This action might not be possible to undo. Are you sure you want to continue?
Robert J. Fitzgibbons, Jr, MD
The overwhelming success of laparoscopic cholecystectomy resulted in the retraining of general surgeons so that they became experienced and facile in the principles of therapeutic laparoscopy. Soon many surgeons began to apply their newly developed skills in laparoscopy to other commonly performed general surgical operations in hopes of achieving the same benefits as were realized with laparoscopic cholecystectomy. Inguinal herniorrhaphy was no exception. The two commonly performed laparoscopic herniorrhaphies, the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP), are modeled after the conventional preperitoneal operations popularized by Stoppa, Reeves, Nyhus I and others. The major difference is that the preperitoneal space is entered through three trocar sites rather than a large conventional incision. The ensuing radical dissection of the preperitoneal space with the placement of a large prosthesis is similar to the conventional preperitonea! operation. Laparoscopic inguinal hernia repair has the following potential advantages: (1) less postoperative discomfort/ pain; (2) reduced recovery time, allowing earlier return to full activity; (3) easier repair of a recurrent hernia because the repair is performed in tissue that has not been previously dissected; (4) the ability to treat bilateral hernias; (5) the performance of a simultaneous diagnostic laparoscopy; (6) the highest possible ligation of the hernia sac; (7) and an improved cosmesis. Numerous single center, multicenter, and comparative studies have proven that an inguinal hernia can be repaired using the laparoscopic method (Tables 1-3). The question that must be answered now is should an inguinal hernia be repaired using the laparoscopic method. Skepticism exists among many surgeons concerning the benefits of laparoscopic herniorrhaphy because the severity of possible complications and the precise indications are a matter of considerable debate. An extensive discussion of the advantages and disad-
vantages of the laparoscopic approach compared with the conventional operation is beyond the scope of this article. The question cannot be answered definitively until the results of several randomized, prospective comparative trials that are now either ongoing, or in development, are completed. The purpose of this review is to describe the technical details of the TAPP procedure.
A thorough knowledge of the anatomy of the groin from an opposite perspective to what is normally taught, that is, proceeding from deeper structures to more superficial, is critical to a successful laparoscopic inguinal herniorrhaphy. A laparoscopic view of a left direct hernia can be seen in Figure 1. The most important anatomical landmarks are the medial umbilical ligament, the inferior epigastric vessels, and the internal ring. The vas deferens and the internal spermatic vessels converge at the internal ring to form the cord structures. Cooper's ligament and the symphysis pubis are not always visible laparoscopically but can easily be defined by palpation with laparoscopic instruments. Figure 2A is a cadaver preparation of the right groin with the peritoneum and preperitoneal fatty tissue stripped away. The inferior epigastric vessels, the symphysis pubis, the Cooper's ligament, the vas deferens, and the internal spermatic vessels are important landmarks to be exposed during the course of a laparoscopic TAPP procedure, and, therefore, knowledge of their location is crucial for the laparoscopic surgeon intent on performing this type of repair. Also of importance are the anastomotic pubic branches, because troublesome bleeding will ensue if they are damaged during the dissection of Cooper's ligament. A structure that is not routinely exposed during a laparoscopic TAPP herniorrhaphy but nevertheless must be appreciated, is the iliopubic tract because this marks the inferior boundary for staple placement when affixing the prosthesis lateral to the internal spermatic vessels. The genitofemoral nerve and the lateral femoral cutaneous nerve exit the pelvis close to the inferior surface of the iliopubic tract. Figure 2B is the same cadaver photograph with mesh stapled in place in a desirable position for performing a laparoscopic preperitoneal herniorrhaphy. The reason
From the Department of Surgery, Creighton University School of Medicine, Omaha, NE. Address reprint requests to Robert J. Fitzgibbons, Jr, MD, Department of Surgery, Creighton University School of Medicine, 601 North 30th St, Suite 3740, Omaha, NE 68131. Copyright 9 1999 by WB. Saunders Company 1524-153X/99/0102-0006510.00/0
in General Surgery, Vol 1, No 2 (December), 1999: pp 169-184
170 why placing staples below the level of the iliopubic tract lateral to the internal spermatic vessels frequently results in troublesome neuralgia is obvious. Two other nerves, the ilioinguinal and the iliohypogastric, although lying in a more superficial plane between the external and internal oblique muscles, may also be injured if staples are placed too deeply, especially when using a vigorous bimanual technique (see Fig 3). Finally, the laparoscopic surgeon should be aware of the location of the external iliac vessels and the femoral nerve. Although these structures would generally be considered outside the normal field of dissection, injuries to them are particularly debilitating.
