Laparoscopic repair of inguinal hernias

laparoscopic repair of
inguinal hernia
The term "Laparoscopy" was introduced by Jocobaeus. The
Trendelenburg position was advocated by the Danish Nordentoeft
brothers, while carbon dioxide was considered the gas of choice by
the Swiss Zollikofer. Veress described his needle for
pneumoperitoneum), but a variant of which is now used in
laparoscopy. Pertinent advances in the optical area and many
technical and operative developments from the 1960s lead to the
introduction of "cold light", automatic Insufflators, and pressure
monitoring and irrigation technique. lastly, the introduction of the
computer chip video camera in 1986 added more to the field of
operative laparoscopy. Semm performed the first laparoscopic
appendectomy and Mouret the first laparoscopic cholecystectomy in
1987 (Bridgwater, 1997).
Since the introduction of laparoscopic cholecystectormy,
surgons have developed laparoscopic approaches to other commonly
performed open abdominal and thoracic procedures (Shultz, 1993).
Inguinal hernias have been recognized for centuries, described
first by the ancient Egyptians and Greeks. Since then, many different
methods have been advocated to repair the posterior wall, most
requiring approximation of the tissues under tension to close the
defect, till recently when surgeons advocated tension-free repair of
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Laparoscopic repair of inguinal hernia

the hernial defect using inert foreign materials such as polyprolene
mesh, Dacron mesh, or PTFE (polytetrafluoroethylen). With a
tension free technique, recurrence rate can be reduced to 2% as
supported by recent studies (Klein et al., 1992).
But despite acceptable results, most patients still experience
significant post-operative groin discomfort, which usually persists for
7 to 10 days up to 4 weeks. This is related to the necessary skin
incision and subsequent dissection of the posterior wall of the
inguinal canal. Moreover, most mesh repairs are performed ventral
to the posterior wall of the inguinal canal so increased intraabdominal
pressure will tend to prolapse the repair away from the wall (Klein et
al., 1992).
The first attempt to repair a hernia using a laparoscope was first
done and published by Ger et al., in (1982). It was a simple
laparoscopic closure of the hernia defect with no attempt to
approximate well-defined anatomic structure using a proprietary
stapling device. In 1990 reports were published about newly
developed video-laparoscopic skills and equipments. Early reports
described simple plugging of the inguinal canal with mesh (the "plug
repair"), plugging and subsequent covering with mesh (the "plug and
mesh" repair), or simply covering the defect by placing an intra-
abdominal sheet of mesh over it (the intraperitoneal on-lay method or
"IPOM"). Theses new techniques were condemned due to reduced
efficacy, safety, as well as low cost-effectiveness. However,
continuous refinement and changing in the technique have lead to the
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introduction of the transabdominal preperitoneal repair (TAPP)
which became the gold standard for laparoscopic hernia repair due to
reduced morbidity, low recurrence rate and loss of contact between
the prosthetic materials and viscera (Swanstorm, 1996).
In 1993 Mc Kernan and Laws described the total
extraperitoneal repair (TEP) which avoids insertion of trocars into the
abdominal cavity and confines dissection to the peritoneum. This
technique gained favor because of less complication from trocar
insertion, however the above procedures require general anesthesia.
Recently, preliminary reports are appearing describing techniques of
repair under local anesthesia, or using standard instruments without
trocars by the "gasless" technique, which may solve some taken to
place the staples vertically along the inferior edge of the mesh to
minimize the chances of entrapping the femoral branch of the
genitofemoral nerve of the laterofemoral cutaneous nerve. Along the
lower margin of the mesh, staples should be placed lightly and
further apart (2 cm) to avoid damage to the iliac vessels and the vas
deferens. A few staples are also used to fix the superior and central
portion of the mesh to the anterior abdominal wall. Medially, every
effort should be made to secure the mesh to Cooper's ligament. The
anteriorly placed inferior epigastric vessels immediately beneath the
peritoneum should be avoided in the stapling process. Staples should
not be used near the inferior and infero-lateral aspect of the internal
ring for fear of injuring the structures passing through it (Rosenthal
and Franklin, 1993).
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To repair a contra-lateral hernia, the same procedure is carried
out on the opposite side. Some authors do not combine this type of
surgery with operations on the bowel or the biliary tree. As the
trocars are sequentially removed, the video camera examines the
trocar sites to ensure that no bleeding is present (Rosenthal and
Franklin, 1993).
Finally, the umbilical port is withdrawn with the camera and its
cannula. To prevent potential herniation, all 10 mm trocar sites are
closed by repairing the underlying fascia or aponeurosis with zero
Vicryl or polysorb, skin edges are approximated using adhesive tape.
The patients are generally discharged the evening of surgery or the
following morning (Camps et al., 1995).
