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Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
Acs0528 Laparoscopic Hernia Repair 2005
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Acs0528 Laparoscopic Hernia Repair 2005

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  • 1. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 1 28 LAPAROSCOPIC HERNIA REPAIR Liane S. Feldman, M.D., F.A.C.S., Marvin J.Wexler, M.D., F.A.C.S., and Shannon A. Fraser, M.D. Since its first description in 1990,1 laparoscopic inguinal hernior- measuring the results of laparoscopic repair against those of open rhaphy has shown a great deal of promise; however, concurrently repair and comparing the outcomes of TAPP repair with those of with its development, open anterior herniorrhaphy has evolved TEP repair. into a tension-free, mesh repair that is easily performed with the patient under local anesthesia and that is also associated with rapid recovery and low recurrence rates [see 5:27 Open Hernia Laparoscopic Inguinal Hernia Repair Repair].2,3 Thus, the key question about laparoscopic inguinal her- ANATOMIC CONSIDERATIONS nia repair at present is whether it provides a significant advantage over the tension-free open repair now in use. To most surgeons, inguinal anatomy as viewed through the The two most common techniques for laparoscopic inguinal her- laparoscope appears unfamiliar. This is particularly true for the nia repair involve the insertion of mesh into the preperitoneal space; TEP approach, in which the preperitoneal space must be devel- one makes use of a transabdominal preperitoneal (TAPP) approach, oped. The surgical perspective on the pelvic anatomy from the the other a totally extraperitoneal (TEP) approach. Both approach- intraperitoneal view has been elegantly described by Skandalakis es would appear to offer potential advantages, such as reduced post- and coworkers10 and has been elegantly demonstrated in cadaver operative pain, shortened recovery, quicker and more accurate as- dissections by Spaw and colleagues,11 whose work forms the basis sessment and repair of bilateral groin hernias simultaneously, and, in of the descriptions we present in this chapter. Excellent descrip- the case of recurrent hernia, avoidance of previously dissected and tions of the preperitoneal space by Wantz12 and Condon13 are also technically difficult scarred areas. In practice, however, the advan- worthy of review. tages are not invariably realized; a laparoscopic approach is not al- During laparoscopic herniorrhaphy, a number of structures ways minimally invasive, and various disadvantages accrue from the that are usually visible during open herniorrhaphy (e.g. the current requirement for general anesthesia, the need to traverse the inguinal ligament, the pubic tubercle, the lacunar ligament, and abdominal cavity in the TAPP technique, and the increase in operat- the ilioinguinal and iliohypogastric nerves) are not seen initially. ing room time and costs.4 Conversely, a number of structures that are visible only after sig- Meticulous attention to surgical technique is essential. Because nificant dissection in the open approach are easily viewed through surgeons may be unfamiliar with inguinal anatomy as viewed from the laparoscope [see Figure 1]. Identification of the iliopubic tract, inside the abdomen and because the potential for complication Cooper’s ligament, and the transversus abdominis arch is manda- necessitating laparotomy is increased with the laparoscopic tory to ensure proper coverage by the prosthetic material used in approach, surgeons must be proficient in laparoscopic techniques the repair. and must have a precise knowledge of anatomic relations in the During a TAPP repair, four important landmarks should be region of the groin as seen from the peritoneal surface. seen at initial laparoscopic inspection of the inguinal region [see Since the late 1990s, laparoscopic video techniques have also Figure 2]: the spermatic vessels, the obliterated umbilical artery been increasingly applied to the repair of incisional hernias.5-9 (also referred to as the medial umbilical ligament or the bladder Laparoscopic repair of large incisional hernias resembles open ligament), the inferior epigastric vessels (also referred to as the lat- repair in that mesh is inserted to cover the defect in the abdomi- eral umbilical ligament), and the external iliac vessels. During a nal wall fascia [see 5:27 Open Hernia Repair]. A laparoscopic TEP repair, once the preperitoneal space has been established, the approach is theoretically attractive because an open approach usu- first easily identified landmarks are Cooper’s ligament and the ally necessitates a large incision as well as extensive and tedious inferior epigastric vessels; identification of these structures is help- wide dissection to expose the abdominal wall defect, resulting in ful in guiding early dissection. considerable postoperative pain and a risk of wound complica- Spermatic Vessels tions—problems that a laparoscopic approach to the defect from within might minimize. The testicular artery and vein descend from the retroperitoneum, It may be many more years before the true safety and efficacy of travel directly over and slightly lateral to the external iliac artery, and laparoscopic herniorrhaphy can be determined and the correct indi- enter the internal spermatic ring posteriorly.These vessels are cov- cations for its use established. In the meantime, every repair per- ered only by the peritoneum and are usually well visualized as flat formed should be subjected to careful classification, documentation, structures in the abdominal cavity that assume a cordlike appear- and quality-of-life assessment. Surgeons should not perform laparo- ance when joined by the vas deferens immediately before entering scopic herniorrhaphy simply because it is relatively new or potential- the internal spermatic ring. If no hernia is present, a mere dimple ly economical; they should perform it only when convinced that it is will be seen [see Figure 2]. In the TAPP approach, an indirect hernia, anatomically and physiologically correct and logical. if present, will be immediately apparent and will have an obvious In what follows, we discuss laparoscopic repair of both inguinal opening. In the TEP approach, the indirect sac will be seen later, af- and incisional hernias. In addition to describing current operative ter dissection of the tissue on the anterior abdominal wall.The vas techniques, we address inguinal surgical anatomy, preoperative deferens is best identified where it joins the spermatic vessels. From planning, and complications. Finally, we review selected trials there, the vas can be traced back medially as it courses over the 1
  • 2. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 2 a Internal Oblique Muscle External Oblique Muscle b Transversus Abdominis Aponeurosis Arch Transverse Spermatic Semicircular Line Fascia Sling Cord Transversus Abdominis Muscle and Aponeurosis Transverse Reflected Fascia External Oblique Aponeurosis Inferior Epigastric Vessels Superficial Iliopubic Tract Spermatic Cord Henle's Ligament Inguinal External Iliac Vessels Ring Cooper's Ligament Figure 1 Laparoscopic inguinal hernia repair. Shown are (a) the anatomy of the left groin region as seen from 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 large space separates the transversus abdominis aponeurosis from the inguinal ligament (a). A preperitoneal view of the groin region shows the distance between the transversus abdominis tendon and Cooper’s ligament, the iliopubic tract, and the inguinal ligament (b). pelvic brim and falls into the pelvis and behind the bladder.There is and identification of the internal ring [see Figure 3]. However, dis- a small artery that runs with the vas deferens and is not well seen or section in the incorrect plane when the preperitoneal space is ini- known. It is white and cordlike in appearance and can usually be tially established may strip these vessels off the abdominal wall. seen just beneath the peritoneum. External Iliac Vessels Obliterated Umbilical Artery The lateral spermatic vessels and the medial vas deferens merge The obliterated umbilical artery is an unfamiliar but sometimes at the internal inguinal ring and enter the inguinal canal, where prominent structure that is seen in the TAPP approach. It courses they form the apex of the so-called triangle of doom [see Figure 4a, along the anterior abdominal wall toward the umbilicus, often with insert]. Beneath this triangle lie the external iliac artery and the an apparent mesentery. It is most prominent in the region of the external iliac vein. More laterally, the femoral nerve can be found. medial inguinal space.This ligament is most readily identified when The external iliac vessels are often difficult to visualize, though in the umbilical laparoscope is directed toward the pelvic midline, an elderly patient, a calcified pulsating artery may be prominent. where the ligament’s bilateral structure is best seen as it is oriented Extreme care must be taken not to dissect within the triangle of toward the umbilicus. Medial retraction of this structure is usually doom, because such dissection can result in serious bleeding. necessary for full exposure of the medial aspect of the inguinal canal. Cooper’s Ligament Inferior Epigastric Vessels Cooper’s ligament is a condensation of the transversalis fascia and The inferior epigastric artery and vein lie in the medial aspect of the periosteum of the superior pubic ramus lateral to the pubic tu- the internal inguinal ring and ascend the inferior surface of the rec- bercle. It can be seen only in the preperitoneal space and is the first tus abdominis. In the TAPP approach, these vessels may be diffi- landmark that should be identified during a TEP repair. In the initial cult to visualize, particularly in obese patients. They are best iden- stages of a TAPP repair, with the peritoneum intact, it is often easier tified by locating the internal inguinal ring at the junction of the vas to palpate the ligament than to see it, but once the ligament has been deferens and the testicular artery and vein. At this location, the ves- identified and cleaned, its glistening white fibers are apparent. Care sels exit the medial margin of the internal ring. However, they can must be taken during dissection to avoid the tiny branches of the ob- quickly fade from view as they travel superiorly and medially along turator vein that often run along the ligament’s surface.The iliopubic the anterior abdominal wall. In the TEP approach, early identifica- tract inserts into the superior ramus of the pubis just lateral to Coop- tion of the inferior epigastric vessels helps guide lateral dissection er’s ligament, blending into it.