Robert J. Fitzgibbons, Jr
All adult patients with inguinal hernias who are candidates for general anesthesia can be considered candidates for the laparoscopic TAPP inguinal hernia repair. At the present time, however, it is not clear that there are sufficient advantages for patients with uncomplicated inguinal hernias to outweigh the major disadvantages of
the procedure, which include (1) a laparoscopic accident, (2) bowel obstruction secondary to adhesions or an internal or a ventral hernia, and (3) increased cost. Currently, we do not recommend laparoscopy for every hernia (ie, unilateral and nonrecurrent). However, certain types, such as those that are recurrent, bilateral, or otherwise complicated are particularly suited for the laparoscopic approach. Absolute contraindications include any sign of intra-abdominal infection or coagulopathy. Relative contraindications include intra-abdominal adhesions from previous surgery, ascites, or previous "space of Retzius" surgery because of the increased risk of bladder injury. Severe underlying medical illness is also a relative contraindication because of the added risk of general anesthesia. These patients are better suited for a conventional operation under local anesthesia. An incarcerated sliding scrotal hernia is a relative contraindication, especially when it involves the sigmoid colon, because of the high risk of perforation during the dissection.
T a b l e 1. N o n c o m p a r a t i v e Trials of L a p a r o s c o p i c Inguinal H e r n i a R e p a i r (LIHR) Hernias recurrent at enrollment (%) 12 14 10 53 14.5 11 17 14 5 5 13 15 18 NA 8 14 11 17 10 1.6 14 16 12 32 NA 0 NA NA 0 33 NA NA NA NA 0 NA Hernia (n) 100 147 143 200 867 450 100 102 173 135 205 222 106 120 382 733 326 200 244 3229 290 118 365 160 632 20 776 206 3,400 144 7,661 237 803 215 11,222 58 Recurrence rate (%) 0 1.3 1.4 0.5 4.5 0.6 2 NA 0 0 0 1.8 0 48 0.3 0.3 1.6 3.5 1 1.6 2.1 0.5 0 3.1 0 0 3.9 3.0 0.5 0 0.4 3.2 1.5 1.4 2.7 7 Length of follow-up (mos) 18 NA 7 18 34 30 NA 1 NA 18 21 18 12 0 9 24 22 24 34 22 NA NA 15 NA 14 10 NA 29 NA 40 36 NA 24 30 NA 15
Authors Corbitt 1a Arregui et al 2 Hawasli 3 Begin 4 Fitzgibbons et al 5 Geis et al 6 Himpens 7 Newman et ai 8 Quilici et al 9 Wheeler 1~ Felix et a111 Paget 12 Panton and Panton ~3 Rubio TM Felix et aP 5 Felix et a115 Ferzli and KieP 6 Kald et a117 Kavic 18 Phillips et aP 9 Ramshaw et al 2~ Ramshaw et al 2~ Voeller et al 2~ Batorfi et a[ 22 Litwin et a123 Schmidt and Anta124 Sievers et a125 Barry et a126 Bittner et 8.127 Cohen et a128 Felix et a129 Ferzli et al 3~ Hussein et a131 Kiruparan and Pettit 32 Sayad et a133 Toouli et a134
Year 1991 1992 1992 1993 1993 1993 1993 1993 1993 1993 1994 1994 1994 1994 1995 1995 1995 1995 1995 1995 1995 1995 1995 1997 1997 1997 1997 1998 1998 1998 1998 1998 1998 1998 1998 1998
Technique TAPP TAPP, extra TAPP, mushroom plug and patch Extra TAPP, extra, IPOM TAPP TAPP TAPP TAPP TAPP, mesh plus plug TAPP, single or double buttress TAPP TAPP IPOM Extra, balloon, CO2 TAPP Extra, balloon, CO2, blunt TAPP TAPP Variety TAPP TEP Extra, balloon, CO2 TAPP TAPP TEP TAPP TAPP TAPP TEP TAPP/TEP TEP TEP TAPP TAPP/TEP TAPP
Abbreviations: NA, information not available; IPOM, intraperitoneal onlay mesh procedure.