Because of the unusualness of the repair and the need for
equipment that was not readily available, this technique did not gain
widespread acceptance. It was not until 1990, when reports were
published about newly developed video laparoscopic skills and
equipment, that interest in laparoscopic herniorraphy achieved Hill
attention. Unfortunately, early reports described techniques that were
considered outlandish, including simple plugging of the hernia canal
with mesh (the plug repair), plugging and subsequently covering with
mesh (the plug and patch repair) or simply covering the defect by
placing an intra-abdominal sheet of mesh over it the peritoneal on lay
[IPOM method). This condemnation was focused on two issues, the
first of which was the fact that the laparoscopic repair was different
from any open repair and therefore had not have its efficacy and
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safety established. The second and by far, more persuasive argument
was that surgeons were taking a procedure that had a low morbidity
and low cost effectiveness - open hernia repair - and turning it into a
risky, more expensive and more time-consuming procedure.
Therefore, early practitioners of laparoscopic herniorrhaphy were
subjected to criticism based both on a new awareness of cost-
effective surgical practices and the historical resistance to any new
changes in hernia repair techniques (Roger, 1990)
Follow up reports seemed to support this wide spread
disparagement when reports of high recurrence rates, unusual
complications, and high costs were reported. Even in the face of this
barrage of criticism, several investigators continued refining and
changing the technique in an attempt to solve some of its problems.
Recurrence rates and concerns about the contact of viscera with
prosthetic materials were addressed by the introduction of the trans-
abdominal Preperitoneal repair (TAPP), This technique rapidly
became the gold standard for laparoscopic hernia repairs, as early
results showed it to have low recurrence rate and low morbidity. In
addition, it more closely resembled historic preperitoneal, mesh
repairs, which satisfied another criticism as well. Unfortunately, the
cost and operating room time issues remained. Outcomes of studies
showed that the cost of the TAPP repair greatly exceeded that of
comparable hernia repairs. In addition, this procedure required a
general anesthetic, which continued to be a potential risk for the
patient. (Stoppa, I995)
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In 1993, McKernan and Laws published a report, describing a
new approach to Laparoscopic hernia repairs; the total extra-
peritoneal repair (TEP). This technique avoided the insertion of
trocars into the abdominal cavity and confined the dissection to the
pre-peritoneal. This technique has rapidly gained favor because it
potentially has less risk, of complications from trocar insertion and
has been shown to reduce operative time, particularly with the
addition of dissecting balloons to create (the pre-peritoneal space.
There ate reports of other developments including laparoscopic
repairs under local anesthesia or using standard instruments without
trocars by the "Gasless" technique, which may in the future solve
some of the cost and safety issues of laparoscopic repairs. (Roger,
1996)
Indications For Laparoscopic Inguinal Hernia Repair :
1. All adult patients fit for general anesthesia can be considered
candidates for laparoscopic inguinal hernia repair.
2. Patients with recurrent are particularly suited for a
Laparoscopic approach because the pre-peritoneal space has usually
not been dissected and previously formed scar tissue can be avoided,
3. The presence of bilateral hernia is also an indication for
laparoscopic repair as both side& can be approached from the same
three cannula sites.
4. Recent studies have shown that laparoscopic inguinal
herniorrhaphy can be safely performed at the time of another intra-
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abdominal procedure in the absence of a septic process. Thus,
patients with inguinal hernias undergoing laparoscopy for another
disease process are candidates for a laparoscopic inguinal
herniorrhaphy. (Davis and Arregui, 2003)
For the simple non recurrent unilateral inguinal hernia, the use
of a laparoscopic approach is controversial. For this type of patients,
laparoscopy should he reserved for those patients needing to return
rapidly to normal activities, (Davis and Arregui, 2003)
Contraindications to laparoscopic inguinal hernia repair:
The laparoscopic hernia repairs traditionally require general
anesthesia, CO2 pneumo-peritoneum, and the use of prosthetic
material.
Some patients may have relative contraindications, these
include:
• High anesthetic risk. (Cardiopulmonary contraindication)
• Pediatric patients.
• Incarcerated hernias may be difficult to reduce via
laparoscopic dissection.
• Uncontrolled coagulopathy
• History of recent peritonitis or multiple abdominal operations.
• Prior laparoscopic herniorrhaphy
• Massive Scrotal hernia
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• Prior pelvic lymph node resection
• Prior groin irradiation (Davis and Arregui, 2003)
Advantages & disadvantages of lapar oscopic hernia repair:
Laparoscopic inguinal herniorrhaphy has the following
potential advantages:
1. Less postoperative discomfort pain.
2. Reduced recovery time, allowing an earlier return to full activity.
3. Easier repair of a recurrent hernia, because the repair is
performed in tissue that has not been dissected previously.
4. The ability to treat bilateral hernias besides, the repair of any
unexpected, accidentally discovered, contralateral hernia.
(Reported to occur in 25% to 40% of patients).
