheese hernia) may be seen.



pital. Oral intake is begun immediately. Patients are dischargedwhen oral intake is tolerated and pain is controlled with oral med-ication. Patients are informed that fluid will accumulate at the her-nia site and are asked to report any fever or redness. Finally, pa-tients are instructed to resume all regular activities as soon as theyfeel capable.

SPECIAL SITUATIONS

Suprapubic Hernia

For hernial defects that extend to the pubic bone, a three-wayFoley catheter is inserted. After adhesiolysis, the patient is placedin the Trendelenburg position, and the bladder is distended withmethylene blue in saline. The bladder is dissected off the pubicbone until Cooper’s ligament is reached.The mesh is then placedso that it extends behind the bladder and is tacked to the pubicbone, to Cooper’s ligament, or to both.

Subxiphoid or Subcostal Hernia

A hernia in which there is no fascia between the hernia and theribs or the xiphoid (e.g., a poststernotomy hernia) poses signifi-cant challenges for fixation. Because of the risk of intrathoracicinjury, the mesh is not tacked to the diaphragm. Although somesurgeons perform mesh fixation to the ribs, this measure is oftenassociated with significant postoperative pain and morbidity. Inthese situations, we take down the falciform ligament and lay themesh along the diaphragm above the liver, placing tacks andsutures up to but not above the level of the costal margin.Takingdown the falciform ligament may be a helpful step for all upperabdominal wall hernia repairs.The recurrence rates for subxiphoidand subcostal hernias are higher than those for hernias at otherlocations.69

Parastomal Hernias

As many as 50% of stomas are complicated by parastomal her-nia formation, 70-72 and 10% to 15% will require operative inter-vention for obstruction, pain, difficulty with stoma care, or unsat-isfactory cosmesis.Three methods of repair have been described:

Figure 21 Laparoscopic incisional hernia repair. The contoursof the incisional hernial defect are marked on the abdomen, asmeasured after gas insufflation has been released (here, 8 × 7 cm).Ideally, the mesh should overlap the defect by 3 cm on all sides,meaning that it should be at least 14 × 13 cm.

Figure 22 Laparoscopic incisional hernia repair. Shown is anexternal view of the orientation of a two-sided mesh swatch over-lying the marked hernial defect. The sites of suture placement arenumbered.

Figure 24 Laparoscopic incisional hernia repair. Shown is two-handed tacking.

Figure 23 Laparoscopic incisional hernia repair. Shown is aninternal view of a two-layer mesh covering the hernial defect andfixed to the abdominal wall with sutures and spiral tacks.



primary fascial repair, repair with mesh, and stoma relocation [see5:27 Open Hernia Repair]. Repair via a laparoscopic approach thatuses ePTFE mesh has shown promising short-term results.72,73

The technique that currently seems to be the most successful isthe one described by LeBlanc and Bellanger.73 Rather than lateral-izing the intestine (as in the technique described by Sugarbaker74),this method centralizes the intestine in the mesh by cutting anappropriately sized hole in the middle of the mesh sheet, alongwith a slit to allow it to be placed around the intestine.This step isrepeated on a second piece of mesh, but with the slit oriented tothe opposite side.The mesh is fixed with sutures and tacks in sucha way that it overlaps the defect by at least 3 cm (more common-ly, 5 cm) on all sides, as in other ventral hernia repairs. Thismethod appears to minimize the risk of mesh prolapse and bowelherniation alongside the stoma. The authors reported no recur-rences within their 3- to 11-month follow-up period and no mor-bidity. In contrast, a subsequent study reported recurrences with-in 12 months in five of nine patients who underwent a variation ofthis repair, in which a slit in the mesh (instead of a central defect)was created and only one mesh sheet (instead of two) was used tocover the defect.71

Laparoscopic parastomal hernia repair appears to be a viablealternative to laparotomy or stoma relocation, but long-term mul-ticenter evaluation is necessary for full assessment of this tech-nique’s value in this setting.

