SUR GEONS GR OUP

LAP AR 0SC0PI C

LAPAROSCOPIC
SURGEONS
GROUP

Laparoscopic Repair of
Inguinal Hernias
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LAPAROSCOPIC

Overview
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 Laparoscopic repairs have had to compete with the current gold

standard for anterior or conventional inguinal hernia repairs.
Initially, some of these laparoscopic repairs, such as the "plug and
patch" (PAP) and "on lay technique" (IPOM ), failed to demonstrate
good results and were abandoned. Only two laparoscopic repairs
have proven to be viable with early results comparable or superior to
the Liechtenstein repair. These repairs are the Extraperitoneal
Laparoscopic Repair (TEP) and the Trans-Abdominal
Preperitoneal Repair (TAPP). Some authors are now claiming
newer and simpler open laparoscopic inguinal hernia repairs such as
"Plug" or "Klug" Repair are effectively competing with the
laparoscopic inguinal hernia repairs without the increased cost. On
our surgical service, the laparoscopic inguinal hernia repair remain
the best surgical modality for the management of inguinal hernia. It
is however a sophisticated technique whose performance remains
linked to the laparoscopic experience of performing the surgeon.

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Overview
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 Currently, the two most popular laparoscopic techniques are the

TAPP and the TEP.
 The most ardent critique of the TAPP procedure is that it is an intra-
abdominal procedure with significant potential morbidity. On the
other hand, the TEP procedure avoids intra-abdominal access.
 The most persuasive argument for using this procedure is the same
argument favoring all laparoscopic procedures: the postoperative
benefits to the patients, i.e., less postoperative pain, decreased
disability and small incisions.
 However, it continues to be a procedure with limited long term
follow-up and analysis.
 Surgeons performing laparoscopic inguinal hernia repair should be
familiar with the TEP and TAPP Repair.

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Laparoscopic
Inguinal Anatomy
 The anatomy of the inguino-femoral region viewed via a telescope placed in intra-
abdominal position differs radically from the anatomy observed via an open or
anterior approach. The laparoscopic surgeon needs to become familiar with the
anatomical structure of this region. As all anatomical landmarks are covered with
peritoneum, in the TAPP technique the peritoneum has to be first incised and a
lower flap developed in order to expose the region adequately. In the TEP repair,
the anatomical landmarks need to be meticulously exposed with blunt dissection.
 Guidelines for the performance of a safe and secure laparoscopic inguinal hernia
repair, mandate the following structures should be clearly and unequivocally
identified:
• Cooper's Ligament
• The Epigastric Vessels
• The Spermatic Cord or the Round Ligament
• The Femoral Canal and the Iliac Vessels
• In addition, the laparoscopic anatomical distinction between direct, indirect
inguinal and femoral hernias should be well understood. Before a surgeon
attempts to perform a laparoscopic inguinal or femoral hernia repair, he should
memorize and be very familiar with the following diagrams.

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Anatomy with & without

Peritoneal Coverage

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Actual Views – TAPP Rep

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Actual Views - TEP Repair

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Recurrent Inguinal Hernia from an

Open Repair

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Candidates and Selection

 The surgeon decides on a per case basis if an extensive,
lengthy enterolysis is in the best interest of the patient or if a
TEP technique should be used. It has been reported that the
major indications of this technique are recurrent inguinal
hernias and bilateral inguinal hernias. We recommended that
all inguino-femoral hernias including single, unilateral defects
be repaired via laparoscopy.

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Choice of Repair: TEP vs TAPP

 The TEP and TAPP laparoscopic techniques are identical techniques with
different, anatomical access routes. The TAPP is a Trans-Abdominal route, the
TEP a Pro-Peritoneal route (see technique). There is no increase in the rate of
intra-operative injuries with the TEP or TAPP technique when performed by
experienced laparoscopic surgeons. Surgeons should however take advantage of
these different access routes in different clinical settings.
 Use these techniques in the following settings:
 - Incarcerated Inguinal-Femoral Hernia: TAPP Repair,
 - Inguino-Femoral Hernia / Patients with previous major lower abdominal
surgery: TEP Repair,
 - Massive Inguinal Hernias with scrotal extension: TEP Repair or Anterior Repair,
 - Bilateral Inguinal Hernias: TAPP or TEP Repair.

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Choice of Mesh Placement

 Although various prosthetic Mesh-s were used to perform
these repairs, we routinely use a tailored 6"x 6" USSC
SurgiPro® Mesh. As we reported, we initially used a 3 x 5
Mesh. When analyzed most of our recurrence could have
been prevented by using a larger 6x6 Mesh. For this
reason, we now use large SurgiPro® Mesh for all repairs.
 We have used two different variations for the placement of
this Mesh. Approximately 500 cases were done with the
graft wrapped around the spermatic cord and more than
700 cases were on lay placement. To date, there has been
no difference in outcome or recurrence rates with either of
these variations. As of October 1996, we now preferentially
use the on lay Mesh placement with TAPP or TEP Repairs.

