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Aug 12

Laparoscopic Inguinal Hernia Repair (TEP/TAPP)

The surgical history of inguinal hernias dates back to ancient Egypt. From Bassini’s heralding of the modern era to today’s mesh-based open and laparoscopic repairs, this history parallels closely the evolution in anatomical understanding and development of the techniques of general surgery.[1, 2]

Accounting for 75% of all abdominal wall hernias, and with a lifetime risk of 27% in men and 3% in women, inguinal hernia repair is one of the most commonly performed surgeries in the world.[3] In the United States, inguinal herniorrhaphy accounts for approximately 800,000 cases annually.[4]

Most randomized studies comparing laparoscopy to open repair have confirmed the following findings:[5, 6]

  • Pros

    • Reduced postoperative pain
    • Earlier return to work
  • Cons

    • Increased cost
    • Lengthier operation
    • Steeper learning curve
    • Higher recurrence and complication rates early in a surgeon’s experience

Although open, mesh-based, tension-free repair remains the criterion standard, laparoscopic herniorrhaphy, in the hands of adequately trained surgeons, produces excellent results comparable to those of open repair.[7, 8] In a comparison of open repair with laparoscopic (totally extraperitoneal patch) repair, Eklund et al found that 5 years postoperatively, 1.9% of patients who had undergone laparoscopic repair continued to report moderate or severe pain compared with 3.5% of those in the open repair group.[9]

For information on manual reduction of hernias, see eMedicine article Hernia Reduction. For a discussion of open repair, see Hernia Inguinal Repair, Open.

Definitions

Laparoscopic inguinal herniorrhaphy can refer to any of the following 3 techniques:

  • Totally extraperitoneal (TEP) repair: See the sections below for a detailed description of this technique
  • Transabdominal preperitoneal (TAPP) repair: The abdomen is accessed and pneumoperitoneum is achieved using standard laparoscopic techniques. The preperitoneal space is then exposed transabdominally by sharply incising and bluntly stripping the peritoneum that overlies the inguinal anatomy. A mesh is then deployed and fixed in place as with the TEP technique and the peritoneum returned to its anatomical position.
  • Intraperitoneal onlay mesh (IPOM) repair: A dual-layer mesh is placed over the myopectineal orifice transabdominally and fixed in place. The preperitoneal space is not entered and minimal dissection is carried out.
  • The most commonly performed laparoscopic techniques are the TEP and TAPP repairs.[5, 6, 7]

Anatomy

Poor familiarity with the complex anatomy of the posterior inguinal view is an important contributor to the steepness of the laparoscopic inguinal herniorrhaphy learning curve.[10, 11, 12]

While this section describes the anatomy from a laparoscopic point of view, a working knowledge of the inguinal region and the anterior abdominal wall remains paramount, and the reader is directed to the eMedicine article Hernia Inguinal Repair, Open for a detailed description of the region.

The preperitoneal space is contained between the transversalis fascia and the parietal peritoneum. It contains areolar and adipose tissue and the inferior epigastric artery and vein.

Transabdominal laparoscopic landmarks useful when performing the TAPP repair are the obliterated fetal remnants, which divide the posterior surface of the anterior abdominal wall into 3 fossae.[13]

  • The median umbilical ligament is a remnant of the embryonic urachus. It forms the center divide by arising in the midline from the apex of the bladder toward the umbilicus.[13]
  • Laterally, the paired medial umbilical ligaments, vestiges of the fetal umbilical arteries, arise from the superior vesicle arteries toward the umbilicus.[13]
  • Between the median and medial ligaments lie the supravesical fossae, where external supravesical hernias occur.[13]
  • Most lateral are the paired lateral umbilical ligaments, which contain the inferior epigastric arteries. Between them and the medial ligaments lies the medial fossa, which contains the Hesselbach triangle, the zone of direct hernias. Lateral to the inferior epigastric arteries is the lateral fossa, which is the site of indirect hernias. Thus, the lateral umbilical ligaments separate the lateral and medial fossae, and delineate between indirect and direct hernias, respectively.[13]

The following 3 landmarks (shown in the image below) found in the preperitoneal space are constant in their presence and location. They are a good starting point to get one’s bearings in this difficult region. They are also helpful in cases of large hernias or recurrences.