5. The performance of simultaneous diagnostic laparoscopy.
6. The highest possible ligation of the hernia sac.
7. Decreased chance of testicular ischemia.
8. An improved cosmetic
Finally, it is theorized that laparoscopic inguinal hernia repair
might have a lower recurrence rate than conventional inguinal
herniorrhaphy because of the mechanical advantage gained by
placing the prosthesis in the pre-peritoneal space and the tension-free
nature of the repair. (Crawford and Phillips, 2002)
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The main arguments against laparoscopic inguinal hernia
repair are as follows:
1. Conventional inguinal herniorrhaphy is an effective operation
already performed as an outpatient procedure with low
morbidity and mortality.
2. Conventional inguinal herniorrhaphy may be performed under
local anesthesia whereas laparoscopic inguinal hernia repair
usually requires general anesthesia.
3. Laparoscopic inguinal hernia repair is more expensive. The
direct operating room cost of
Laparoscopic herniorrhaphy has generally been shown to be
higher than that of traditional open repair. This is primarily due to
longer operating room times, anesthesia charges, and the price of
laparoscopic instruments. (Fitzgibbons and Filipi, 2002)
Types of laparoscopic repair of inguinal hernias:
Nowadays, the two most common laparoscopic hernia repairs
are the transabdominal preperitoneal repair (TAPP) and the total
extraperitoneal repair (TEP). Other laparoscopic techniques, such as
closure of the internal ring, ring plasty, mesh plug and patch repair
and the intraperitoneal onlay mesh (IPOM) have been largely
abandoned, at least in America and Europe. Both the TAPP and TEP
have the same basic principle of placing a mesh in the preperitoneal
space. However, the TEP technique was introduced mainly for
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patients who had previously undergone major lower abdominal
surgery. (Davis and Arregui, 2003)
Choice of operation (TAPP vs. TEP):
The TEP and TAPP laparoscopic techniques are identical
techniques with different, anatomical access routes. The TAPP is a
Trans-Abdominal route, the TEP a Pre-Peritoneal route (see
technique). Recent analysis showed there was no increase in the rate
of intra-operative injuries with the TEP or TAPP technique when
performed by experienced laparoscopic surgeons. Surgeons should
however take advantage of these different access routes in different
clinical settings especially, the presence of extensive intra-abdominal
adhesions where, in such case the TEP technique is preferred.
(Quilici et al, 2000)
I. Transabdominal Preperitoneal Laparoscopic Repair Of
Inguinal Hernia (TAPP)
Laparoscopic trans-abdominal pre-peritoneal inguinal
herniorrhaphy is currently the most popular type of laparoscopic
repair. It is based on the conventional pre-peritoneal repairs
popularized by Rives and Stoppa in France and Nyhus and Condon in
the United States. In the conventional repairs, the pre-peritoneal
space is entered through a skin incision. However, by making a
peritoneal incision, the pre-peritoneal space can also be effectively
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entered laparoscopically. A prosthetic repair can then be
accomplished in a manner essentially identical to the conventional
method. (Robert et at, 1995)
• Choice of mesh:
♦ Ussc Surgipro® Mesh
This the most used mesh in laparoscopic repair.
♦ Ethicon-EndoSurgery Soft Prolene® Mesh
This Prosthetic Mesh (Polypropylene Mesh) is rather new. It is
softer than the USSC SurgiPro Mesh and for some surgeons this may
be an operative advantage. It also has horizontal blue stripes which
theoretically can help orient the mesh when deployed.
♦ Bard 3DMAX® Mesh
This Mesh is a "three dimensional Mesh" and is custom
constructed to deploy and mold the afflicted inguinal region. It has a
good "fit" in totally extra-peritoneal repairs and many authors have
used it without fixation or tacks/staples. The postulated advantage of
placing a Mesh without fixation is a probable decrease in post-
operative neuropathies (lateral cutaneous nerve, femoral branch and
genital branches of the genitofemoral nerve). This Mesh is unilateral
(for left or right side repair) and comes in different sizes. (Quilici et
al, 2000)
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• Setup :
The surgeon usually stands on the opposite side table from the
hernia, because this provides the appropriate angle for dissection and
staple placement. After induction of general anesthesia, a Foley
catheter is placed to ensure continuous decompression of the bladder.
(Fitzgibbons and Filipi, 2002)
Figure (20) Trocars position (Fitzgibbons and Filipi, 2002)
• Trocars :
Same Trocar insertion sites can be used for both techniques, the
TAPP and TEP. subumblical area-10mm Trocar .Rt. Lateral- 5mm
Trocar Lt. lateral- 5mm Trocar. 4th
10mm Trocar can be added at the
epigastrium to change position of the camera. (Fitzgibbons and
Filipi, 2002)
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Figure (21) ports position in TAPP (Fitzgibbons and Filipi, 2002)
• Operative Technique :
Step 1: Entering the intra-abdominal cavity :
A pneumoperitoneum is created in the usual fashion (sub-
umbilical position). The first Trocar is inserted [10mm] in sub-
umbilical position. The intra-abdominal cavity is visualized with the
Telescope and intra-abdominal findings are reported [intra-abdominal
pathology and inguinal hernia defects and sacs]. If an asymptomatic
hernia sac is identified on the contralateral side, it mandates its repair.