  • 3. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 3 Internal Inguinal Ring In the TAPP approach, the internal inguinal ring is normally identified by a slight indentation of the peritoneum at the junction of 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 directly into the hernial sac or insert the laparoscope into the sac, which often 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 cord position seen in the classic exterior groin approach to open herniorrhaphy. The medial border of the internal inguinal ring is formed by the transversalis fascia and the inferior epigastric ves- sels.The inferior border is formed by the iliopubic tract, a distinct structure that is the internal counterpart of the inguinal ligament. Anteriorly, the internal inguinal ring is bordered by the transversus abdominis arch, which passes laterally over the internal ring and Figure 3 Laparoscopic inguinal hernia repair: TEP approach. forms a very well defined visible edge.The layers of the abdominal The significant anatomic landmarks are identified at the internal wall constituting the lateral border of the internal inguinal ring ring: the inferior epigastric vessels, Cooper’s ligament, and the appear the same as when viewed from the exterior approach, and spermatic vessels and cord, as well as the potential indirect space this border, like all margins of the internal inguinal ring, is visible seen lateral to the cord structures. only when an indirect hernia is present. Femoral Canal Iliopubic Tract The femoral canal is seen only in the presence of a femoral her- The iliopubic tract originates laterally from the anterior superi- nia in the most medial aspect of the femoral triangle.The anterior or spine of the ilium and courses medially, forming the inferior and medial borders are formed by the iliopubic tract, the posteri- margin of the internal inguinal ring and the roof of the femoral or border is formed by the pectineal fascia, and the lateral border canal before inserting medially into the superior pubic ramus. is formed by the femoral sheath and vein. This tract is formed by the condensation of the transversalis fas- cia with the most inferior portion of the transversus abdominis Trapezoid of Disaster muscle and aponeurosis, and it is usually sturdy along its entire Another area worthy of careful attention is the so-called trape- course. All inguinal hernia defects lie above the iliopubic tract, zoid of disaster, containing the genitofemoral, ilioinguinal, iliohy- either anterior or superior to it. Conversely, femoral hernias occur pogastric, and lateral cutaneous nerves of the thigh, which inner- below the tract, either posterior or inferior to it. Fibers of the ilio- vate the spermatic cord, the testicle, the scrotum, and the upper pubic tract extend into Cooper’s ligament medially, where they and lateral thigh, respectively. A detailed knowledge of the anatom- become the medial margin of the femoral canal. The iliopubic ic courses of the nerves and careful avoidance of these structures tract is frequently confused with the inguinal ligament. This liga- during dissection are essential [see Figure 4]. ment, though nearby, is part of the superficial musculoaponeu- rotic layer, which is not seen laparoscopically, whereas the iliopu- Genitofemoral nerve The genitofemoral nerve arises from bic tract is part of the deep layer. the first and second lumbar nerves; pierces the psoas muscle and fascia at its medial border opposite L3 or L4; descends under the peritoneum, on the psoas major; and divides into a medial genital and a lateral femoral branch. The femoral branch descends lateral to the external iliac artery and spermatic cord, passing posteroinfe- rior to the iliopubic tract and into the femoral sheath to supply the skin over the femoral triangle.The genital branch crosses the lower end of the external iliac artery and enters the inguinal canal through the internal inguinal ring with the testicular vessels. This branch supplies the coverings of the spermatic cord down to the skin of the scrotum. The genitofemoral nerve is the most visible of the cuta- neous nerves and is sometimes confused with the testicular vessels if the latter are not well appreciated in their more medial position. Ilioinguinal and iliohypogastric nerves When dissected from the anterior position, the ilioinguinal and iliohypogastric nerves lie between the external oblique and the internal oblique muscles above the internal inguinal ring and descend with the Figure 2 Laparoscopic inguinal hernia repair. Shown is a laparo- spermatic cord. In the abdomen, the ilioinguinal and iliohypogas- scopic view of the anatomy of the left groin with the peritoneum tric nerves arise from the 12th thoracic and first lumbar nerve intact in a patient without a hernia. (IEV—inferior epigastric ves- roots, are more laterally located, and run subperitoneally, emerg- sels; IR—internal ring; MUL—medial umbilical ligament; TV— ing from the lateral psoas border to pierce the transversus abdo- testicular vessels; VD—vas deferens) minis near the iliac crest, then piercing and coursing between the
  • 4. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 4 a Quadratus Lumborum b Muscle Aorta Iliohypogastric Nerve L3 Iliohypogastric Ilioinguinal Nerve Nerve Genitofemoral Nerve Genitofemoral Nerve Ilioinguinal Lateral Nerve Cutaneous Sympathetic Trunk Nerves Psoas Muscle Iliac Artery Genital Branch of Genitofemoral Iliac Vein Nerve Inguinal Ligament Iliohypogastric Nerve Femoral Nerve Ilioinguinal Nerve Femoral Branches of Genitofemoral Nerve Lateral Femoral External Genital Branch of Cutaneous Nerve Spermatic Nerve Genitofemoral Nerve Femoral Branch of Genitofemoral Nerve Inferior Epigastric Vessels Rectus Abdominis Spermatic Vessels Internal Ring Iliopubic Tract Pubic Tubercle Anterior Superior Cooper 's Iliac Spine Ligament Vas Deferens Iliac Vein and Artery Lateral Psoas Muscle Iliacus Muscle Cutaneous Nerve of Femoral Branch of Thigh Genitofemoral Nerve Figure 4 Laparoscopic inguinal hernia repair. Shown are the courses of the genitofemoral and ilioinguinal nerves of the right groin (a) and of the left groin (b). Inset shows the preperitoneal anatomy of the right groin, as seen by the laparoscopic surgeon. internal oblique and the external oblique muscles close to the toneum on the iliac muscle and only comes to lie in a superficial internal inguinal ring. Aberrant branches sometimes descend with position 3 cm below the anterosuperior iliac spine. the genital nerve.The ilioinguinal nerve supplies a small cutaneous PREOPERATIVE EVALUATION area near the external genitals. Lateral cutaneous nerve of thigh Supplying the front and History and Physical Examination lateral aspect of the thigh, the lateral cutaneous nerve of the thigh Preoperative assessment is necessary to determine whether a arises from the second and third lumbar nerves and emerges at the patient is a suitable candidate for laparoscopic herniorrhaphy. A lateral border of the psoas. There, it descends deep to the peri- careful surgical history, including both previous hernia repairs and
  • 5. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 5 other procedures (particularly those involving the lower pose an increased risk, we prefer open anterior repair using local abdomen), should be elicited. A cardiovascular history should also or regional anesthesia. In infants and young children with indirect be obtained and risk factors for general anesthesia determined. hernias, for whom repair of the posterior canal wall is unnecessary, Physical examination should confirm the presence of an we recommend high ligation of the sac via the anterior approach. inguinal hernia. If the patient reports a history of a bulge but no Previous lower abdominal surgery, though not an absolute con- hernia is felt on physical examination, an occult hernia may be traindication, may make laparoscopic dissection difficult. In par- presumed. Ultrasonography may be helpful for distinguishing an ticular, with respect to TEP repair, previous lower abdominal wall incarcerated groin hernia from other causes of inguinal swelling incisions may make it impossible to safely separate the peritoneum (e.g., lymphadenopathy or venous varix). from the abdominal parietes for entry into the extraperitoneal plane, and conversion to a TAPP repair or an open repair may be Selection of Patients required. Previous surgery in the retropubic space of Retzius, as in Indications With the evolution of the open anterior prostatic procedures, is a relative contraindication that is associat- approach to tension-free prosthetic mesh repair, determining ed with an increased risk of bladder injury16 and other complica- which patients will benefit significantly from laparoscopic hernior- tions.17 Similarly, previous pelvic irradiation may preclude safe dis- rhaphy has become increasingly important. In 2003, the Cochrane section of the peritoneum from the abdominal wall.18 Database of Systemic Reviews4 published an update to its original OPERATIVE PLANNING 2000 report on laparoscopic versus open techniques for hernia repair, which indicated that whereas laparoscopic repairs (TAPP and TEP) generally took longer and had a higher rate of more seri- Preparation ous complications (bowel, bladder, and vascular injuries) than General anesthesia is administered routinely. Prophylactic antibi- open repairs, they also were associated with shorter recovery times otics are unnecessary.19 The patient is instructed to void before sur- and a lower incidence of persistent pain and numbness.14 Reduced gery, which renders bladder catheterization unnecessary. hernia recurrence was related to the use of mesh rather than to operative technique.The overall risk of recurrence with the laparo- Patient Positioning scopic approach may be related to the surgeon’s level of experi- The patient is placed in the supine position with both arms ence.15 We believe that patients are best served when a surgeon has tucked against the sides. The anesthesia screen is placed as far several approaches at his or her command that can be applied to toward the head of the table as possible to allow the surgeon a and, if necessary, modified for individual circumstances. wide range of mobility with the laparoscope. The skin is prepared Currently, we treat primary unilateral hernias with an open and draped so as to allow exposure of the entire lower abdomen, anterior mesh repair, preferably with the patient under local or the genital region, and the upper thighs because manipulation of regional anesthesia; possible exceptions include manual laborers the hernial sac and the scrotum may be necessary. After the and athletes who desire a rapid return to vigorous physical activi- laparoscope has been introduced, the patient is placed in a deep ty. We generally reserve laparoscopic inguinal herniorrhaphy for Trendelenburg position so that the viscera will fall away from the the following clinical situations: inguinal areas. Further bowel manipulation is rarely necessary, except to reduce hernial contents. Rotation of the table to elevate 1. Recurrent hernia after previous anterior repair. In such the side of the hernia can provide additional exposure, if necessary. cases, a laparoscopic approach allows the surgeon to avoid A single video monitor is placed at the foot of the bed, directly fac- the scar tissue and distorted anatomy present in the anteri- ing the patient’s head. or abdominal wall by performing the repair through unvio- The surgeon usually begins the repair while standing on the lated tissue, thereby potentially reducing the risk of damage side contralateral to the defect; the assistant surgeon stands oppo- to the vas deferens or the testicular vessels. This is especial- site the surgeon, and the nurse stands on the ipsilateral side [see ly true when mesh has previously been placed anteriorly. Figure 5]. A two-handed operating technique provides a distinct 2. Bilateral hernias or a unilateral hernia when the presence of technical advantage. a contralateral hernia is strongly suspected. In such cases, a laparoscopic approach allows the surgeon to repair the two Equipment hernias simultaneously (and perhaps more rapidly) without Because inguinal hernias occur in the anterior abdominal wall, having to make additional incisions. visualization through the umbilicus requires that the laparoscope 3. Repair of an inguinal hernia concurrent with another lap- be angled close to the horizontal plane.The view is paralleled ante- aroscopic procedure, provided that there is no contamina- riorly by the surface of the lower abdominal wall, which may make tion of the peritoneal cavity. visualization with a 0° laparoscope difficult. In addition, an indi- The choice of laparoscopic technique depends on the patient’s rect hernia is a three-dimensional tubular defect that can be well history and on the type of hernia present. In general, we favor TEP visualized in its entirety only with an angled lens. For these reasons, repair for most patients because it does not involve entry into the we recommend routine use of an oblique, forward-viewing 30° or abdominal cavity. The TEP approach reduces the risk of compli- 45° laparoscope. Excellent laparoscopes are currently available in cations affecting intra-abdominal structures, theoretically decreas- 10 mm and 5 mm sizes. For the TAPP repair, one 10/12 mm and es the risk of adhesions, maintains an intact peritoneal layer two 5 mm trocars are used.The dissection is performed with a dis- between the mesh and the intra-abdominal contents, and allows sector and scissors, to which an electrocautery may be attached. the mesh to be placed without the use of fixation. However, it has For mesh fixation, we currently use a spiral tacker (e.g.,TACKER; a steeper learning curve than TAPP does, and it may not be feasi- U.S. Surgical Inc., Norwalk, Connecticut). ble in patients who have undergone lower abdominal procedures. In a TEP repair, besides the equipment needed for a TAPP repair, a balloon-tipped blunt trocar is used to gain access to the Contraindications We do not treat acutely incarcerated her- preperitoneal space. We usually develop the preperitoneal space nias laparoscopically. In patients to whom general anesthesia may with a balloon system [see Operative Technique,Totally Extraperi-