Inguinal anatomy from the laparoscopic viewpoint.
Inguinal anatomy from the laparoscopic viewpoint.
  • The inferior epigastric artery and vein complex: This complex lies on the rectus muscles bilaterally.

    • Medial to these vessels but above the iliopubic tract (see below) is the external ring, which is not visible in patients without a direct hernia.
    • The internal ring is lateral to the inferior epigastric artery and vein but is often obscured by them, even when a hernia is present. The location of the internal ring can be approximated by locating the junction of these vessels and the cord structures.
    • The femoral ring is inferior and lateral to the external ring and lies below the iliopubic tract just medial to the external iliac vessels. (The external iliac vessels change their name to the common femoral vessels after they pass beyond the inguinal ligament. Since preperitoneal hernia repair is performed dorsal to the inguinal ligament, these vessels still retain their intra-abdominal name.)
  • Cooper ligament: This is the name given to the periosteum of the superior pubic ramus. The pubic ramus can be easily palpated with a blunt grasper and is an excellent starting point for dissection.
  • Iliopubic tract: Another fundamental structure that deserves careful recognition is the iliopubic tract (commonly referred to as the shelving edge of the inguinal ligament in open surgery).

    • This aponeurotic stretch of tissue is located posterior to the inguinal ligament and extends from the anterior superior iliac spine to the superior pubic ramus. As a continuation of the transverse abdominus aponeurosis and fascia at the upper border of the femoral sheath, it passes medially to form the inferior border of the internal inguinal ring, crossing over the femoral vessels.[13, 14, 15]
    • Importantly, the iliopubic tract forms the superolateral border of the so-called “triangle of pain,” an area bounded medially by the spermatic vessels (as shown in the image below). In this area, tacking of the mesh is to be avoided because of the risk of injury to the femoral branch of the genitofemoral nerve or the lateral femoral cutaneous nerve.[10, 13, 14, 16]

    Triangle of pain.
    Triangle of pain.

Another anatomical zone that requires the surgeon’s awareness is the so-called “triangle of doom,” bordered medially by the ductus deferens, laterally by the spermatic vessels, and with its apex at the deep inguinal ring, as shown in the image below. This area contains the external iliac artery and vein; thus, tacking of the mesh must be avoided within its boundaries.[13, 15] .

Triangle of doom.
Triangle of doom.