The two additional 5 mm Trocars are inserted under direct vision.
Type of hernia can be identified by the relation to the inferior
epigastric vessels being lateral to vessels in indirect inguinal hernia
or medial in case of direct one or extending into the femoral canal in
femoral one. (Fitzgibbons and Filipi, 2002)
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Step 2: Creating the peritoneal flap :
The laparoscope is Pointed toward the afflicted inguinal canal.
The peritoneal Defect or hernia is identified. The Lateral Umbilical
Ligament is located as well as the Inferior Epigastric Artery and
Vein. A Peritoneal incision is made using scissors or the Ultracision
Instrument. The incision, 2cm above the defect, is extended from
the medial umbilical ligament to the anterior superior iliac spine.
For obese patients, this ligament may have to be transected in order
to obtain additional exposure. The peritoneal flap is mobilized
downward using sharp and blunt dissection. The inferior epigastric
vessels, fascia transversalis, and cord structures are exposed.
Step 3: Identifying the anatomical landmarks:
With blunt dissection, Cooper's Ligament is exposed as well
as the Inferior Epigastric Vessels and the Spermatic Cord.
Step 4: Dissecting the hernial sac:
For direct hernias the sac and pre-peritoneal fat are reduced
from the hernia orifice using gentle traction. The thinned out
transversalis fascia lining the defect is left behind, if necessary
separating it by sharp dissection. The dissection is completed by
mobilizing the cord structures away from the peritoneal flap and the
sac. Indirect hernias are clearly more difficult to deal with. If the sac
is small, it can be mobilized from the cord structures and reduced
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back into the abdomen. However, if it is large or extending into the
scrotum, complete mobilization of the sac may result in an increased
incidence of spermatic cord or testicular complications. In this
situation the hernia is best treated by dividing the sac at the internal
ring, leaving the distal sac in situ and with dissection of the proximal
sac away from the cord structures. The iliac vessels are not dissected
but their positions are clearly identified. It is essential to expose the
uncovered abdominal wall meticulously (without peritoneum) and
remove all fatty layers until the triangle of Doom is clearly identified.
(Fitzgibbons and Filipi, 2002)
Figure (22) Actual Views
– TAPP Repair (Fitzgibbons and Filipi, 2002)
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Step 5: Deploying and Anchoring the mesh:
The 10x15 Mesh is rolled like a cigarette and inserted uncut via the
10mm Trocar into the intra-abdominal cavity and deployed over the
inguinal region. The Mesh is attached or secured to Cooper's
Ligament, and lateral to the Inferior Epigastric Vessels using tacks
delivered via the Protack® Instrument. The Protack© Instrument is
dramatically differrent from the classical polypropylene mesh is
currently the most popular mesh, but other materials are occasionally
used. The size of the prosthesis used is important as many of the
earlier recurrences with laparoscopic herniorrhaphy have been
thought to be due to inadequate coverage of all of the potential sites
of recurrent groin herniation. It is important that the size of the
prosthesis be not less than 10X15 cm. The mesh must be sufficiently
large to cover the defect and provide an extensive overlap. This
allows the intra-abdominal pressure to act on an area of strong
healthy tissues, thus tending to keep the patch in position rather than
encouraging it to herniate through the defect.
Figure (23) Protack used in fixing the mesh in TAPP (Fitzgibbons
and Filipi, 2002)
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Whether the mesh is wrapped around the spermatic cord or
only placement is used, to date, there has been no difference in
outcome or recurrence rates with either of these variations.
However, the former requires additional mobilization of the
cord structures posteriorly to accommodate the mesh, while in the
onlay technique the mesh is simply laid over the cord structures
avoiding this dissection. Most surgeons prefer the latter as this avoids
dissection, which increases the incidence of cord or testicular
problems. The former maneuver adds stability to the prosthesis and in
fact creates a new internal ring. The controversy will not be settled
until longer follow-up data are obtained. (Fitzgibbons and Filipi,
2002)
Stapling is begun along the upper border of the posterior rectus
sheath and transversalis fascia at least 2 cm above the defect. The
mesh is stapled to the Cooper's ligament medially, and the iliopubic
tract laterally. When stapling the lower level of staples, care must be
taken not to place staples below the level of the iliopubic tract. A
helpful maneuver in this situation is to use a bimanual technique:
Staples are not placed without being able to palpate the head of the
stapler through the abdominal wall with the left hand; this ensures
that the surgeon is above the iliopubic tract. When stapling the
upper edge, care must be taken not to injure the inferior epigastric
vessels. (Fitzgibbons and Filipi, 2002)
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Finally, the lateral edge is stapled at a point approximately 1cm
medial to the anterior superior iliac spine. (Fitzgibbons and Filipi,
2002)
During the course of staple placement, excess mesh is trimmed
in situ so that the prosthesis is perfectly tailored to the pre-peritoneal
space.