  • 6. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 6 toneal Repair, below], but this can also be done with blunt dissec- Anesthesia 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 laparoscopic Electrosurgery hernia repair, developed by McKernan,20,21 attempts to duplicate the open preperitoneal repair described by Stoppa22-24 and Assistant Wantz.12,25 In a TEP repair, the trocars are placed preperitoneally Surgeon in 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. Surgeon (Contralateral Side Step 1: creation of preperitoneal space With the patient from Defect) in the Trendelenburg position, the anterior rectus fascia is opened through a 1 cm infraumbilical transverse incision placed slightly Nurse toward the side of the hernia, which helps prevent inadvertent opening of the peritoneum. An index finger is inserted on the medial aspect of the exposed rectus abdominis and slid over the posterior rectus sheath. In this plane, a preperitoneal tunnel be- tween the recti abdominis and the peritoneum is created in the midline 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 preperitoneal Primary Monitor space with fascial stay sutures. Video Cart A 30° or 45° operating laparoscope is inserted into the trocar for Sterile Table visualization of the development of the correct plane while insuffla- tion of the preperitoneal space is begun, with the recti abdominis seen anteriorly and the peritoneum posteriorly. Maximal inflation pressure is 10 to 12 mm Hg to prevent disruption of the peritoneum or development of extensive subcutaneous emphysema. Blunt gentle dissection with the laparoscope is employed to develop the space suf- ficiently to allow placement of additional trocars. Figure 5 Laparoscopic inguinal hernia repair. Shown is one of An alternative approach to dissection of the preperitoneal several possible OR setups. The surgeon stands on the side con- tralateral to the defect, with a nurse on the ipsilateral side. The space—one that is especially helpful early in a surgeon’s experi- assistant surgeon stands opposite the surgeon. This positioning ence—is to employ a preperitoneal distention balloon system may vary, depending on the surgeon’s preference and handed- (e.g., PDB; U.S. Surgical Inc., Norwalk, Connecticut). This sys- ness, the visibility of the defect, and the type of defect present, as tem consists of a trocar with an inflatable balloon at its tip, which well as on the prominence of the medial umbilical ligament and is used to develop the preperitoneal space by atraumatically sepa- the need for its retraction rating the peritoneum from the abdominal wall. The balloon is a b c PDB Umbilicus Trocars Skin and Subcutaneous Inflated PDB Tissue Scope Abdominal Cavity Peritoneum Preperitoneal Space 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 the pubis, the PDB is inflated under laparoscopic vision (b). Once the preperitoneal space is created, the PDB is removed 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).
  • 7. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 7 Figure 8 Laparoscopic inguinal hernia repair: TEP approach. Figure 7 Laparoscopic inguinal hernia repair: TEP approach. The edge of the peritoneum is identified lateral to the internal Shown is standard trocar placement for TEP repair. As in TAPP ring and is dissected cephalad off the abdominal wall. repair, three trocar sites are used. One trocar is placed in the umbilicus; the second is placed in the midline, midway between the umbilicus and the pubis; and the third is placed above the a direct hernia is present medial to the inferior epigastric vessels, pubic arch. The trocars should not penetrate the peritoneum. it will often be reduced by the balloon dissector [see Figure 9]. If not, the sac and the preperitoneal contents are carefully dissect- ed away from the fascial defect and swept cephalad as far as pos- inserted into the preperitoneal space below the umbilicus by sible. Gentle traction is applied to expose and dissect away the means of an open Hasson technique and is tunneled inferiorly attachment of the peritoneum to the transversalis fascia [see toward the pubis until the bone is felt with the tip of the balloon Figure 10]. trocar.With the laparoscope in the trocar, the preperitoneal work- The indirect space is then exposed by sweeping off the tissue ing space is developed by gradual inflation of the balloon to a vol- lateral to the inferior epigastric vessels until the peritoneum is ume of 1 L; the transparency of the balloon permits constant found. If a lipoma of the cord is present, it will be lateral to and laparoscopic visualization throughout the distention process. Once covering the peritoneum and should be dissected out of the inter- the working space is created, the PDB is removed and replaced nal ring in a cephalad direction to prevent it from displacing the with a blunt sealing trocar. S-retractors are used to elevate the rec- mesh.18 If there is no indirect hernia, the peritoneum will be found tus and help ensure correct positioning of the trocar above the cephalad to the internal ring. To ensure secure mesh placement, posterior fascia. The preperitoneal space is then reinsufflated to a the peritoneum is bluntly dissected off the cord structures and pressure of 10 to 12 mm Hg [see Figure 6]. placed as far cephalad as possible. Step 2: trocar placement After the peritoneum is dissected away 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 that the bottom port is not covered by the top of the mesh and there- by rendered nonfunctional [see Figure 7]. Care must be taken not to penetrate the peritoneum during trocar placement. If the peri- toneum is penetrated, the resulting pneumoperitoneum can reduce the already limited working space. If the working space is compromised to the point where the repair cannot continue (which is not always the case), the surgeon can either try to repair the rent with a suture or place a Veress needle in the upper abdom- inal peritoneal cavity. If such maneuvers are unsuccessful, the loss of working space may necessitate conversion to a TAPP approach. Step 3: dissection of hernial sac Wide dissection of the preperitoneal space is then undertaken with blunt graspers in a two-handed technique by bluntly dividing the avascular areolar Figure 9 Laparoscopic inguinal hernia repair: TEP approach. tissue between the peritoneum and the abdominal wall [see Shown is a right-side direct hernia, with the inferior epigastric Figure 8]. The pubis, Cooper’s ligament, and the inferior epigas- vessels lateral to the defect, as visualized after initial gas insuffla- tric vessels are located first and used to orient the dissection. If tion and before dissection of preperitoneal fat.
  • 8. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 8 Step 5: closure The operative site is inspected for hemosta- sis. The trocars are removed under direct vision. The insufflated CO2 is slowly released so that the mesh may be visualized as the preperitoneal fat and contents collapse back onto the mesh. The fascia 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 prefer an open technique, in which a blunt-tipped 12 mm trocar is inserted into the peritoneal cavity under direct vision. CO2 is then insufflated into the abdomen to a pressure of 12 to 15 mm Hg. The angled laparoscope is introduced, and both inguinal areas are inspected.Two 5 mm ports are placed, one at the lateral border of each rectus abdominis at the level of the umbilicus, to allow place- ment of the camera and the instruments [see Figure 13].The 5 mm Figure 10 Laparoscopic inguinal hernia repair: TEP approach. lateral ports may be replaced with 10 mm ports if only a 10 mm The transversalis fascia is seen adherent to the hernial sac. The laparoscope is available. sac must be separated from the fascia and dissected cephalad to the level of the umbilicus. Step 2: identification of anatomic landmarks The four key anatomic landmarks mentioned earlier [see Laparoscopic Inguinal Hernia Repair, Anatomic Considerations, above]—the If an indirect hernia is present, the sac will be lateral and ante- spermatic vessels, the obliterated umbilical artery (medial umbili- rior to the cord structures. A small indirect hernial sac is bluntly cal ligament), the inferior epigastric vessels (lateral umbilical liga- dissected off the spermatic cord with a hand-over-hand technique ment), and the external iliac vessels—are identified on each side. and reduced until an area sufficient for mesh placement is created In the presence of an indirect hernia, the internal inguinal ring is [see Figure 11]. To prevent early recurrence, all attachments of the easily identified by the presence of a discrete hole lateral to the junc- peritoneum should be dissected cephalad to where the inferior tion of the vas deferens, the testicular vessels, and the inferior epigas- edge of the mesh will be. If a large indirect sac is not easily reduced tric vessels. Identification of a direct hernia can be more difficult. from the scrotum, it may be transected in its superolateral edge, Sometimes, a direct hernia appears as a complete circle or hole; at dissected off the cord structures, and closed with an endoscopic other times, it appears as a cleft, medial to the vas deferens–vascular ligating loop. The distal sac is then left in place and not ligated. junction; and at still other times, it is completely hidden by preperi- Unlike a TAPP repair, in which any indirect hernia present is toneal fat and the bladder and umbilical ligaments.Visualization can readily apparent at first inspection, a TEP repair always requires be particularly difficult in obese patients, who may have considerable that the space lateral to the inferior epigastric vessels be dissected lipomatous tissue between the peritoneum and the transversalis fas- to make sure that there is no indirect component. This dissection cia, or in patients whose hernia consists of a weakness and bulging of should be done even if a direct or femoral hernia is identified.The the entire inguinal floor rather than a distinct sac. For adequate defi- medial border of dissection is the iliac vein or its overlying fat, and nition of this type of hernia and deeper anatomic structures, the peri- the lateral border of dissection is the psoas muscle. Superiorly, dis- toneum must be opened, a peritoneal flap developed, and the under- section should reach the level of the umbilicus. lying fatty layer dissected.26 Direct hernial defects are often situated Step 4: placement of mesh As a rule, we use a large (10.8 × 16 cm) piece of polypropylene mesh shaped to the contours of the inguinal region. A number of different products can also be used for this purpose, including various forms of polypropy- lene and several types of polyester. A marking suture is placed at the superior edge of the mesh on the concave side, which is to be apposed to the peritoneum.The mesh is wrapped around a 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, and the rectus abdominis superiorly [see Figure 12].Tacks or sutures are not usually needed for fixation, but if they are used, they should be placed into Cooper’s ligament and the anterior abdominal wall; to prevent nerve injury, no tacks should be placed inferior to the iliopubic tract lateral to the internal ring. Some surgeons believe that with direct hernias, there is a risk that the mesh may migrate into a large defect. Accordingly, they place several tacks into Cooper’s ligament to prevent this occur- Figure 11 Laparoscopic inguinal hernia repair: TEP approach. rence. For bilateral hernias, two identical repairs are done, and two Shown is an indirect hernial sac retracted laterally, with cord mesh patches are used. structures visualized medially.