Indications

  • The general indications for laparoscopic inguinal hernia repair versus watchful waiting are the same as for open inguinal hernia repair.
  • Classically, the existence of an inguinal hernia has been reason enough for operative intervention. However, recent studies have shown that the presence of a reducible hernia is not, in itself, an indication for surgery and that the risk of incarceration is less than 1%.[17]
  • Symptomatic patients (with pain or discomfort) should undergo repair; however, up to one third of patients with inguinal hernias are asymptomatic.[17] The question of observation versus surgical intervention in this asymptomatic or minimally symptomatic population was recently addressed in 2 randomized clinical trials. The trials found similar results, namely that after long-term follow-up, no significant difference in hernia-related symptomology was noted, and that watchful waiting did not increase the complication rate.[18, 19]
  • In one study, the substantial patient crossover from the observation group to the surgery arm led the authors to conclude that observation may delay but not prevent surgery.[17] This reasoning holds particularly true in the younger patient population. Thus, even an asymptomatic patient, if medically fit, should be offered surgical repair. After a long-term follow-up, one study determined that most patients with a painless inguinal hernia will develop symptoms over time, and, therefore, surgery is recommended for medically fit patients.[20]
  • Some reports have listed specific indications for laparoscopy over open repair, including recurrent hernias, bilateral hernias, and the need for earlier return to full activities.[21, 22, 23, 24]
  • Patient preference plays perhaps the greatest role in choosing one type of repair over another.
  • Surgical expertise also plays a role in selecting the appropriate type of repair. Data show that the recurrence rate drops significantly with increased surgeon experience with the laparoscopic technique. Some studies suggest that the learning curve for totally extraperitoneal (TEP) laparoscopic herniorrhaphy may be as high as 250 cases (as opposed to 25 for open repair).[8] Transabdominal preperitoneal (TAPP) repair has a learning curve closer to that of the open technique.[25] A large randomized controlled trial comparing laparoscopic to open repair found that, with adequate training, laparoscopic repair produced equivalent recurrence rates but reduced postoperative pain and allowed earlier return to work.[21]
  • A Cochrane database meta-analysis comparing TEP to TAPP found no significant difference in recurrence but did find that TAPP was associated with a higher risk of intra-abdominal injury. The authors concluded that further randomized controlled trials are needed to definitively compare these 2 techniques.[26]
  • The intraperitoneal onlay mesh (IPOM) technique has fallen out of favor because of reports of unacceptably high rates of organ injury, nerve injury, and hernia recurrence.[23]
  • Conclusions regarding inguinal hernias in female patients are difficult to draw because most of the inguinal hernia literature involves male patients. In fact, Koch et al found that recurrence rates were higher in women and that recurrence in women was 10 times more likely to be of the femoral variety than in men.[27] This has led some to the conclusion that repairs that provide coverage of the femoral space (eg, laparoscopic repair) at the time of initial operation are better suited for women as a primary repair.[28] A well-designed randomized controlled trial comparing laparoscopic to open herniorrhaphy has yet to be completed.
  • The actual hospital costs of laparoscopic repairs are higher than those of open repairs but may be offset by the societal benefits of earlier return to full activities.[7, 29]

Contraindications

  • General contraindications for laparoscopic herniorrhaphy parallel those of open repair.
  • Inguinal hernia repair has no absolute contraindications. Just as in any other elective surgical procedure, the patient must be medically optimized. Any medical issues, whether acute (eg, upper respiratory tract or skin infection) or exacerbations of underlying medical conditions (eg, poorly controlled diabetes mellitus), should be fully addressed and the surgery delayed accordingly.
  • Patients with elevated American Society of Anesthesiologists (ASA) scores and high operative risk should undergo a full preoperative workup and determination of the risk-to-benefit ratio.
  • Contraindications specific to the laparoscopic technique include a lower midline incision, previous preperitoneal surgery (eg, prostatectomy), irreducible hernia, and inability to tolerate general anesthesia.

Anesthesia

  • General anesthesia is preferred for laparoscopic inguinal hernia repairs.
  • Although the totally extraperitoneal (TEP) technique can be performed with epidural anesthesia, the authors routinely use general anesthesia for the occasional development of pneumoperitoneum due to an inadvertent peritoneal rent.
  • Elective inguinal hernia repair is considered a clean procedure and, as such, should carry a < 2% surgical site infection rate. Current data remain controversial, but the most recent meta-analysis supports the use of antibiotic prophylaxis when performing a mesh-based repair.[30] Typically, a cephalosporin antibiotic (eg, cefazolin) is administered by the anesthesiologist as a single dose prior to the skin incision.[31] A properly powered, well-constructed, prospective, randomized study has yet to be completed in order to definitively answer the antibiotic question.