Step 6: Closing the peritoneum:
The final step is to close the peritoneum with staples, thus
isolating the prosthetic patch from the abdominal contents. It is
important not to leave gaps between the staples because bowel has
been reported to slip between these gaps causing obstruction. A long
acting local anesthetic can be injected into the pre-peritoneal space at
this stage to reduce postoperative discomfort. The trocars are
removed under direct vision. The fascia of the sub-umbilical trocar
site is closed as needed (Quilici et al, 2000; Fitzgibbons and Filipi,
2002(
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II. Laparoscopic Totally Extra-Peritoneal Repair Of
Inguinal Hernia (TEP)
Figure (24) Positioning of the patient and the team (Crawford and
Phillips, 2002)
The patient is placed on the operating room table in the supine
position. Urinary catheter is applied or patient asked to void
immediately preoperatively. Single dose of prophylactic antibiotic is
given. For bilateral hernias, the operating surgeon is on the side
opposite the hernia being repaired. The assistant surgeon stands on
the opposite side, and the surgical nurse on the patient's right side.
For unilateral hernias, the operating surgeon should be on the contra-
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lateral side of the hernia. The monitor is placed at the patient feet.
The abdomen is shaved from umbilicus to pubis and then the entire
abdomen is prepared in the usual fashion. (Crawford and Phillips,
2002)
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Figures (25) Ports position in TEP (Crawford and Phillips, 2002)
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Mckernan technique:
This approach described by McKernan and Laws in 1993,
avoids the peritoneal cavity completely :
Step 1: Creating the pre-peritoneal space:
Under general anesthesia a sub-umbilical incision (midline-
2cm) is made. Using retractors, the sub-cutaneous planes are
retracted until the linea-alba and the anterior rectus sheaths are
exposed. A 2 cm incision is made on the anterior rectus sheath, off
the midline (on the affected side). The rectus muscle and its most
medial aspect are visualized. (Crawford and Phillips, 2002)
(Crawford and Phillips, 2002)
Using a finger and blunt dissection, a tunnel is created in the
direction of the pubis between the rectus muscle and the
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preoperational fat and the dilating trocar is inserted. (Crawford and
Phillips, 2002)
The insert of the trocar is removed and replaced by the 0° or
30° Telescope. Under direct vision, the balloon with the hand pump
is introduced
The balloon is inflated, opened and unfolded. When the balloon
is totally unfolded (the balloon will look "unwrinkled1), the telescope
is removed and the balloon deflated. The dilating trocar is then
removed. The pre-peritoneal space has been created and the
peritoneum has been dissected free from the posterior aspect of the
rectus muscle. (Crawford and Phillips, 2002)
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Step 2: Creating the pneumo-preperitoneum:
The structural 10 mm trocar is inserted in the same position of
the dilating trocar. Using the hand pump, the structural balloon is
inflated. It is then secured by sliding the adjustable outer ring of the
trocar to seal the entry site. The insufflation port is connected to the
insufflations Pump. A pneumo-preperitoneum is created.
Insufflations pressure should be kept below 12 mmHg to prevent the
development of hypercabnic acidosis. (Crawford and Phillips,
2002)
Two 5 mm Versaports are inserted under direct vision.
Although some surgeons place these trocars in the midline (2cm and
4 cm below the umbilicus / midline), lateral placement of these
trocars can be done (identical placement as in a TAPP repair).
However, in most cases the dilating balloon does not extend and push
the peritoneal layer superiorly enough to safely place these trocars
without entering the abdominal cavity. Using the telescope, the
dissection of the peritoneum is bluntly extended superiorly; once the
first 5 mm trocar is inserted a blunt grasper is used to perform the
same maneuver on the other side.
If a peritoneal defect is created at this time it should be
immediately closed. (Crawford and Phillips, 2002)
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Step 3: Identifying anatomical landmarks:
The anatomical landmarks are identical when performing a
TAPP repair. However, the view is not as "clean" as in a TAPP
repair. Therefore, it is essential for the surgeon to get familiar with
the actual preoperational view as seen in the picture below.
The entire area should be meticulous and bluntly dissected
starting from the pubic ramus (easily identifiable landmark). Cooper's
Ligament, the Inferior Epigastric Vessels, the Spermatic Cord and the
position of the iliac vessels are clearly identified.(Crawford and
Phillips, 2002)
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Step 4: Dissecting the hernia sac:
The indirect inguinal hernia sac should be dissected carefully
from the Spermatic Cord. If large the proximal portion is ligated
while the distal one is left open. Direct hernia sacs are easily
dissected. This is done by gentle traction with traumatic graspers.