  • 9. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 9 Step 3: creation of peritoneal flap The curved scissors or the hook cautery is used to create a peritoneal flap by making a transverse incision along the peritoneum, beginning 2 cm above the 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 to avoid the inferior epigastric vessels. Bleeding from these vessels can usually be controlled by cauterization, but application of hemostatic clips may be necessary on occasion. Another solution is to pass percutaneously placed sutures above and below the bleeding point while applying pressure to the bleeding vessel so as not to obscure the field of vision. If the monopolar cautery is used to create the peritoneal flap, the entire uninsulated portion of the instrument must be visible at all times to ensure that inadvertent bowel injury does not occur. The incised peritoneum is grasped along with the attached preperitoneal fat and the peritoneal sac and is dissected cephalad Figure 12 Laparoscopic inguinal hernia repair: TEP approach. with blunt and sharp instruments to create a lower peritoneal flap The mesh is oriented so as to cover the indirect, direct, and [see Figure 15]. Dissection must stay close to the abdominal wall. femoral spaces (inguinal floor). The dissected hernial sac is A significant amount of preperitoneal fat may be encountered, placed over the top of the mesh to reduce the risk that the sac will and this should remain with the peritoneal flap so that the abdom- slide underneath the mesh and cause a recurrence of the hernia. inal wall is cleared. When the correct preperitoneal plane is entered, dissection is almost bloodless and is easily carried out. medial to the ipsilateral umbilical ligament, and retraction or even division of this structure is sometimes necessary. Division of this structure 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.Traction on the ipsilateral testicle can demonstrate the vas deferens when visualization is obscured by overlying fat or pressure from the pneumoperitoneum. Umbilicus Figure 14 Laparoscopic inguinal hernia repair: TAPP approach. Shown is dissection of a left direct inguinal hernia. The hernial sac is inverted and the peritoneum incised superior to the sac. 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 through the umbilical trocar, and two additional trocars are placed in the right and the left midabdomen. To ensure that the first trocar is not placed too close to the surgical field, the first trocar should be placed either in the umbilicus or immediately above it. The two Figure 15 Laparoscopic inguinal hernia repair: lateral trocars should be placed lateral to the rectus sheath to pre- TAPP approach. A flap of peritoneum is dissected vent bleeding and postoperative muscle spasms. At least one tro- downward, revealing a hernial defect and the inferior car must be 10/12 mm to allow insertion of the mesh. epigastric vessels (arrow) on the left side.
  • 10. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 10 Step 6: placement of mesh A 10 × 6 cm sheet of polypropylene mesh is rolled into a tubular shape and introduced into the abdomen through the 10/12 mm umbilical trocar. Prolene is preferable to Marlex in this application because it is less dense, conforms more easily to the posterior inguinal wall, and has Direct larger pores, which facilitate visualization and subsequent secur- Defect ing with staples or tacks. The inherent elasticity and resiliency of Prolene 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 entire inguinal 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 to prevent any migration.We use an endoscopic multifire spiral tack- er to secure the mesh, beginning medially and proceeding lateral- Figure 16 Laparoscopic inguinal hernia repair: TAPP approach. ly. The upper margin is first tacked to the rectus abdominis and Dissection of the preperitoneal space on the left side allows iden- the transversus abdominis fascia and arch, with care taken to stay tification of the anatomic landmarks. The dissector points to the iliopubic tract inferior to the direct hernial defect. 1 to 2 cm above the level of the internal inguinal ring and to avoid the inferior epigastric vessels, up to a point several centimeters lat- eral to the internal inguinal ring or the indirect hernial defect. Step 4: dissection of hernial sac The hernial sac, if pres- Extending mesh fixation to the anterior iliac spine is neither nec- ent, is removed from Hesselbach’s triangle or the spermatic cord essary nor desirable. A two-handed technique is recommended for and surrounding muscle through inward traction, countertrac- tack placement: one hand is on the tacker, and the other is on the tion, and blunt dissection with progressive inversion of the sac abdominal wall, applying external pressure to place the wall until the musculofascial boundary of the internal inguinal ring against the tacker.The tacker itself is frequently pushed against the and the key deep anatomic structures are identified. In most tissues and used as a spreader and palpator. However, it must not cases, the hernial sac can be slowly drawn away from the trans- be forced too deeply into the abdominal wall superolateral to the versalis fascia or the spermatic cord. The sac is grasped at its spermatic cord; doing so might lead to inadvertent entrapment apex and pulled inward, thus being reduced by inversion. The of the sensory nerves. The tacker can be moved from the left to indirect sac may be visualized more easily if it is grasped and the right port, depending on which position more readily allows retracted medially; this step facilitates its dissection away from placement of the staples perpendicular to the mesh and the abdo- the cord structures. minal wall. Spermatic cord lipomas usually lie posterolaterally and are exten- Once the superior margin is fixed, fixation of the inferior margin is sions of preperitoneal fat. In the presence of an indirect defect, such accomplished, beginning at the pubic tubercle and moving laterally lipomas should be dissected off the cord along with the peritoneal along Cooper’s ligament.The mesh is lifted frequently to ensure ad- flap to lie cephalad to the internal inguinal ring and the subsequent equate visualization of the spermatic cord. Care is taken to avoid the repair so that prolapse through the ring can be prevented. adjacent external iliac vessels, which lie inferiorly. Lateral to the cord A large indirect hernial sac can be divided at the internal ring structures, all tacks are placed superior to the iliopubic tract to pre- if it cannot be readily dissected away from the cord structures. vent subsequent neuralgias involving the lateral cutaneous nerve of This step may prevent the type of cord injury that can result from the thigh or the branches of the genitofemoral nerve. If the surgeon extensive dissection of a large indirect sac. Division of a large in- can palpate the tacker through the abdominal wall with the non- direct sac is best accomplished by opening the sac on the side op- dominant hand, the tacker is above the iliopubic tract. The mesh posite the spermatic cord, then completing the division from the should lie flat at the end of the procedure. inside.16 Step 7: closure of peritoneum The peritoneal flap, includ- Step 5: reidentification and exposure of landmarks Once ing the redundant inverted hernial sac, is placed over the mesh, the peritoneal flap has been created, the key anatomic landmarks and the peritoneum is reapproximated with the tacker [see Figure mentioned earlier [see Laparoscopic Inguinal Hernia Repair, 17]. Reduction of the intra-abdominal pressure to 8 mm Hg, cou- Anatomic Considerations, above] must be reidentified and pled with external abdominal wall pressure, facilitates a tension- exposed so that neurovascular structures can be protected from free reapproximation. Alternatively, the peritoneum may be injury and the tissues required for reliable mesh fixation can be sutured over the mesh, but in most surgeons’ hands, this closure located. The pubic tubercle is often more easily felt than seen. takes longer. Cooper’s ligament is initially felt and subsequently seen along the pectineal prominence of the superior pubic ramus as dissection Step 8: closure of fascia and skin The peritoneal repair is continues laterally and fatty tissue is swept off to expose the glis- inspected to ensure that there are no major gaps that might result tening white structure. Care must be taken to avoid the numerous in exposure of the mesh and subsequent formation of adhesions. small veins that often run on the surface of the ligament, as well The trocars are then removed under direct vision, and the pneu- as to avoid the occasional aberrant obturator artery.The iliopubic moperitoneum is released. The fascia at the 10/12 mm port sites tract is initially identified at the inferior margin of the internal is closed with 2-0 polydioxanone sutures to prevent incisional her- inguinal ring, with the spermatic cord above, and is then followed nias. The skin is closed with 4-0 absorbable subcuticular sutures. in both a medial and a lateral direction. Minimal dissection is car- POSTOPERATIVE CARE ried out inferior to the iliopubic tract so as not to injure the geni- tal femoral nerve, the femoral nerve, and the lateral cutaneous Patients are observed in the recovery room until they are able nerve of the thigh [see Figure 16]. to ambulate unassisted and to void; if they are unable to void at
  • 11. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 11 the time of discharge, in-and-out catheterization is performed. Pa- Complications of access to peritoneal cavity A TAPP tients are advised to resume their usual activities as they see fit; repair exposes the patient to several potentially serious risks relat- driving a car is permitted when pain is minimal. Outpatient pre- ed to the choice of the transabdominal route.Trocar injuries to the scriptions for acetaminophen, naproxen, and oxycodone are bowel, the bladder, and the vascular structures can occur during given, and follow-up visits in the surgical clinic are scheduled for the creation of the initial pneumoperitoneum or the subsequent postoperative day 7 to 14. Patients who live alone, have had intra- insertion of the trocars.14,37 Visceral injury rates reported for the operative complications, have significant nausea or vomiting, or laparoscopic approach, though quite low, are still about 10 times experience unexplained or inordinate pain are admitted those reported for the open approach.14 Another complication overnight. related to trocar placement is incisional hernia,14 which can lead to postoperative bowel obstruction14,15,38; however, this complica- DISADVANTAGES AND COMPLICATIONS tion can be minimized by using 5 mm trocars and a 5 mm laparo- scope instead of the larger 10/12 mm instruments. Disadvantages Need for general anesthesia The need for pneumoperi- Complications of dissection Injuries occurring during dis- toneum and thus for general anesthesia in laparoscopic hernior- section are often linked to inexperience with laparoscopic inguinal rhaphy is sometimes considered a major disadvantage. Nausea, anatomy. If serious enough, they can necessitate laparotomy. dizziness, and headache are more common in the recovery room Fortunately, such conversion is rare (< 3%).14 The most common after TAPP repair than after Lichtenstein repair.27 It is not neces- vascular injuries occurring during laparoscopic inguinal herniorrha- sarily true, however, that local or regional anesthesia is safer than phy are those involving the inferior epigastric vessels and the sper- general anesthesia.28 Anesthesiology studies critically appraising matic vessels.14 The external iliac, circumflex iliac, profunda, and anesthetic techniques for hernia surgery have shown the choice of obturator vessels are also at risk. A previous lower abdominal oper- general anesthesia over local or regional anesthesia to be safe and, ation is a risk factor.16 The source of any abnormal bleeding during in many cases, advantageous, particularly in patients who are in the procedure must be quickly identified. All vessels in the groin can poor health. Furthermore,TEP repair has been successfully done be ligated except the external iliac vessels, which must be repaired.16 with patients under epidural and local anesthesia.14,29,30 