Equipment

  • All methods of laparoscopic hernia repair require the following standard laparoscopic equipment:

    • Blunt graspers
    • Hook electrocautery
    • A 30º laparoscope
    • A tacking device or fibrin glue applicator system
  • A laparoscopic clip applier and suction irrigator should be available on standby.
  • Foley catheter: The authors routinely place a Foley catheter to decompress the bladder and maximize the preperitoneal space. Patients undergoing unilateral hernias (short procedure) and with no history of urinary retention can probably avoid a Foley catheter if they void immediately prior to the operation.
  • Balloon dissector and trocars: The authors find that a balloon dissector saves time but does add cost to the totally extraperitoneal (TEP) technique. Simple blunt dissection with the laparoscope can be used instead to create the preperitoneal space. The authors routinely use an integrated trocar/dissector balloon system for the infraumbilical port. In addition, the authors use a 5-mm trocar and an 11-mm trocar. The TAPP technique requires an umbilical Hasson 12-mm trocar and 2 5-mm trocars placed at the midclavicular lines bilaterally.
  • Mesh: The mesh must be a permanent material large enough to produce a wide overlap beyond the defect’s edges. Although some surgeons prefer anatomical mesh configurations, a polypropylene or polyester flat sheet of mesh (5 X 10 cm to 7 X 15 cm) works just as well and is more cost-effective.
  • Tacks: The authors routinely use nonabsorbable tacks for mesh fixation and exercise extreme caution to avoid the danger zones (see Anatomy above). Laparoscopic absorbable tackers are now available, which may add an extra layer of security. The potential benefit is that even if a nerve is inadvertently impinged, the tack will be resorbed with time. This benefit has not been critically evaluated.

    • Some authors have reported on the use of fibrin glue for mesh fixation with excellent results.[32]
    • Still others use no fixation at all but instead rely on peritoneal pressure to maintain the mesh in proper position.[33]

Positioning

  • Confirm and mark the correct surgical site preoperatively in the holding area.
  • Position the patient supine, comfortably securing the upper extremities at the patient’s sides.
  • For large defects, slight Trendelenburg positioning may help exposure by reducing the visceral contents into the abdomen.
  • Shave the surgical site with electric clippers.
  • Prepared and drape the surgical site in standard surgical fashion, exposing an area from above the umbilicus to below the pubis. The prepared area should be wide enough to allow for conversion to an open technique if this becomes necessary.
  • The authors place a single monitor at the foot of the bed. The operating surgeon stands on the side opposite the hernia. The assistant stands on the same side as the hernia.