Laparoscopic TAPP Herniorrhaphy
T a b l e 2. Early L a p a r o s c o p i c V e r s u s C o n v e n t i o n a l H e r n i o r r h a p h y : C o m p a r a t i v e Trials Authors Stoker et a135 Type of Study Prospective, randomized Intervention TAPP vs Nylon darn Results
6 vs 18 pain tablets Pain analogue score 1.8 vs 3.1 Return to activity 14 vs 28 days T Cost Cornell and Kerlakian 36 Prospective vs historical TAPP vs (not stated) Earlier return to activity 92% vs 29% at 14 days Earlier return to work 73% vs 14% in 3 weeks I Pain T Cost Brooks 37 Prospective, nonrandomized TAPP vs tension-free (plug) Earlier return to work No difference in pain medication 1"Cost Millikan et a138 Prospective, nonrandomized TAPP vs variety l Time off work I Pain medication l Complications Hospital days better 1"Cost Wilson et a139 Prospective, nonrandomized TAPP vs Lichtenstein Earlier return to activity (7 vs 14 days) Earlier return to work (10 vs 21 days) No difference in analgesic requirements or pain scale Payne et ai 4~ Prospective, randomized TAPP vs Lichtenstein Return to work 9 vs 17 days Improved SLR at I week 1"Cost Vogt et a141 Prospective, randomized IPOM vs tension-free Oral narcotics (5 vs 16 doses) 1" Return to normal activity (7.5 vs 18.5) Cost not mentioned Lawrence et a142 Prospective, randomized TAPP vs Nylon darn SF-36, pain analogue scores better early No difference in return to work T Complication rate 1"Cost Better quality of life Barkun et a143 Prospective, randomized TAPP vs various I Postoperative narcotics Better quality of life at I month T Satisfaction with LH 1"Cost Wright et a144 Prospective, randomized Extra vs Lichtenstein and Stoppa's repair l Pain scores (63 vs 35) 1 Analgesia doses (2.5 vs 2.0) I Wound complications Liem et a145 Prospective, randomized TAPP vs Lichtenstein I Incidence of wound abscesses (0 vs 6, P = .03) 1"Resumption of normal activity (6 vs 10 days) 1"Return to work (14 vs 21 days) 1" Resumption of athletic activities (24 vs 36) I Recurrence rate (3% vs 6%, P = .05) Abbreviations: 1, decrease in; 1", increase in; vs, versus; SLR, straight leg-raising; SF-36, Short Form Health Status Survey-36; LH, laparoscopic herniorrhaphy. Reprinted with permission from the MRC Laparoscopic Groin Hernia Trial Group: Laparoscopic versus open repair of groin hernias: A randomised. Lancet 354:185-190, 1999.