Injuries to the urinary tract may also occur. Four bladder injuries necessitating repair were documented in a collected series Lower cost-effectiveness A study comparing costs at of 762 laparoscopic repairs by different surgical groups.37,39,40 North American teaching hospitals found that TEP repair cost Bladder injuries are most likely to occur when the space of Retzius US$852 more than Lichtenstein repair; however, this study could has been previously dissected (e.g., in a prostatectomy). Renal and not quantify the cost savings arising from faster recuperation and ureteral injuries identified intraoperatively should be repaired earlier reentry into the workforce.31 Some studies have demon- immediately. Often, however, these injuries are not apparent until strated economic savings with the use of a laparoscopic approach, the postoperative period, when they present as lower abdominal in the form of fewer days of work missed and reduced worker’s pain, renal failure, ascites, dysuria, or hematuria—all of which compensation costs.32,33 Operating costs can also be reduced by should be investigated promptly. Although indwelling catheter avoiding the use of disposable instruments.34 In addition, operat- drainage may constitute sufficient treatment of a missed retroperi- ing time has been shown to decrease as the surgeon’s experience toneal bladder injury, intraperitoneal injuries are best treated by with the procedure increases.15,35,36 direct repair via either laparoscopy or laparotomy. Complications Complications related to mesh Complications related to Most randomized trials comparing laparoscopic repair with the use of mesh include infection, migration, adhesion formation, open mesh repair have found the overall complication rate to be and erosion into intraperitoneal organs. Such complications usu- comparable between groups.14,15 In general, however, the rate of ally become apparent weeks to years after the initial repair, pre- serious perioperative complications, though still low, is increased senting as abscess, fistula, or small bowel obstruction. with the laparoscopic approach.15 Mesh infection is very rare. In the 2003 Cochrane review of antibiotic prophylaxis for nonmesh hernia repairs,19 the overall infection rate was 4.69% in the control group and 3.08% in the treatment group. Thus, to prevent one infection in 30 days, 50 patients would have to be treated, and these patients would then be at risk for antibiotic-associated complications. Laparoscopic repairs were excluded from this review; however, in a meta-analy- sis comparing postoperative complications after laparoscopic inguinal hernia repair with those after open repair, superficial infection was less frequent in the laparoscopic groups.14 Deep mesh infection was rare in both groups. Mesh infection usually responds to conservative treatment with antibiotics and drainage. On rare occasions, the mesh must be removed; this may be accomplished via an external approach. It is noteworthy that removal 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 TAPP repair, appropriate stapling of the mesh should reduce this possi- Figure 17 Laparoscopic inguinal hernia repair: TAPP approach. bility. In a TEP repair, stapling does not appear to be necessary to The peritoneum is stapled over the mesh. prevent migration.35,42
  • 12. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 12 The risk that adhesions to the mesh will form is augmented if A great deal of attention has rightly been focused on the risk of the mesh is left exposed to the bowel. The long-term durability nerve injury with laparoscopic hernia repair, as well as on ways of and effectiveness of the sometimes flimsy peritoneal coverage preventing it. At the same time, it is important to note that pain and employed in the TAPP approach have been questioned. Even in numbness, including thigh numbness, can also occur after open the TEP approach, small tears in the peritoneum may expose the repair and may in fact be more common in that setting than was bowel to the mesh. previously realized. In one study, persistent groin pain was present in 9.5% of patients after Lichtenstein repair versus 5.5% of patients Urinary complications Injuries to the urinary tract aside [see after TAPP.48 In the Cochrane meta-analysis, persistent pain and Complications of Dissection, above], urinary retention, urinary tract numbness 1 year after surgery were found to be significantly infection, and hematuria are the most common complications. reduced with either TEP or TAPP repair.14 This finding was con- Avoidance of bladder catheterization reduces the incidence of these firmed by a 2004 study that reported a 9.8% incidence of neuralgia complications, but urinary retention still occurs in 1.5% to 3% of pa- or other pain at 2 years in patients who underwent laparoscopic tients.15 General anesthesia and the administration of large volumes repair, compared with a 14.3% incidence in open repair patients.15 of I.V. fluids may also predispose to retention. Miscellaneous complications Laparoscopic repair appar- Vas deferens and testicular complications Wantz43 be- ently reduces the incidence of hematomas while increasing that of lieved that the most common cause of postoperative testicular seromas.14 Lipomas of the spermatic cord, if left unreduced in swelling, orchitis, and ischemic atrophy is surgical trauma to the patients with indirect hernias, may produce a persistent groin testicular veins (i.e., venous congestion and subsequent thrombo- mass and a cough impulse that mimic recurrence, especially to an sis). Because spermatic cord dissection is minimized with the uninitiated examiner. These lipomas are always asymptomatic. laparoscopic approach, the risk of groin and testicular complica- OUTCOME EVALUATION tions resulting from injury to cord structures and adjacent nerves may be reduced.15 Although there is a large body of literature on laparoscopic Most testicular complications, such as swelling, pain and epi- inguinal hernia repair—including a variety of randomized, con- didymitis, are self-limited. Testicular pain occurs in about 1% of trolled trials—the benefits of the laparoscopic approach have not patients after laparoscopic repair,33 an incidence comparable to yet been clearly defined or widely accepted. Given the low mor- that seen after open repair.15,44 A similar number of patients expe- bidity and relatively short recovery already associated with the rience testicular atrophy,37 for which there is no specific treatment. conventional operation, demonstration of any significant differ- The risk of injury to the vas deferens appears to be much the ences between the open mesh and laparoscopic techniques same in laparoscopic repair as in open repair.14 If fertility is an requires large study samples. The previously cited meta-analysis issue, the cut ends should be reapproximated if the injury is rec- done by the Cochrane collaboration addressed this question.14 ognized intraoperatively. Forty-one trials were included in this meta-analysis, ranging in size from 38 to 994 randomized patients. The duration of follow-up Postoperative groin and thigh pain Unlike patients who ranged from 6 weeks to 36 months.The results of the meta-analy- undergo open anterior herniorrhaphy, in whom discomfort or sis suggested that whereas operating times were longer and the risk numbness is usually localized to the operative area, patients who of rare but serious complications higher in the laparoscopic undergo laparoscopic repair occasionally describe unusual but groups, recovery was quicker and persistent pain and numbness specific symptoms of deep discomfort that are usually positional less frequent. Recurrence rates did not differ significantly. and are often of a transient, shooting nature suggestive of nerve In addition, a large randomized, multicenter Veterans Affairs irritation. The pain is frequently incited by stooping, twisting, or (VA) study published in 2004 compared open mesh repair with lap- movements causing extension of the hip and can be shocklike. aroscopic mesh repair (TEP, 90%; TAPP, 10%) in 2,164 patients.15 Although these symptoms can frequently be elicited in the early Patients with previous mesh repairs were excluded. In this study, postoperative period, they are usually transient. If tacks or staples the laparoscopic approach was associated with a higher risk of com- were used and neuralgia is present in the recovery room, prompt plications and, in contrast to the findings of the meta-analysis, a reexploration is the best approach.16 higher overall recurrence rate at 2 years after operation. Pain was Persistent pain and burning sensations in the inguinal region, reduced and recovery time shortened in the laparoscopic group. the upper medial thigh, or the spermatic cord and scrotal skin Thus, there remains a degree of controversy regarding the ideal region occur when the genitofemoral nerve or the ilioinguinal approach to and outcome for inguinal hernia repair. Accordingly, nerve is stimulated, entrapped, or unintentionally injured. When we will briefly review the salient outcomes of a number of studies these symptoms persist, they may result in severe morbidity.45 A that compare laparoscopic inguinal herniorrhaphy with open more worrisome symptom is lateral or central upper medial mesh repair. thigh numbness, which is reported in 1% to 2% of patients and often lasts several months or longer. Whether this numbness is Laparoscopic Repair versus Open Mesh Repair related to staple entrapment, fibrous adhesions, cicatricial neu- Operating time The Cochrane meta-analysis suggested that roma, or mesh irritation is unknown. Numbness and paresthesia overall, the average operating time was 15 minutes longer with the of the lateral thigh are less frequent and are related to the laparoscopic approach; however, for bilateral hernias, laparoscop- involvement of fibers of the lateral cutaneous nerve.These prob- ic repair required no more time than open repair.14 The surgeon’s lems can be prevented by paying careful attention to anatomic level of experience with laparoscopic technique was not explicitly detail and technique.46 Anatomic study, based on cadaveric dis- stated in all of these studies, which made it difficult to assess the sections, suggests that both the genitofemoral nerve and the lat- impact of this variable on operating time. It has been shown that eral cutaneous nerve of the thigh will be protected in all cases if with more experience and greater specialization, the differences in no staples are placed further than 1.5 cm lateral to the edge of operating time between laparoscopic and open repair tend to the internal ring.47 decrease and become clinically unimportant.35,49