Technique

  • Make a longitudinal 10-mm infra-umbilical incision and deepen it to expose the anterior rectus sheath.[13]
  • Incise the anterior rectus sheath longitudinally slightly off the midline (thus avoiding entering the peritoneal space in the midline, where the anterior and posterior rectus sheaths merge).[13, 14, 24] Grasp the midline raphe with a Kelly clamp and retract the underlying rectus muscle fibers laterally, revealing the posterior rectus sheath.
  • Using the posterior rectus sheath as a guide, introduce a dissecting balloon and slip it along the rectus sheath as shown in the video below. Advance the balloon past the arcuate line and into the preperitoneal space down to the pubic symphysis. Then, inflate the dissection balloon under direct laparoscopic vision to dissect the preperitoneal space.[13, 14, 24, 34] Balloon dissection.
  • Once adequate dissection is attained, deflate and remove the dissector balloon.
  • Insufflate the preperitoneal space with CO2 to a pressure of 12 mm Hg.
  • Insert a 5-mm trocar 2 finger breadths above the pubis as shown in the image below. Place an 11-mm trocar midway between the 5-mm trocar and the umbilical port.
 Trocar placement.
Trocar placement.
  • Insert a 30°-angled laparoscope at the umbilical port.[13, 24] This provides the best visualization of the inguinal region in the tight preperitoneal space.[14]
  • The authors always begin the dissection with exposure of the Cooper ligament and the pubic tubercle. This is most easily performed using a 2-handed technique, whereby 2 blunt graspers are placed against the bone at a single point, then gently spread apart as shown below. Carry out continued gentle dissection with meticulous hemostasis to expose the direct space and the femoral space by clearing the Cooper ligament down to the iliac vessels. Direct space dissection.
  • A direct hernia often reduces spontaneously with pneumo-preperitoneum but may require careful gentle traction and freeing of fibrous bands to get a complete reduction. Clearing the Cooper ligament in its entirety ensures that a direct hernia is fully reduced.
  • Great care must be exercised as one approaches the iliac vessels. In addition, obturator vessels often cross the dissection planes and may need to be clipped and divided.
  • Carry out the dissection of the preperitoneal space superolaterally toward the anterior superior iliac spine by gently pushing the peritoneum away from the ventral abdominal wall as shown below.[13, 14, 24, 34] Care must be exercised when separating the peritoneum from the muscle layers of the abdominal wall. The peritoneum is often very thin and may be tightly adhesed. Attempting to disconnect these structures may result in a peritoneal rent. This is especially evident cephalad. Inferolaterally, the abdominal wall must be cleared to below the iliopubic tract. Lateral abdominal wall dissection.
  • Next, attention is shifted to the internal ring to identify an indirect hernia sac. Perform careful gentle separation of the cord structures from the sac by elevating the cord/sac bundle then delicately stripping the areolar tissue downward until a window is found between the sac and cord structures as shown below.[13, 14, 24, 34] Indirect sac isolation.
  • If possible, the sac should then be reduced back into the peritoneal cavity. If this is not possible, ligate the sac proximally and leave it open to drain distally to prevent formation of a hydrocele. The simplest way to do this in a wide mouth sac is to fire a vascular 30-mm linear stapler across the sac and then divide the sac distal to the staple line. Other techniques for sac ligation include Endoclips or an Endoloop.
  • Be careful to avoid injury to any intraabdominal sac contents or slider component.
  • Once the dissection is complete, introduce a mesh under direct vision via the 11-mm trocar and drag it as lateral as possible toward the anterior superior iliac spine (ASIS) as shown in the video below. Then flatten out the mesh across the myopectineal orifice and drape it over the cord structures. Place a single tack at the pubic tubercle. This serves as a fixation point that allows for easy arrangement of the mesh in the tight preperitoneal space. Mesh deployment and fixation.
  • Manipulate the mesh so its upper border lies above a line from the pubic symphysis to the ASIS. Then place the remaining tacks down the Cooper ligament, up the midline, and along the upper border of the mesh.
  • Each fire of the tacker beyond the inferior epigastric artery and vein complex must be above a line from the pubic symphysis to the ASIS. This ensures that no tacks are placed in proximity to nerve structures or iliac vessels (the triangle of pain and triangle of doom). This can be further verified by carefully palpating the tacker head through the abdominal wall and comparing its relationship to this line prior to each fire. No more than 1-2 tacks are needed in this hazardous location.
  • Attention is now turned to the contralateral side if the patient has bilateral pathology. Close the larger trocar site fascial defects with a figure-of-eight 0-absorbable suture, approximate the skin, and remove the Foley catheter.
  • The complete procedure is depicted in the video below from SAGES.Laparoscopic inguinal hernia repair. Video courtesy of SAGES.
  • A transabdominal preperitoneal repair for recurrent inguinal hernia is depicted in the video below from SAGES.Transabdominal preperitoneal repair of recurrent inguinal hernia. Video courtesy of SAGES.