Figure (29) dissection of the sac (Crawford and Phillips, 2002)
Step 5: Deploying and anchoring the mesh:
The Mesh is rolled like a cigarette and inserted via the 10-5mm
Structural Trocar, uncut into the pre-peritoneal space and deployed
over the inguinal region. (Crawford and Phillips, 2002)
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Figure (30) Preparing of mesh (Crawford and Phillips, 2002)
The standard mode of placement of the mesh is the "onlay
Mesh Placement" which cover the entire inguinal region. The graft is
first attached or secured to Cooper's Ligament, and the superior
aspect of the pubic ramus using the Protack Instrument. The Mesh is
then tacked on the posterior aspect of the Linea Alba. The anchoring
is continued around and lateral to the Inferior Epigastric Vessels. A
few tacks are used to staple the Mesh lateral to the internal ring. The
Mesh should gently and generously cover the Iliac Vessels without
major gaps. (Crawford and Phillips, 2002)
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In case of bilateral inguinal hernias, two identical pieces of
polypropylene mesh are prepared. The two are stapled to one another
in the midline.
Step 6: Completing the repair:
The pre-peritoneal space will be checked for any peritoneal
defects. If any, they should be closed using the 5 mm trocars are
removed under direct vision. The pre-peritoneal space will collapse.
If there is any question about a missed peritoneal defect, a
completion laparoscopy could be performed. The structural balloon is
deflated. The trocar is removed and the fascial defect closed with the
appropriate suture. The skin edges are approximated in the usual
manner. (Crawford and Phillips, 2002; Quiiici et.al, 2000)
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Phillips' technique (TEP with peritonoscopy):
In contrast to McKernan technique which avoids the peritoneal
cavity completely, in Phillips technique pneumo-peritoneum is
established via the Veress needle through an umbilical incision. A
10-11 mm or a 5 mm trocar is then inserted into the peritoneal cavity
and a 30° 10 mm or 5 mm laparoscope is introduced. The hernia
defects are examined directly from within the peritoneal cavity. A 10
mm incision is made just superior to McBurney's point on the right
side of the abdomen. This corresponds to the site of a pre-peritoneal
fat pad commonly located in this position. A Kelly clamp is then used
to bluntly dissect through the oblique muscles under direct vision
until the transversalis fascia is reached. A large Mayo clamp is then
used to continue the dissection until the tip of the clamp is seen
through the peritoneum, the so-called "metal sign".(Crawford and
Phillips, 2002)
The Mayo clamp is then turned curve up toward the underside
of the abdominal wall, advanced toward the pubis, spread, and
withdrawn in the spread position, creating a pathway for a blunt-
tipped 10 mm trocar, or a 10 mm trocar with a blunt probe. The
trocar is placed into the pre-peritoneal space and a blunt-tipped
grasper is advanced toward the symphysis pubis. Care must be taken
to assure that the grasper is advanced between the epigastric vessels
and the peritoneum. A rowing motion is used to develop the pre-
peritoneal space with the grasper. (Crawford and Phillips, 2002)
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Carbon dioxide is then introduced into the pre-peritoneal space
via the lateral trocar, while the intra-peritoneal carbon dioxide is
slowly released until the pre-peritoneal space is insufflated. There are
two options at this point. One is to make an incision in the midline 3
cm below the umbilical incision. A Mayo clamp is used to bluntly
dissect down to the peritoneum in this location. A 10 mm blunt-
tipped trocar is then inserted inferiorly toward the pubis in the
midline in the pre-peritoneal space. The other option is to re-
insufflate the intra-peritoneal space via the umbilical trocar to 10
mmHg. The umbilical trocar is then backed out slowly until the
peritoneum, and fascia are visualized. The laparoscope is oriented so
the 30° angle faces down. It is advanced into the pre-peritoneal
space, and then the trocar is slide over it. This saves one trocar and
one incision. (Crawford and Phillips, 2002)
In both techniques, the laparoscope is placed in this pre-
peritoneal midline trocar and bluntly advanced until it touches the
symphysis pubis. The scope is then gently rocked from side to side,
further developing this space. The laparoscope is then withdrawn,
cleaned, and re-inserted in the midline trocar.
Starting in the midline, Copper's ligament is identified
,followed laterally until the content of the femoral canal are
identified. The epigastric vessels and spermatic cord are then located.
If at any time during the dissection the surgeon becomes confused or
has lost anatomic orientation. Cooper's ligament and epigastric
vessels should serve as a reference point. Direct hernias should be
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reduced until the edges of the defect are seen circumferentially.
Indirect hernias, as well as large cord lipomas should be dissected
and reduced off the spermatic cord. Large indirect sacs may be
transected and proximally ligated with an endoloop. (Crawford and
Phillips, 2002)
After all hernias have been reduced and all potential hernia
sites, including possible femoral hernias, have been inspected, the
mesh is prepared. And repair is performed as in Mekernan technique.