  • 13. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 13 Recovery time The most significant short-term outcome Recurrent hernias Approximately 10% of patients under- measure after hernia repair is recovery time, defined as the time going hernia repair present with recurrent inguinal hernia.54 required for the patient to return to normal activities. One of the Patients with recurrent hernias may potentially derive greater ben- most frequently cited benefits of laparoscopic herniorrhaphy is efits from a laparoscopic approach through an undisturbed plane the patient’s rapid return to unrestricted activity, including work. of dissection, rather than a second groin exploration via an open The Cochrane meta-analysis revealed that recovery time was technique, dissecting through scar tissue and potentially causing significantly shorter after laparoscopic repair than after open significant tissue trauma. This is especially true when mesh was mesh repair.14 In a cost comparison between TEP repair and used for the previous open repair. Lichtenstein repair, recovery time was 15 days after the former, Open mesh repair has been associated with long-term recur- compared with 34 days after the latter.31 In the 2004 VA study, rence rates of 1% or less, even when not performed by hernia spe- laparoscopic repair patients returned to their normal activities 1 cialists.2, 55 If the laparoscopic approach is to be a viable alternative day earlier.15 to open repair, it should have comparable results. With respect to short-term results, prospective, randomized trials suggest that her- Postoperative pain After laparoscopic repair, most nia recurrence rates are comparable in laparoscopic repair and patients experience minimal immediate postoperative pain and open mesh repair groups.14 However, the Cochrane meta-analysis have little or no need for analgesics after postoperative day 1. found that reductions in hernia recurrence were effected primari- Patients are able to perform some exercises better after laparo- ly by the use of mesh rather than by any specific placement tech- scopic repair than after Lichtenstein repair.48 That patients expe- nique.14 This finding is consistent with the Cochrane meta-analy- rience less postoperative pain after laparoscopic repair than after sis of open mesh inguinal hernia repair versus open nonmesh open mesh repair has been reported in several randomized stud- repair, which indicated that tension-free mesh repair led to a sig- ies.27,32,40,44,50,51 In the Cochrane meta-analysis, persistent pain nificant reduction in hernia recurrence.3 In a 5-year follow-up and numbness 1 year after surgery was significantly less after study from 2004, the recurrence rate after laparoscopic mesh either TEP or TAPP repair than after open repair.14 In a 2003 repair still was not significantly different from that after open mesh report describing a 5-year follow-up of 400 patients treated with repair.34 In the VA study, the hernia recurrence rate at 2 years was either Lichtenstein open mesh repair or TAPP repair, the inci- higher in the laparoscopic group (10%) than in the open mesh re- dence of permanent paresthesia and groin pain was lower with pair group (4%) for primary, unilateral hernias.15 In both groups, the TAPP approach.52 Moreover, all of the patients with pain and the recurrence rates were higher than generally expected. How- paresthesia significant enough to affect their daily lives were in ever, these rates were found to be affected by the surgeon’s level of the open repair group. A later study that evaluated postoperative experience: those who had performed more than 250 laparoscop- neuralgia in 400 patients who underwent either TAPP repair or ic repairs reported a recurrence rate of 5%. Lichtenstein repair reported similar findings.48 Most reported recurrences after laparoscopic herniorrhaphy come at an early stage in the surgeon’s experience with these pro- Quality of life The studies that have assessed quality of life cedures and arise soon after operation.56 The majority can be immediately after hernia repair have tended to favor the laparo- attributed to (1) inadequate preperitoneal dissection; (2) use of an scopic approach, albeit marginally. Using the SF-36 (a widely inadequately sized patch, which may migrate or fail to support the accepted general health-related quality-of-life questionnaire), one entire inguinal area, including direct, indirect, and femoral spaces; group found that at 1 month, greater improvements from baseline or (3) staple failure with TAPP repair. were apparent in the laparoscopic group in every dimension except general health; however, by 3 months, the differences Transabdominal Preperitoneal Repair (TAPP) versus between the two groups were no longer significant.27 Another Totally Extraperitoneal Repair (TEP) group also found no differences in any SF-36 domains at 3 The TAPP approach is easier to learn and perform than the months after operation.37 Yet another study, however, using the TEP approach, and even experienced laparoscopic hernia sur- Sickness Impact Profile, found some benefit to the laparoscopic geons report more technical difficulties with the latter.15,57 approach.53 In contrast, no postoperative differences in SF-36 Nonetheless, there is a growing body of literature to suggest that domains were found in the VA study.15 TEP repair, by avoiding entry into the peritoneal cavity, has sig- nificant advantages over TAPP repair.4 In particular, the TEP Bilateral hernias Laparoscopy allows simultaneous explo- approach should reduce the risk of trocar site hernias, small bowel ration of the abdominal cavity (TAPP) and diagnosis and treat- injury and obstruction, and intraperitoneal adhesions to the mesh. ment of bilateral groin hernias, as well as coexisting femoral her- In a study that included 426 patients, TAPP repairs were per- nias (which are often unrecognized preoperatively), potentially formed in 339 and TEP repairs in 87, and the patients were fol- without added risk or disability. Bilateral hernias accounted for lowed for a mean of 23 and 7 months, respectively.58 Time off 9% of the hernias reviewed in the Cochrane database.14 Operating work was shorter after TEP. A total of 15 major complications time was longer in the laparoscopic groups than in the open were noted, including one death, two bowel obstructions, one groups; however, recovery time, the incidence of persistent numb- severe neuralgia, three trocar site hernias, one epigastric artery ness, and the risk of wound infection were significantly reduced in hemorrhage, and seven recurrences.With the exception of the epi- the former. These results are consistent with those of a prospec- gastric artery hemorrhage, all of these complications occurred in tive, randomized, controlled trial from 2003 that compared TAPP the TAPP group. It is possible, however, that these results can be repair with open mesh repair for bilateral and recurrent hernias.54 partly explained by the learning curve, in that the TAPP repairs In this study, TAPP repair not only was less painful and led to an were all done before the TEP repairs. That six TAPP recurrences earlier return to work but also was associated with a shorter oper- occurred in the first 31 cases, whereas only one occurred in the ating time. Further prospective, randomized trials designed to subsequent 395 cases, lends support to this possibility. compare simultaneous bilateral open tension-free repair with In a study comparing 733 TAPP repairs with 382 TEP repairs, bilateral TEP laparoscopic repair should be undertaken. 11 major complications occurred in the TAPP group (two recur-
  • 14. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 14 rences, six trocar site hernias, one small bowel obstruction, and Table 1 Meshes Used for Incisional two small bowel injuries), whereas only one recurrence and no Hernia Repair intraperitoneal complications occurred in the TEP group.59 Seven TEP procedures were converted to TAPP procedures. Time off Manufacturer Product Name Composition work was equal in the two groups but was prolonged in patients receiving compensation. As in the study cited above,58 the TAPP Gore Dualmesh Dual-sided ePTFE patients were followed longer than the TEP patients, and the Dualmesh Plus Dual-sided ePTFE, antibiotic- impregnated TAPP cases occupied the first part of the learning curve.To avoid this type of selection bias would require a randomized study. Bard/Davol Composix Polypropylene/ePTFE laminate Not all surgeons are convinced that TEP repair is the laparo- Composix E/X Polypropylene/ePTFE laminate scopic procedure of choice. A 1998 study compared 108 TAPP Composix Kugel Polypropylene/ePTFE laminate repairs with 100 TEP repairs.57 Although the TEP repairs were Visilex Polypropylene Dulex Dual-sided ePTFE done only by surgeons who were already familiar with TAPP Reconix Dual-sided ePTFE repair, many of the surgeons still encountered technical difficulties and problems with landmark identification. Overall, complications Genzyme Sepramesh Polypropylene/HA/CMC laminate did not occur significantly more frequently in either group, but Sofradim Parietex Polyester/type I collagen hydrophilic they seemed more severe in the TAPP group: four trocar site her- film laminate nias, one bladder injury, and six seromas were noted in the TAPP Brennen Medical Glucamesh Polypropylene/β-glucan laminate group, compared with one cellulitis and six seromas in the TEP Glucatex Polyester/β-glucan laminate group. The authors concluded that because TAPP repair is easier and does not increase complications significantly, it is an “ade- Ethicon Endo- Proceed Polypropylene/oxidized regenerated quate” procedure. The sample size may have been too small to Surgery cellulose permit detection of small differences in complication rates. Cook Surgisis Porcine intestinal submucosa Regardless of any individual preference for one technique or the Surgisis Gold other, laparoscopic hernia surgeons ideally should be capable of performing both TEP and TAPP well. For example, a planned ePTFE—expanded polytetrafluoroethylene HA/CMC—hyaluronate/carboxymethyl- cellulose TEP repair may have to be converted to a TAPP repair, or a TAPP approach may be required if the surgeon is doing another intra- peritoneal diagnostic or therapeutic procedure. egory includes virtually all incisional hernias, in that even small 0000(< 10 0cm2) de0f000ects are known to carry a significant risk of recurrence.62 Both upper abdominal and lower abdominal inci- Laparoscopic Incisional Hernia Repair sions are amenable to a laparoscopic approach, although hernias Incisional hernias develop in approximately 2% to 11% of at the extremes of the abdominal wall—abutting the pubis, the patients undergoing laparotomy.60,61 It has been estimated that xiphoid, or the costal margins—pose a technical challenge for 90,000 ventral hernia repairs are done in the United States every effective mesh fixation. The so-called Swiss cheese hernia, which year.5 When prosthetic mesh is not used, repair of large incisional comprises multiple small defects, is particularly well suited to this hernias is associated with recurrence rates as high as 63% after 10 approach; open repair would necessitate a large incision for access years, compared with 32% when mesh is used.62 In addition to to the multiple fascial defects, and small defects might not be these high recurrence rates, even with the use of mesh, open inci- appreciated. Incarcerated hernias can also be approached laparo- sional hernia repair may be associated with significant complica- scopically; however, the suspected presence of compromised tions and a substantial hospital stay. bowel is a contraindication. An abdomen that has undergone Initially described in 1992,9 laparoscopic repair of incisional multiple operations and contains dense adhesions presents a hernias has evolved from an investigational procedure to one that challenge in terms of both access to the abdominal cavity and can safely and successfully be used to repair ventral hernias.Taking access to the hernia site. If the surgeon cannot obtain safe access a laparoscopic approach allows the surgeon to minimize abdomi- to the peritoneal cavity for insufflation, a laparoscopic approach nal wall incisions, avoid extensive flap dissection and muscle mobi- is contraindicated. lization, and eliminate the need for drains in proximity to the mesh, thereby potentially achieving reductions in pain, recovery Contraindications Laparoscopic incisional herniorrhaphy is time, and duration of hospitalization, as well as lower rates of sur- contraindicated in patients with suspected strangulated bowel or gical site infection (SSI).8,63,64 In addition, the improved visualiza- loss of domain. Hernias in which the fascial edges extend lateral to tion of the abdominal wall associated with the laparoscopic view may result in better definition of the defect, the discovery of unrec- ognized hernia sites, and improved adhesiolysis. Improved visual- Table 2 Devices Used for Mesh Fixation ization permits more precise and accurate placement and tailoring in Incisional Hernia Repair of the mesh, as is suggested by the reduced recurrence rates (9% to 12%) reported up to 5 years after laparoscopic incisional Manufacturer Device Name Fixation Method herniorrhaphy.64-66 U.S. Surgical (AutoSuture) TACKER Steel spiral tacks PREOPERATIVE EVALUATION Ethicon Endo-Surgery EndoANCHOR Nitinol anchors Selection of Patients Sofradim Pariefix Polyglycolic T-fasteners Laparoscopic incisional hernia repair may be considered for any Wire loop deployment Onux Medical Salute ventral hernia in which mesh will be used for the repair. This cat-