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SurgiPro® Mesh Around Onlay Placement of

Spermatic Cord SurgiPro® Mesh -

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Anchoring the Mesh

 Anchoring the Mesh has been subject to most controversy. Early on
in the history of this laparoscopic technique, some surgical teams
claimed the anchoring or stapling of the Mesh has been responsible
for a significant rate of post-operative neuropathy. Compression of
branches of the genito-femoral and lateral cutaneous nerve by
staples or tacks on the lateral aspect of the inguinal ring may have
been the cause for this post-operative complication. For these
reasons, authors have developed numerous techniques, i.e. "no
anchor-staple technique" or no lateral fixation of the Mesh. Our
experience is somewhat different. A recent analysis of 2300
laparoscopic inguinal hernia repair ( with lateral fixation of the
Mesh) demonstrated that patients may develop a transient
neuropathy without any reported permanent neuropathy. In addition
we firmly believe that stapling or anchoring the Mesh is responsible
for reported low recurrence rate.
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The Learning Curve Phenomenon

 The laparoscopic inguinal hernia repair remains a difficult

surgical repair. It is best demonstrated by the analysis of our
mean operating time versus the number of cases performed.
Our mean operative time was 1 hour and 39 minutes for our
first ten patients. For the last 50 patients, it was 27 minutes.
We strongly believe these repairs are best done by surgeons
who have performed at least 40 procedures assisting other
laparoscopic surgeons well-trained in this procedure.
Neophyte operators performing this repair without the proper
training or guidance may generate an inordinate and
inappropriate morbidity rate.

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Instruments
SURGEONS
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 Telescope Straight Forward 10

mm O Deg.
 Camera Storz 3C High Def.
Camera
 Insufflator High Flow Insufflator
 Video Out Optional

The TEP Repair Dilating Trocar

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Operating Room
Set-up

 This set-up is the same for TAPP or

TEP Repair

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Trocars Placement
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m
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 aFavor the same trocar insertion sites for TEP and TAPP repair. In some cases,
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Right Lateral - 5 mm
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TAPP Repair:
The Technique

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STEP 1:
GROUP

Entering the Intra-abdominal Cavity

 A pneumoperitoneum is created in the usual fashion (sub-
umbilical position). The first trocar is inserted [11-5mm
Versaport™] in sub-umbilical position.
 The intra-abdominal cavity is visualized with the Telescope
and intra-abdominal findings are reported [intra-abdominal
pathology and inguinal hernia defects and sacs].
 If an asymptomatic hernia sac is identified on the contralateral
side, our protocol mandates its repair, even though at this time
we are unsure of its exact clinical significance.
 The two additional 5 mm VersaPort ™ Trocars are inserted
under direct vision.

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STEP 2: Creating the Peritoneal

L AP A R 0 S C0 P I C

LAPAROSCOPIC
SURGEONS
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Flap
 The repair is initiated. The
laparoscope is pointed toward the
afflicted inguinal canal. The
peritoneal defect or hernia is
identified. The Lateral Umbilical
Ligament is located as well as the
Inferior Epigastric Artery and Vein.
A peritoneal incision is made using
scissors or the EndoShear*
Instrument. The incision is extended
from the lateral aspect of the
inguinal region to the Lateral
Umbilical Ligament.

 For obese patients, this ligament may have to be transected in order to obtain
additional exposure. The operator should be meticulous in making this incision as
high as possible to maximize the exposure of the region

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STEP 3:
Identifying the Anatomical Landmarks
 With blunt dissection, Cooper's Ligament is exposed as well as the Inferior Epigastric
Vessels and the Spermatic Cord. The iliac vessels are not dissected but their positions
is clearly identified. It is essential to expose the uncovered abdominal wall
meticulously (without peritoneum) and remove all fatty layers.

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STEP 4:
Dissecting the Hernia Sac
 The indirect inguinal hernia sac should be dissected carefully from the
Spermatic Cord. The most difficult hernia sacs to dissect are large, indirect
inguinal sacs where iatrogenic injuries to the spermatic cord can occur. For
this reason it is essential to expose and know at all times where the
spermatic cord is located. Direct hernia sacs are easily dissected.
 Caution: Be attentive not to injure the Vas Deferens.
 Particular care should also be taken not to dissect lateral and inferior to
Cooper's ligament, as the Iliac Artery and Vein will enter the femoral canal
at this site.

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SURGEONS

STEP 5:
GROUP

Deploying and Anchoring the Mesh

 The 6x6 i Mesh is rolled like a cigarette and
inserted uncut via the 11-5mm Versaport™
Trocar into the intra-abdominal cavity and
deployed over the inguinal region. The
Mesh is attached or secured to Cooper's
Ligament, around and lateral to the Inferior
Epigastric Vessels using tacks delivered via
the Protack® Instrument.
 Caution: Be attentive not to place staples or
tacks over the inguinal vessels.
 The Protack® Instrument is dramatically
different from the classical Multifire
EndoHernia* stapler. The tacks are
inserted by rotating; these tacks are more
secure than the endostaples, and in most
cases, we use 25 to 30 tacks (one disposable
instrument) to perform one repair. Again,
the operator should be meticulous to avoid
the iliac vessels and to place tacks lateral to
the inguinal ring. Caution: Be attentive not to
grossly place staples of tacks
over visible nerve branches.
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STEP 6:
Testing the Fixation of the Mesh

 The operator should check the Mesh is well anchored to the

surrounding structures. Using a closed grasper, pressure is
applied with the end or tip of the grasper directly at the center of
the covered direct and indirect defect. The Mesh should not
migrate and remain in place.

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STEP 8:
Closing the Peritoneum
 The peritoneum is closed meticulously and no defect between the
peritoneum and the abdominal wall should be left open. In addition, it
should cover the entire Mesh.
 The closure should be initiated on the lateral aspect of the repair. The
peritoneal flap is held by a grasper and pulled over the upper peritoneal
layer. Tacks are used to close the peritoneal flap. The epigastric vessels
should be meticulously visualized prior to stapling around them.
 Caution: Be attentive not to place staples or tacks over the Epigastric
vessels.
 The trocars are removed under direct vision. The fascia of the sub-
umbilical trocar site is closed as needed.

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