In this manner the femoral, indirect, and direct portion of the
inguinal floor, are covered. The laparoscope is then returned to the
peritoneal cavity. Pneumo-peritoneum is reestablished in the
peritoneal cavity while carbon dioxide is allowed to escape from the
pre-peritoneal trocars. The repair is inspected to see how the mesh
lies, to make sure there have been no injuries to the peritoneum. All
fascial defects are closed with 0 vicryl suture. (Crawford and
Phillips, 2002)
Laparoscopic Hernia in Children
Laparoscopy has been tried in little children’s. Only closure of
ring and herniotomy is possible in pediatric age group. The sac is
simply inverted and tied internally. The care should be taken that the
vas or vessels should not be caught in the ligature.
132

Surgical technique
With the patient under general anesthetic and orotracheal intubation,
a Crede´ maneuver was performed to empty the bladder (older
children were asked to urinate prior to entering the operating room).
The umbilicus was cleaned with an alcohol swab and a wound
infection prophylaxis dose of cefazolin was administered
intravenously. The patient was positioned supine midway down the
operating table in moderate reverse Trendelenburg position, with the
laparoscopy monitor at the foot of the bed (Glick PL, Boulanger
SC .2006)
Fig. (32) Diagram of patient positioning (Glick PL, Boulanger SC .2006(
AVeress needle in a STEPTM (US Surgical, Norwalk, CT) sheath
was introduced at the umbilicus and a pneumoperitoneum
of 10–12 mmHg (depending on patient size) was established at a flow
rate of 3 L/min. A 3-mm STEP port was placed at the umbilicus and
a 2.7-mm 30_ angled Hopkins rod lens was introduced . (Glick PL,
Boulanger SC .2006)
133

Fig. (33) The camera port is placed at the umbilicus and a
grasper is inserted through a left lower quadrant stab incision. A
25-gauge needle is used to identify the internal ring
transcutaneously (Glick PL, Boulanger SC .2006)
Both hernial orifices were visualized to determine the presence of a
patent internal inguinal ring. For patent processus vaginalis, a sac
depth of 1 cm was used to indicate repair. This was measured by
inserting the telescope to its maximum depth in the internal ring, and
then marking the shaft of the scope where it entered the umbilical
port. The scope was then withdrawn until the tip was at the internal
ring, and a second mark was made where the scope entered the port.
The distance between the two marks indicated the depth of the sac. In
males, a 2-mm stab incision was made in the lateral left lower
quadrant through which a 3-mm grasper instrument was inserted and
used only for manipulation of the vas deferens, spermatic vessels,
and the peritoneal sac. The cord structures were not grasped. Hernia
134

contents were reduced manually, or with the use of the additional
grasper. (Schier F, Montupet P, Esposito C ,2002)
A 25-gauge needle was used for external location of the internal ring
by inserting the needle transabdominally and visualizing the needle
with the telescope . At this point on the skin, a 2-mm stab incision
was made using a scalpel, and the subcutaneous tissues were gently
spread with a hemostat in order to bury the nonabsorbable knot. A 2–
0 Ethibond (Johnson & Johnson, Cincinnati, OH) suture on a CT-1
needle was then passed through this skin incision and identified
intracorporeally with the telescope. The needle was not allowed to
traverse the peritoneum at the start of the procedure. (Schier F,
Montupet P, Esposito C ,2002)
Working in a right to left direction (regardless of the side of the
hernia), the needle was carried around the neck of the hernia sac (in a
properitoneal plane) at the base of the internal ring. Upon reaching
the coalescence of the vas deferens and testicular vessels, the needle
traversed the peritoneum to bypass these structures, then was
reinserted into the properitoneal space. The needle was navigated just
lateral to the epigastric vessels. In some instances, the needle can be
navigated between the peritoneum and the cord structures, allowing
for a truly hermetic seal. Traversing the peritoneum is unnecessary in
females, and the round ligament can be included in the repair.
(Schier F, Montupet P, Esposito C ,2002)
135

Once around the neck of the hernia sac , the needle was brought back
out the skin, being careful to halt the swage of the needle in the
subcutaneous tissues. After the needle swage entered the
subcutaneous tissues, it was pushed retrograde in this plane and
brought out of the original inguinal skin stab incision (the ‘‘seesaw’’
maneuver)
The needle and suture were then brought out and the needle cut off.
With pneumoperitoneum reduced to 7 torr, and all insufflations gas
manually reduced from the hernia sac, the suture was tied securely
with a minimum of seven knots
Hernias on both sides, and patent processus vaginalis, were repaired
in this fashion. Associated hydrocele that could not be manually
drained through the internal ring were aspirated trans-scrotally using
a 25-gauge needle. (Gorsler CM, Schier F . 2003)
All ports and instruments were removed after reducing the
pneumoperitoneum. Local 0.25% bupivicaine was injected at all the
incisions. The fascia at the umbilicus was closed using a 2-0 Vicryl
suture, and skin reapproximated using simple interrupted 5-0 plain
gut. Although the inguinal stab wound(s) is small enough for a
simple closure, a single interrupted buried subcuticular absorbable
closure was performed because of the fear of extrusion of the
nonabsorbable, bulky hernia repair knot.