COMPLICATIONS

Overall, fewer complications are reported after laparoscopicincisional herniorrhaphy than after open mesh repair.8,63,75-77

There are, however, several specific complications that are of par-ticular relevance in laparoscopic procedures (see below).

Bowel Injury

A missed bowel injury is a potentially lethal complication.Theoverall incidence of bowel injury does not differ significantlybetween open repair and laparoscopic repair and is generally lowwith either approach (1% to 5% when serosal injuries are includ-ed). It should be noted, however, that pneumoperitoneum mayhinder the recognition of bowel injury at the time of operation.There have also been several reports of late bowel perforation sec-ondary to thermal injury with laparoscopic repair.65,76-79 Onestudy reported two bowel injuries that were not discovered untilsepsis developed; these late discoveries resulted in multiple opera-tions, removal of the mesh, prolonged hospital stay, and, in onepatient, death.The incidence of bowel injury is likely to be higherwith less experienced surgeons80 and in patients who requireextensive adhesiolysis. In one series describing a surgeon’s first100 cases, four of six inadvertent enterotomies were made in thefirst 25 cases.81

To reduce the risk of bowel injury, we strongly discourage theuse of electrocauterization and ultrasonic dissection. The visual-ization afforded by the pneumoperitoneum, which helps placeadhesions between the abdominal wall and the bowel under ten-sion, and the magnification afforded by the laparoscope facilitateidentification of the least vascularized planes.As far as possible, weavoid grasping the bowel itself, preferring simply to push it or tograsp the adhesions themselves to provide countertraction. Exter-nal pressure on the hernia may also help. Larger vessels in theomentum or adhesions are controlled with clips. Some degree ofoozing from the dissected areas is tolerated; such oozing almostalways settles down without specific hemostatic measures.

As noted, if dense adhesions are present, it is preferable todivide the sac or the fascia rather than risk injury to bowel. In the

case of densely adherent polypropylene mesh, it may be better toexcise it from the abdominal wall rather than attempt to separateit from the serosa of the bowel. If there is reason to suspect thatbowel injury may have occurred, immediate and thorough inspec-tion should be carried out; if this is not done, it may be difficult orimpossible to find the exact site of injury later, once the bowel hasbeen released after being freed of its attachments. If an injury tothe bowel is recognized, the extent of the injury and the surgeon’slevel of comfort with laparoscopic suture repair will determine thebest approach. If there is no or minimal spillage of bowel contents,the injury may be treated with either laparoscopic repair or openrepair; the latter usually can be carried out through a several cen-timeter counterincision over the injured area. Whether a meshprosthesis will be placed depends on the degree of contamination.If there has been minimal or no contamination, any small openincision is closed, and laparoscopic lysis of adhesions and meshplacement can continue. If the contamination is more significant,adhesiolysis is completed, but the patient is brought back for meshplacement at another date. More significant bowel injuries maynecessitate conversion to open repair.

Chronic Pain

In about 5% of patients, the transfascial fixation sutures used tosecure the mesh cause pain that lasts more than 2 months. In mostcases, postoperative pain decreases over time; if it does not, injec-tion of local anesthetic into the area around the painful suture maybe helpful.82

Seroma

Seroma formation is one of the most commonly reported com-plications: it occurs immediately after operation in virtually allpatients, to some extent.65,80,83 Patients sometimes mistake a tenseseroma for recurring incisional hernia, but appropriate preopera-tive discussion should provide them with significant reassuranceon this point. Seroma formation seems not to be related to partic-ular mesh types or to the use of drains.80 Virtually all seromasresolve spontaneously over a period of weeks to months, withfewer than 5% persisting for more than 8 weeks.64 They are rarelyclinically significant. Aspiration may increase the risk of meshinfection.84