T a b l e 3. A S u m m a r y of M o r e R e c e n t C o m p a r a t i v e , P r o s p e c t i v e , R a n d o m i z e d Trials of L a p a r o s c o p i c (LIHR) a n d C o n v e n t i o n a l Inguinal H e r n i a R e p a i r (CIHR) Authors Champault et a147 Liem et al 4s Sarli et a151 Aitola et a146 Dirksen et a148 Khoury 49 Paganini et al 5~ Tanphiphat et a152 Wellwood 53 Beets et al s4 Lucas and Arregui 55 Juul and Christensen 56 Year 1997 1997 1997 1998 1998 1998 1998 1998 1998 1999 1999 1999 Hernias LH vs OH (n) 100 vs 100 487 vs 507 64 vs 66 24 vs 25 114 vs 103 169 vs 146 52 vs 56 60 vs 60 200 vs 200 56 vs 52 292 vs NA 138 vs 130 Intervention TEP vs Stoppa TEP vs anterior repair TAPP vs Lichtenstein TAPP vs Lichtenstein TAPP vs Bassini TEP vs mesh plug TAPP vs Lichtenstein TAPP vs Bassini-modify TAPP vs Lichtenstein TAPP vs PMR TAPP/TEP TAPP vs Shouldice Recurrence 6.0% vs 1.0% 3.0% vs 6.0% 0 vs 0 13% vs 8.0% 7 vs 22 2.5% vs 3.0% 1 vs 0 1 vs 0 0 vs 0 7 vs 1 2 vs NA 4 vs 3 Follow-Up (mos) 36 24 36 18 24 36 28 32 3 34 12
Abbreviations: LH, laparoscopic herniorrhaphy; NA, not available; OH, open herniorrhaphy; PMR, preperitoneal mesh repair.
Robert J. Fitzgibbons, Jr
1 The left-inguinal floor as viewed with the laparoscope. The landmarks, which should routinely he identified at this point, are the inferior epigastric vessels, the internal inguinal ring, the cord structures, and the medial umbilical ligament. In this photomicrograph, the vas deferens and Cooper's ligament can also be appreciated through the peritoneum. (Reprinted with permission from Fitzgibbons RJ Jr, Filipi CJ, Ryberg AA: Transperitoneal approach to inguinal hernia, in Toouli J, Gossot D, Hunter JG (eds): Endosurgery. New York, NY, Churchill Livingstone, 1996, pp 961-975.)
Laparoscopic TAPP Herniorrhaphy
2 (A) Photograph of a cadaver preparation (right side) showing the preperitoneal space after removal of the peritoneum and preperitoneal adipose tissue (the urachial remnant has been resected and the bladder retracted posteriorly). (B) Polypropylene mesh placed as if one were performing a TAPP herniorrhaphy Note tile proximity of certain nerves to locations where a surgeon might want to fix mesh. A lack of appreciation for this anatomical configuration was responsible for the excessive number of neuralgias in the developmental stages of the TAPP procedure. RM, rectus abdominis muscle; IE, inferior epigastric vessels; AP, anterior pubic branch and fliopubic vein; AA, aponeurotic arch of the transversus abdominis muscle; TS, transversalis fascia sling; U, ureter; CL, Cooper's ligament; UA, umbilical artery; PB, anastomotic pubic branches; RE retropubic vein; IV, external iliac vein; IA, external iliac artery; ES, external spermatic vessels; VD, vas deferens; IP, iliopubic tract; IPA, iliopectineal arch; DC, deep circumflex iliac vessels; GN, genitofemoral nerve; GB, genital branch of the genitofemoral nerve; FB, femoral branch of the genitofemoral nerve; FN, femoral nerve; LC, lateral femoral cutaneous nerve; IL, ilioinguinal nerve; IM, iliacus muscle; PM, psoas major muscle; IS, internal spermatic (testicular) vessels; LV, iliolumbar vessels; B, bladder (retracted posteriorly). Thick arrow, deep inguinal ring; thin arrow, femoral ring. (Reprinted with permission from Annibali R, Quinn T, Fitzgibbons RJ Jr: Surgical anatomy of the inguinal region and lower abdominal wall: The laparoscopic perspective, in Bendavid R (ed): Prostheses and Abdominal Wall Hernias. Austin, TX, RG Landes, Co, 1994, pp 82-103.)