(Gorsler CM, Schier F . 2003)
136

Advantages and disadvantages
It is difficult to improve on the traditional high ligation approach to
pediatric inguinal hernia due to its very low morbidity and recurrence
rates. It does, however, some disadvantages, including the need for a
visible groin incision, the need to dissect the cord structures from the
sac and thus place them at risk of injury, and the need for a separate
incision to repair contralateral hernia. Laparoscopy has the potential
to address some of these drawbacks, but must not compromise
recurrence rates. (Chan KL, Tam PK . 2004)
The laparoscopic hernia repair (by the method described) is a simple,
quick, and effective way to repair hernias in children with recurrence
rates comparable to the open technique. In addition, there are a
number of distinct advantages to this laparoscopic procedure that we
have identified with growing experience. Most importantly, it is a
‘‘no-touch’’ technique, meaning that the vas and vessels are not
subject to dissection and thus unlikely to be injured. Bilateral hernias
can be diagnosed and repaired simultaneously. It was found that this
technique particularly useful in premature infants, for incarcerated
hernia, and for recurrent hernia. (Chan KL, Tam PK . 2004)
The recurrence rate for both premature infants and incarcerated
hernia fell significantly below the rates for open operation. In both
clinical scenarios, the sac tends to be thin and fragile, and hence
highly susceptible to tearing during dissection, leading to a high
137

recurrence rate with the classic repair. With the transcutaneous
approach, the sac is not dissected at all, hence the chance of tearing
eliminated. (Chan KL, Tam PK . 2004)
Furthermore, we have found it unnecessary to wait the customary 24–
48 h to allow edema resolution after incarcerated hernia reduction
before repairing the hernia. The edema actually enables needle
navigation around the sac by creating a plane. For recurrent hernias,
particularly if previously performed open, the wound is not re-
explored and thus the higher incidence of vas injury associated with
the redo procedure is eliminated. (Chan KL, Tam PK . 2004)
There are some potential disadvantages to the transcutaneous
procedure that we use. By traversing the peritoneum to exclude the
vas and vessels, a tiny defect is left in the hernia repair that may lead
to recurrent hernia or hydrocele. We have not experienced a
concerning increase in postoperative hydrocele, and the small sac
defect has not manifested with high recurrence rates. (Chan KL,
Tam PK . 2004)
It is possible with careful needle manipulation to navigate the needle
between the cord structures and the peritoneum, without traversing it,
but this is not possible in every patient. In the future, a novel method
of dissecting a plane between the cord structures and the sac will be
useful to eliminate the need to traverse the peritoneum. (Chan KL,
Hui WC, Tam PK . 2005)
138

A second disadvantage is the need to enter into the peritoneal cavity
with laparoscopic equipment. This theoretically puts intra-abdominal
contents at risk, however we have not encountered this problem and
it is generally rare with laparoscopic procedures. (Harrison MR,
Lee H, 2005)
Conversely, laparoscopy allows the surgeon to visualize the
contralateral internal ring to assess for a patent processus. While
there is controversy regarding repairing patent processus vaginalis,
we have elected to repair these defects if there is a sac depth of [1.5
cm (an arbitrary limit). This avoids a potential second procedure,
with practically no added morbidity. (Harrison MR, Lee H, 2005)
The transcutaneous laparoscopic hernia repair is simple and effective,
and a virtually scarless procedure. There is a learning curve
associated with it, but one that is quickly traversed by the
experienced laparoscopist. (Ozgediz D, Roayaie K, Lee H,2007)
Recurrence rates are comparable for the standard hernia, and may be
superior for incarcerated hernias or those in preterm infants.
(Ozgediz D, Roayaie K, Lee H,2007)
139

Percutaneous Endoscopic External
Ring Repair (PEER)
Percutaneous endoscopic ring repair (PEER) is still in its
evaluation stage, but initial results look promising. (Cuschieri, 2002)
* Surgical technique:
The actual repair is done using either Lichtenstein mesh or
hernia plug techniques. Irrespective of repair, only one incision (2.5
cm) is necessary. This placed over the external inguinal ring and
following division of the external spermatic fascia from the margins
of the external ring is performed. The inguinal canal is entered
initially with the index finger. This is then replaced by the
endoscopic inguinal canal retractor which houses a 30°, 5 mm
telescope. (Cuschieri, 2002)
* Advantages:
The advantages of PEER repair include minimal pain and
avoidance of general or epidural anesthesia. (Cuschieri, 2002)
140

Laparoscopic repair of inguinal hernias

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