Infection

Overall wound complication rates have been shown to be lowerwith laparoscopic incisional herniorrhaphy than with openrepair.65,79,80,85 In particular, SSIs appear to be reduced with thelaparoscopic approach. 65,79,80,85 SSI rates for open incisional repairrange from 5% to 20%,63,79,80,83 whereas those for laparoscopicrepair range from 1% to 8%.5,65,72,79 Mesh infection extensiveenough to necessitate mesh removal is rare (incidence ~ 1%); how-ever, SSI after laparoscopic repair, especially when PTFE is used,more frequently results in seeding of the mesh.65,80 Because thistype of mesh does not become well incorporated, antibiotic treat-ment alone is ineffective.80

OUTCOME EVALUATION

Several studies have demonstrated improvements in outcomemeasures—such as decreased postoperative pain, shorter lengthof stay, earlier return to work,86 and reduced blood loss—with thelaparoscopic approach to incisional hernia repair.5,8,63,64,76,84,87-89

The only randomized trial published to date compared 30laparoscopic incisional hernia repairs with 30 open repairs.6 Themean operating time was significantly shorter in the laparoscop-ic group (87 minutes versus 111.5 minutes), as was the postop-



erative length of stay (2.2 days versus 9.1 days). Another studycompared 56 prospective laparoscopic incisional hernia repairswith 49 open incisional hernia repairs assessed through retro-spective chart review.8 The laparoscopic and open groups werecomparable in terms of patient characteristics and hernia size.Although the mean operating time was longer in the laparoscop-ic group (95.4 minutes versus 78.5 minutes), the postoperativelength of stay was significantly shorter after laparoscopic repair(3.4 days versus 6.5 days). In contrast, some studies have foundthe operating time to be 30 to 40 minutes shorter with laparo-scopic repair.63,76

The recurrence rate—the primary long-term outcome measureof interest—is reported to be reduced after laparoscopic repair. Instudies comparing laparoscopic and open incisional hernia repairwith mesh, the recurrence rates after the laparoscopic repairsranged from 0% to 11%, whereas those after the open repairsranged from 5% to 35%.6,8,78,86,88 In expert hands, recurrencerates are low after laparoscopic repair. For example, in a multi-center series of 850 laparoscopic incisional hernia repairs, mostlyfollowed prospectively, the recurrence rate after a mean follow-upperiod of 20 months was 4.7%.77 One group found no recurrencesin the laparoscopic group and two in the open group after a min-imum follow-up period of 18 months.76 Another group, however,reported a recurrence rate of 18%,90 which approached that

reported after open mesh repair. Recurrence has been associatedwith lack of suture fixation, prostheses that overlap the defect byless than 2 to 3 cm, postoperative complications, and previousrepairs.64,65,77,91

The surgeon’s level of experience plays a significant role inpatient outcome, as demonstrated by a group that compared theoutcomes for their first 100 laparoscopic incisional hernia repairpatients with those for their second 100.84 Recurrence rates aftera mean follow-up period of 36 months dropped from 9% in thefirst 100 patients to 4% in the second 100. In addition, the secondset of patients were an average of 9 years older, had a higher per-centage of recurrent hernias, and exhibited more comorbidities,yet despite these added challenges, operating time was not length-ened, length of stay was similarly short, and the complication ratewas no different. Another group reported similar findings for theirlaparoscopic incisional hernia repair learning curve.92 Operatingtimes and complication rates in the first 32 patients were compa-rable to those in the second 32; however, bowel injuries were morecommon in the first 32.

Although the results of large randomized trials are not availableyet, the evidence to date suggests that the laparoscopic approach tothe repair of large incisional hernias is highly promising.The laparo-scopic approach seems to be safe and compares favorably with theopen operation in terms of complication and recurrence rates.

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Acknowledgments

The authors thank Dr. Dennis Klassen for providinginformation on available bioprosthetic meshes and fix-ation devices.Figures 1, 4, 5, 6, 7, 13 Tom Moore.

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