Laparoscopic Transabdominal PreperitonealHerniorrhaphy
Robert J. Fitzgibbons, Jr, MD
The overwhelming success of laparoscopic cholecystec-tomy resulted in the retraining of general surgeons sothat they became experienced and facile in the principlesof therapeutic laparoscopy. Soon many surgeons began toapply their newly developed skills in laparoscopy toother commonly performed general surgical operationsin hopes of achieving the same benefits as were realizedwith laparoscopic cholecystectomy. Inguinal herniorrha-phy was no exception. The two commonly performedlaparoscopic herniorrhaphies, the transabdominal preperi-toneal (TAPP) and the totally extraperitoneal (TEP), aremodeled after the conventional preperitoneal operationspopularized by Stoppa, Reeves, Nyhus I and others. Themajor difference is that the preperitoneal space is enteredthrough three trocar sites rather than a large conven-tional incision. The ensuing radical dissection of thepreperitoneal space with the placement of a large prosthe-sis is similar to the conventional preperitonea! operation.Laparoscopic inguinal hernia repair has the followingpotential advantages: (1) less postoperative discomfort/pain; (2) reduced recovery time, allowing earlier returnto full activity; (3) easier repair of a recurrent herniabecause the repair is performed in tissue that has notbeen previously dissected; (4) the ability to treat bilateralhernias; (5) the performance of a simultaneous diagnos-tic laparoscopy; (6) the highest possible ligation of thehernia sac; (7) and an improved cosmesis. Numeroussingle center, multicenter, and comparative studies haveproven that an inguinal hernia can be repaired using thelaparoscopic method (Tables 1-3). The question thatmust be answered now is should an inguinal hernia berepaired using the laparoscopic method. Skepticism ex-ists among many surgeons concerning the benefits oflaparoscopic herniorrhaphy because the severity of pos-sible complications and the precise indications are amatter of considerable debate.An extensive discussion of the advantages and disad-
From the Department of Surgery, Creighton University School of Medicine,Omaha, NE.Address reprint requests to Robert J. Fitzgibbons, Jr, MD, Department ofSurgery, Creighton University School of Medicine, 601 North 30th St, Suite 3740,Omaha, NE 68131.Copyright 9 1999 by WB. Saunders Company1524-153X/99/0102-0006510.00/0
vantages of the laparoscopic approach compared with theconventional operation is beyond the scope of thisarticle. The question cannot be answered definitivelyuntil the results of several randomized, prospectivecomparative trials that are now either ongoing, or indevelopment, are completed. The purpose of this reviewis to describe the technical details of the TAPP procedure.
A thorough knowledge of the anatomy of the groin froman opposite perspective to what is normally taught, thatis, proceeding from deeper structures to more superficial,is critical to a successful laparoscopic inguinal herniorrha-phy. A laparoscopic view of a left direct hernia can beseen in Figure 1. The most important anatomical land-marks are the medial umbilical ligament, the inferiorepigastric vessels, and the internal ring. The vas deferensand the internal spermatic vessels converge at the inter-nal ring to form the cord structures. Cooper's ligamentand the symphysis pubis are not always visible laparoscop-ically but can easily be defined by palpation withlaparoscopic instruments. Figure 2A is a cadaver prepara-tion of the right groin with the peritoneum and preperito-neal fatty tissue stripped away. The inferior epigastricvessels, the symphysis pubis, the Cooper's ligament, thevas deferens, and the internal spermatic vessels areimportant landmarks to be exposed during the course ofa laparoscopic TAPP procedure, and, therefore, knowl-edge of their location is crucial for the laparoscopicsurgeon intent on performing this type of repair. Also ofimportance are the anastomotic pubic branches, becausetroublesome bleeding will ensue if they are damagedduring the dissection of Cooper's ligament. A structurethat is not routinely exposed during a laparoscopic TAPPherniorrhaphy but nevertheless must be appreciated, isthe iliopubic tract because this marks the inferior bound-ary for staple placement when affixing the prosthesislateral to the internal spermatic vessels. The genitofemo-ral nerve and the lateral femoral cutaneous nerve exit thepelvis close to the inferior surface of the iliopubic tract.Figure 2B is the same cadaver photograph with meshstapled in place in a desirable position for performing alaparoscopic preperitoneal herniorrhaphy. The reason
Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 169-184