Pearls

  • WARNING : Extreme care must be exercised when placing the mesh fixation tacks. This point cannot be overstated. A nerve injury caused by an errant tack can be truly debilitating, and treating these injuries can be very challenging. Tacks should be placed only above  the iliopubic tract.[35] The authors routinely draw a line from the pubic tubercle to the anterior superior iliac spine (ASIS) at the start of the procedure. Prior to firing each tack, carefully palpate the tacker head through the abdominal wall to ensure that it is above this line.
  • Violation of the peritoneum during totally extraperitoneal (TEP) repair causes loss of insufflation from the preperitoneal space into the peritoneal cavity. The preperitoneal space then collapses to some degree, which may make completing the procedure difficult. In addition, it puts intra-abdominal organs at risk for injury and may lead to adhesion formation. Tearing the peritoneum should, therefore, be avoided, if possible. If the rent is small, Endoclips can be placed to close the defect and minimize the leak. Otherwise, conversion to transabdominal preperitoneal (TAPP) or open hernia repair may be necessary. Another option is to place a Veress needle through a stab incision into the abdominal cavity to drain the CO2.
  • Trocar placement should always be done under direct vision. To prevent bleeding and hematoma formation, the trocars should be placed exactly in the midline so as to avoid tearing the rectus muscle fibers.
  • During preperitoneal dissection, the inferior epigastric artery and vein sometimes become separated from the abdominal wall. They then hang down into the operative field. The authors prefer to clip and divide these vessels early in the case rather than struggle and, invariably, injure them anyway.
  • Placing the mesh in such a way as to help with its flush deployment is very helpful. The authors’ technique is to fold the mesh in half lengthwise, grasp the mesh by the fold, and advance the mesh through the trocar toward the ASIS. When the grasper is released, the natural memory of the mesh causes it to spring open in a properly oriented position without the need for time-consuming manipulation.
  • At the completion of the operation but prior to desufflation, the authors like to spray the preperitoneal space with 20 mL of 0.5% bupivacaine with epinephrine for long-acting local analgesia and improved hemostasis as shown below. Local anesthesia infiltration.
  • A blunt grasper should be placed against the lower corner of the mesh just lateral to the cord structures while the preperitoneal space is desufflated under direct vision as shown in the image below. This prevents the mesh from rolling upward and exposing the lateral aspect of the internal ring to recurrence. Desufflation.
  • Rather than pumping the dissector balloon to a preset number of pumps, (manufacturer recommendation is 30-40), the authors prefer to pump under direct vision until no further movement of the tissues is visible, indicating no benefit from further dissection.
  • Vascular injury is a less common but potentially disastrous pitfall. This can be avoided by respecting the proximity of the femoral vessels, particularly when tacking the mesh to the Cooper ligament.[36]
  • The use of an ample-sized mesh is the key to minimizing recurrences. It must be large enough to extend 2 cm medial to the pubic tubercle, 3-4 cm above the Hesselbach triangle, and 5-6 cm lateral to the internal ring.
  • In male patients, always remember to gently pull the testes back down to their normal scrotal position at the end of the case.

Complications

  • Hematoma or seroma formation: This is usually self-limited because of the tamponade effect of the peritoneum. On rare occasions, this complication may require surgical intervention.
  • Nerve injury: Great care must be exercised when securing the mesh with tacks (see Pearls). Nerve injury is usually self-limited but may require steroid injections or, if persistent, neurectomy.
  • Intra-abdominal injury: This is uncommon with totally extraperitoneal (TEP) repair but may occur if the peritoneum is torn and the abdominal cavity is entered. Take extra care with wide-neck hernia sacs that contain abdominal organs. A final intraperitoneal evaluation may be helpful at the completion of the case if an injury is suspected.
  • Adhesion formation: This is very uncommon with TEP repair but has been reported with large peritoneal rents. Closure of this defect may be warranted and can be performed laparoscopically with Endoclips or an Endoloop.
  • Ischemic orchitis leading to atrophic testicle or even necrosis is a catastrophic but known complication of inguinal herniorrhaphy. The exact cause of this vascular injury is unclear, but it is thought to be secondary to venous thrombosis rather than arterial injury. Although rare, a high index of suspicion for this complication and emergency testicular ultrasonography may help avoid orchiectomy. Symptoms include painful testicular swelling and fever commencing 2-3 days after surgery.[37]
  • Peeters et al compared heavyweight and lightweight meshes for laparoscopic inguinal hernia repair in men and found that the use of lightweight meshes for bilateral repair negatively influences sperm motility. In a prospective randomized study in 59 male patients, 1-year followup showed that sperm motility had declined from preoperative levels in patients receiving lightweight mesh (Vypro II, TiMesh) but had increased slightly in those receiving heavyweight mesh (Marlex). No difference was noted in quality of life between recipients of different types of mesh.[38]