  • 15. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 15 the midclavicular line may make trocar placement lateral to the defect impossible. Defects in close proximity to the bony margins of the abdomen, especially those near the xiphoid, pose significant challenges for mesh fixation, though this is also true with open incisional herniorrhaphy. Patients who have undergone multiple previous operations, with or without mesh, may have dense adhe- sions. Patients in whom polypropylene mesh has previously been placed in an intra-abdominal position may have dense adhesions to the underlying viscera. Whether such patients are approached laparoscopically should be determined by the surgeon’s expertise. OPERATIVE PLANNING Preparation The procedure is performed with the patient under general anesthesia. 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 catheter Figure 18 Laparoscopic incisional hernia repair. Shown is an is placed in the bladder. Sequential compression stockings are external view of incisional hernia trocar site placement. Open applied. Patients are routinely given heparin, 5,000 U subcuta- insertion of a blunt 10/12 mm trocar at the left lateral midab- neously, and prophylactic antibiotics.67 domen site is performed, with subsequent placement under direct vision of two 5 mm trocars above and below the initial trocar. Positioning The patient is placed in the supine position with both arms tucked. If the hernia is in the midline, the surgeon can stand on and the abdominal wall. The defect is not closed. The mesh is either side of the patient, with the monitor directly opposite. If the anchored with a minimum of four subcutaneously tied transfascial hernia extends significantly to one side, initial trocar placement is sutures placed at the four corners and is further secured between done on the opposite side. Initially, the assistant stands on the the sutures with intraperitoneally placed tacks and additional same side as the surgeon; however, he or she may later have to sutures as needed. move to the opposite side to help with dissection and stapling. A second monitor on the opposite side of the table is useful. If the Step 1: placement of trocars Because of the probability of defect is subcostal, the surgeon may prefer to operate from extensive intra-abdominal adhesions, we begin with open inser- between the patient’s legs, with a monitor at the head of the bed. tion of a blunt 12 mm trocar. Although open insertion necessitates an often tedious dissection through several layers of the abdomi- Equipment nal wall, it has the advantage of allowing early diagnosis and repair As the wide variety of mesh materials currently available sug- of any iatrogenic bowel injury. Nevertheless, good results have also gests, there is no one ideal mesh. Meshes may be divided into two been reported with insertion of a Veress needle, usually in the left categories: (1) polymeric meshes and (2) meshes made of special- upper quadrant (where adhesions are presumed to be minimal). ly prepared connective tissue (animal or human) [see Table 1].The Ultimately, trocar position is determined by the location of the polymeric meshes are biocompatible materials made of either hernia. For midline hernias, we usually begin on the left side of the polypropylene, polyester, expanded polytetrafluoroethylene patient and insert the first trocar lateral to the edges of the defect, (ePTFE), or laminates of these. Most ePTFE meshes are engi- about midway between the costal margin and the iliac crest. neered so that one side is porous to encourage tissue ingrowth and CO2 is then insufflated to a pressure of 12 to 15 mm Hg, and a the other is smooth to resist adhesion formation.They may also be 5 mm 30° scope is inserted. As in laparoscopic inguinal hernia coated with an adhesion-resisting absorbable material. repair, an angled scope is essential because dissection and repair Because laparoscopic incisional hernia repair leaves the mesh are done on the undersurface of the anterior abdominal wall, exposed to the intraperitoneal cavity, concerns have been which cannot be adequately visualized with a 0° scope. The her- expressed about the risk of adhesion formation and fistulization if nial defect is visually identified, and two additional 5 mm trocars polypropylene mesh is used. Polytetrafluoroethylene (PTFE) are placed on the same side under direct vision, with their precise mesh has been demonstrated to have a reduced propensity for placement dependent on the size and contours of the defect and adhesion formation. on the locations of any adhesions. If possible, these trocars are Additional special equipment used for incisional hernia repair placed superior and inferior to the initial trocar, as far laterally as includes a suture passer, a 5 mm spiral tacker (or other tacking possible, with care taken to ensure that the downward movement device), and 2-0 monofilament sutures. Several tacking devices of the instruments is not limited by the iliac crest or the thigh. and suture placement devices have been developed to facilitate Lateral placement is necessary to optimize exposure of the mesh fixation [see Table 2]. All work in essentially the same man- abdominal wall [see Figure 18]. ner. A Keith or similar needle may also be used. Atraumatic bowel instruments are required to manipulate the bowel if lysis of adhe- Step 2: exposure of hernial defect The edges of the her- sions is needed. nial defect are exposed by reducing the contents of the hernia into the abdominal cavity. All adhesions from bowel or omentum to the OPERATIVE TECHNIQUE abdominal wall in the vicinity of the defect and along the full In essence, the repair consists of the intraperitoneal placement length of the previous incision should be divided. Complete adhe- of a large piece of mesh so that it overlaps the defect in the fascia siolysis of abdominal wall adhesions facilitates the identification of
  • 16. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 16 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 the locations of the defects and the size of the patient.The mesh sheet is laid on the abdominal wall in a position that approximates its eventual intra-abdominal position, and its four corners and those of its representation on the abdominal wall are numbered clock- wise from 1 through 4 for later orientation [see Figure 22]. A mark is made on the inner side of the mesh sheet so that the surgeon can easily determine which side is to face the peritoneum once the mesh is inserted into the peritoneal cavity. If a dual-sided mesh is being used, the smooth side must be the one facing the bowel. A 2-0 monofilament suture is tied in each corner of the mesh, and both 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. Small Figure 19 Laparoscopic incisional hernia repair. Multiple small swatches can be inserted through a 12 mm trocar; for larger hernial defects (so-called Swiss cheese hernia) may be seen. pieces, we remove a large trocar and insert the mesh directly into the abdomen. The trocar is then repositioned and insufflation of CO2 recommenced. Swiss cheese defects [see Figure 19]. Starting in the upper abdomen may be easier, in that bowel adhesions are less likely to be encoun- Step 4: fixation of mesh Once the mesh swatch has been tered. External pressure may also help reduce hernial contents and introduced into the abdomen, it is unfurled and spread out, with facilitate identification of the hernial sac. Placing the patient head the previously placed corner sutures facing the fascia and orient- down or head up and rotating the table will also aid in exposure. ed so that the four numbered corners are aligned with the num- If dense adhesions are present, it is preferable to divide the sac bers marked on the abdominal wall. Small skin incisions are then or the fascia, so as not to risk bowel injury [see Figure 20]. Sharp made with a No. 11 blade.Through each of these incisions, a suture dissection with scissors is recommended to prevent thermal injury passer is inserted to grasp one tail of the previously placed anchor- to the bowel, which may not be immediately recognized. If incar- ing suture and pull it out through the abdominal wall, then rein- cerated bowel cannot be reduced with laparoscopic techniques, an troduced through the incision at a slightly different angle to pull incision is made over the area of concern, and the bowel is freed out the second tail. This is done for each of the four anchoring under direct vision. Once this incision is closed, laparoscopic mesh sutures, and the mesh is unfurled under appropriate tension (with placement can proceed, and there may be no need for full conver- care taken to avoid excessive tension and stretching). Initially, the sion to an open operation. Strategies for avoidance and treatment corner sutures are held with hemostats and not tied; some adjust- of bowel injury are discussed in more detail elsewhere [see ment to achieve optimal positioning of the mesh is often required, Complications, Bowel Injury, below]. especially early in the surgeon’s experience. Once the mesh is in a satisfactory position, each suture is tied Step 3: selection of mesh The contours of the hernial and buried in the subcutaneous tissue to anchor the mesh swatch defect are marked as accurately as possible on the exterior abdom- to the fascia and maintain its proper orientation [see Figure 23]. inal wall; the edges may be delineated with a combination of pal- With large defects, it is usually necessary to place one or more pation and visualization. All Swiss cheese defects are marked.The additional 5 mm trocars contralateral to the initial ports to aid in defect is measured after pneumoperitoneum is released to ensure mesh 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 pressure to 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 can cause bowel injury if left protruding.68 Additional sutures are then passed at 5 cm intervals directly through the mesh with either the suture 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. Careful closure of the site used for open insertion of the first trocar is mandatory to prevent trocar site hernia. The skin is then closed with subcuticular sutures. POSTOPERATIVE CARE Figure 20 Laparoscopic incisional hernia repair. Shown is dis- section of incarcerated small bowel and omentum from an inci- The Foley catheter is removed at the end of the procedure. sional hernia. Unless adhesiolysis was minimal, patients are admitted to the hos-
  • 17. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 17 Figure 23 Laparoscopic incisional hernia repair. Shown is an Figure 21 Laparoscopic incisional hernia repair. The contours internal view of a two-layer mesh covering the hernial defect and of the incisional hernial defect are marked on the abdomen, as fixed to the abdominal wall with sutures and spiral tacks. measured 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. Subxiphoid or Subcostal Hernia A hernia in which there is no fascia between the hernia and the ribs or the xiphoid (e.g., a poststernotomy hernia) poses signifi- cant challenges for fixation. Because of the risk of intrathoracic injury, the mesh is not tacked to the diaphragm. Although some surgeons perform mesh fixation to the ribs, this measure is often associated with significant postoperative pain and morbidity. In these situations, we take down the falciform ligament and lay the mesh along the diaphragm above the liver, placing tacks and sutures up to but not above the level of the costal margin. Taking down the falciform ligament may be a helpful step for all upper abdominal wall hernia repairs.The recurrence rates for subxiphoid and subcostal hernias are higher than those for hernias at other locations.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- Figure 22 Laparoscopic incisional hernia repair. Shown is an isfactory cosmesis. Three methods of repair have been described: external view of the orientation of a two-sided mesh swatch over- lying the marked hernial defect. The sites of suture placement are numbered. pital. Oral intake is begun immediately. Patients are discharged when 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 they feel capable. SPECIAL SITUATIONS Suprapubic Hernia For hernial defects that extend to the pubic bone, a three-way Foley catheter is inserted. After adhesiolysis, the patient is placed in the Trendelenburg position, and the bladder is distended with methylene blue in saline. The bladder is dissected off the pubic bone until Cooper’s ligament is reached.The mesh is then placed so that it extends behind the bladder and is tacked to the pubic Figure 24 Laparoscopic incisional hernia repair. Shown is two- bone, to Cooper’s ligament, or to both. handed tacking.
  • 18. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 18 primary fascial repair, repair with mesh, and stoma relocation [see case of densely adherent polypropylene mesh, it may be better to 5:27 Open Hernia Repair]. Repair via a laparoscopic approach that excise it from the abdominal wall rather than attempt to separate uses ePTFE mesh has shown promising short-term results.72,73 it from the serosa of the bowel. If there is reason to suspect that The technique that currently seems to be the most successful is bowel injury may have occurred, immediate and thorough inspec- the one described by LeBlanc and Bellanger.73 Rather than lateral- tion should be carried out; if this is not done, it may be difficult or izing the intestine (as in the technique described by Sugarbaker74), impossible to find the exact site of injury later, once the bowel has this method centralizes the intestine in the mesh by cutting an been released after being freed of its attachments. If an injury to appropriately sized hole in the middle of the mesh sheet, along the bowel is recognized, the extent of the injury and the surgeon’s with a slit to allow it to be placed around the intestine.This step is level of comfort with laparoscopic suture repair will determine the repeated on a second piece of mesh, but with the slit oriented to best approach. If there is no or minimal spillage of bowel contents, the opposite side.The mesh is fixed with sutures and tacks in such the injury may be treated with either laparoscopic repair or open a way that it overlaps the defect by at least 3 cm (more common- repair; the latter usually can be carried out through a several cen- ly, 5 cm) on all sides, as in other ventral hernia repairs. This timeter counterincision over the injured area. Whether a mesh method appears to minimize the risk of mesh prolapse and bowel prosthesis will be placed depends on the degree of contamination. herniation alongside the stoma. The authors reported no recur- If there has been minimal or no contamination, any small open rences within their 3- to 11-month follow-up period and no mor- incision is closed, and laparoscopic lysis of adhesions and mesh bidity. In contrast, a subsequent study reported recurrences with- placement can continue. If the contamination is more significant, in 12 months in five of nine patients who underwent a variation of adhesiolysis is completed, but the patient is brought back for mesh this repair, in which a slit in the mesh (instead of a central defect) placement at another date. More significant bowel injuries may was created and only one mesh sheet (instead of two) was used to necessitate conversion to open repair. cover the defect.71 Laparoscopic parastomal hernia repair appears to be a viable Chronic Pain alternative to laparotomy or stoma relocation, but long-term mul- In about 5% of patients, the transfascial fixation sutures used to ticenter evaluation is necessary for full assessment of this tech- secure the mesh cause pain that lasts more than 2 months. In most nique’s value in this setting. cases, postoperative pain decreases over time; if it does not, injec- tion of local anesthetic into the area around the painful suture may COMPLICATIONS be helpful.82 Overall, fewer complications are reported after laparoscopic incisional herniorrhaphy than after open mesh repair.8,63,75-77 Seroma There are, however, several specific complications that are of par- Seroma formation is one of the most commonly reported com- ticular relevance in laparoscopic procedures (see below). plications: it occurs immediately after operation in virtually all patients, to some extent.65,80,83 Patients sometimes mistake a tense Bowel Injury seroma for recurring incisional hernia, but appropriate preopera- A missed bowel injury is a potentially lethal complication. The tive discussion should provide them with significant reassurance overall incidence of bowel injury does not differ significantly on this point. Seroma formation seems not to be related to partic- between open repair and laparoscopic repair and is generally low ular mesh types or to the use of drains.80 Virtually all seromas with either approach (1% to 5% when serosal injuries are includ- resolve spontaneously over a period of weeks to months, with ed). It should be noted, however, that pneumoperitoneum may fewer than 5% persisting for more than 8 weeks.64 They are rarely hinder the recognition of bowel injury at the time of operation. clinically significant. Aspiration may increase the risk of mesh There have also been several reports of late bowel perforation sec- infection.84 ondary to thermal injury with laparoscopic repair.65,76-79 One study reported two bowel injuries that were not discovered until Infection sepsis developed; these late discoveries resulted in multiple opera- Overall wound complication rates have been shown to be lower tions, removal of the mesh, prolonged hospital stay, and, in one with laparoscopic incisional herniorrhaphy than with open patient, death. The incidence of bowel injury is likely to be higher repair.65,79,80,85 In particular, SSIs appear to be reduced with the with less experienced surgeons80 and in patients who require laparoscopic approach. 65,79,80,85 SSI rates for open incisional repair extensive adhesiolysis. In one series describing a surgeon’s first range from 5% to 20%,63,79,80,83 whereas those for laparoscopic 100 cases, four of six inadvertent enterotomies were made in the repair range from 1% to 8%.5,65,72,79 Mesh infection extensive first 25 cases.81 enough to necessitate mesh removal is rare (incidence ~ 1%); how- To reduce the risk of bowel injury, we strongly discourage the ever, SSI after laparoscopic repair, especially when PTFE is used, use of electrocauterization and ultrasonic dissection. The visual- more frequently results in seeding of the mesh.65,80 Because this ization afforded by the pneumoperitoneum, which helps place type of mesh does not become well incorporated, antibiotic treat- adhesions between the abdominal wall and the bowel under ten- ment alone is ineffective.80 sion, and the magnification afforded by the laparoscope facilitate OUTCOME EVALUATION identification of the least vascularized planes. As far as possible, we avoid grasping the bowel itself, preferring simply to push it or to Several studies have demonstrated improvements in outcome grasp the adhesions themselves to provide countertraction. Exter- measures—such as decreased postoperative pain, shorter length nal pressure on the hernia may also help. Larger vessels in the of stay, earlier return to work,86 and reduced blood loss—with the omentum or adhesions are controlled with clips. Some degree of laparoscopic approach to incisional hernia repair.5,8,63,64,76,84,87-89 oozing from the dissected areas is tolerated; such oozing almost The only randomized trial published to date compared 30 always settles down without specific hemostatic measures. laparoscopic incisional hernia repairs with 30 open repairs.6 The As noted, if dense adhesions are present, it is preferable to mean operating time was significantly shorter in the laparoscop- divide the sac or the fascia rather than risk injury to bowel. In the ic group (87 minutes versus 111.5 minutes), as was the postop-
  • 19. © 2005 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 Gastrointestinal Tract and Abdomen 28 Laparoscopic Hernia Repair — 19 erative length of stay (2.2 days versus 9.1 days). Another study reported after open mesh repair. Recurrence has been associated compared 56 prospective laparoscopic incisional hernia repairs with lack of suture fixation, prostheses that overlap the defect by with 49 open incisional hernia repairs assessed through retro- less than 2 to 3 cm, postoperative complications, and previous spective chart review.8 The laparoscopic and open groups were repairs.64,65,77,91 comparable in terms of patient characteristics and hernia size. The surgeon’s level of experience plays a significant role in Although the mean operating time was longer in the laparoscop- patient outcome, as demonstrated by a group that compared the ic group (95.4 minutes versus 78.5 minutes), the postoperative outcomes for their first 100 laparoscopic incisional hernia repair length of stay was significantly shorter after laparoscopic repair patients with those for their second 100.84 Recurrence rates after (3.4 days versus 6.5 days). In contrast, some studies have found a mean follow-up period of 36 months dropped from 9% in the the operating time to be 30 to 40 minutes shorter with laparo- first 100 patients to 4% in the second 100. In addition, the second scopic repair.63,76 set of patients were an average of 9 years older, had a higher per- The recurrence rate—the primary long-term outcome measure centage of recurrent hernias, and exhibited more comorbidities, of interest—is reported to be reduced after laparoscopic repair. In yet despite these added challenges, operating time was not length- studies comparing laparoscopic and open incisional hernia repair ened, length of stay was similarly short, and the complication rate with mesh, the recurrence rates after the laparoscopic repairs was no different. Another group reported similar findings for their ranged from 0% to 11%, whereas those after the open repairs laparoscopic incisional hernia repair learning curve.92 Operating ranged from 5% to 35%.6,8,78,86,88 In expert hands, recurrence times and complication rates in the first 32 patients were compa- rates are low after laparoscopic repair. For example, in a multi- rable to those in the second 32; however, bowel injuries were more center series of 850 laparoscopic incisional hernia repairs, mostly common in the first 32. followed prospectively, the recurrence rate after a mean follow-up Although the results of large randomized trials are not available period of 20 months was 4.7%.77 One group found no recurrences yet, the evidence to date suggests that the laparoscopic approach to in the laparoscopic group and two in the open group after a min- the repair of large incisional hernias is highly promising.The laparo- imum follow-up period of 18 months.76 Another group, however, scopic approach seems to be safe and compares favorably with the reported a recurrence rate of 18%,90 which approached that open operation in terms of complication and recurrence rates. References 1. Ger R, Monroe K, Duvivier R, et al: Management of LM, Condon RE, Eds. JB Lippincott Co, Philadel- visceral sac. 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