Robert J. Fitzgibbons, Jr
3 Bimanual technique for placing staples during a laparoscopic herniorrhaphy. It is particularly important when stapling lateral to the internal spermatic vessels because injury to the femoral branch of the genitofemoral nerve or the lateral cutaneous nerve of the thigh can be prevented if the surgeon feels the entire head of the stapler or tacker with the nondominant hand. Care needs to be taken to avoid using this maneuver too vigorously because excessively deep stapling can result in injuries to the flioinguinal and the iliohypogastric nerves. In addition, the skin can actually be caught in a staple or tack, creating an unsightly and sometimes painful dimple.
TAPP Versus TEP One of the major criticisms of the laparoscopic TAPP procedure is the need to enter the peritoneal cavity. The result is the possibility of a laparoscopic accident, resulting in injury to an intra-abdominal organ or intestinal obstruction secondary to adhesive complications or ventral herniation. The TEP operation was developed to address this concern (see article on the TEP procedure by guest editor and author, C. Daniel Smith, MD, within this issue.) Technically, it is not a laparoscopic operation because the peritoneal cavity is never entered. However, because laparoscopic instrumentation is used, it is classified as a "laparoscopic" herniorrhaphy. The TEP procedure is more demanding than the TAPP because of the limited working space. Most authorities believe that the laparoscopic surgeon should be comfortable with the TAPP herniorrhaphy before attempting a TEE The author
tends to recommend the TEP procedure for smaller, simpler hernias, whereas patients with large hernias, those with previous lower abdominal incisions, or any other complicating situation usually undergo a TAPP herniorrhaphy. Operating Room Set-Up
The operating room set-up used for the TAPP procedure is shown in Figure 4. The operation is usually performed under general anesthesia with the patient supine. Arms should be tucked at the side of the patient because outstretched arms may compromise the ability of the surgeon to obtain an optimum angle for fixing the prosthesis. A Foley catheter is placed to establish bladder decompression only if the patient does not void immediately before entering the operating room. A single video monitor is placed at the foot of the operating table. An
Laparoscopic TAPP Herniorrhaphy
I Anesthesia 1 Equipment SURGEON
ANESTHESIOLOGIST CAMERA OPERATOR (OPTIONAL)
SCRUB NURSE Instrument Table
I VideoMonitor and Insufflator
Typical setup for the laparoscopic TAPP procedure. The surgeon stands on the opposite side of the table from the hernia. Three cannulae are inserted: one at the umbilicus, and the other two at the same level but lateral to either rectus sheath. A single video monitor is positioned at the patient's foot.
a n g l e d laparoscope is essential to provide adequate visualization of the inguinal region because it is somew h a t anterior (see Figure 5). The surgeon stands On the opposite side of the table from the hernia. The first assistant stands opposite the surgeon. The first assistant usually acts as the camera operator because there is n o t e n o u g h r o o m for a third person between the two p r i m a r y
surgeons and the head of the table. This assumes the primary surgeon will use a t w o - h a n d e d technique. Alternatively, some surgeons prefer to use a o n e - h a n d e d approach so that they can control the optics themselves because proper visualization is so critical to a successful laparoscopic herniorrhaphy. This is strictly a matter of personal preference.
5 A 0 ~ telescope is shown on the top and a 30 ~ on the bottom. The 0 ~ device significantly restricts vision and should be avoided if at all possible.
Robert J. Fitzgibbons, Jr
6 Except in unusual circumstances, only three cannulae are required. The umbilical cannula (10 to 12 mm) is inserted first and used to introduce the laparoscope. The author prefers placement of the initial cannula using an open technique. It is absolutely imperative that the abdominal cavity is entered safely, avoiding laparoscopic injuries, because this complication would not exist with a conventional herniorrhaphy. After completing a routine diagnostic surveillance laparoscopy, the patient is placed in the Trendelenburg position to allow the bowel to fall away from the pelvis, allowing for good visualization and access to the inguinal floor. Two additional cannulae are placed just lateral to the rectus muscles at the level of the umbilicus (see figure). These can both be 5 mm if the stapling or tacking device is the same diameter. If the surgeon prefers a larger stapling device, it can either be placed through the umbilical cannula, providing a 5-mm telescope is available for observation of the fixation. A simpler solution is to make the lateral cannulae opposite the hernia large enough to accommodate the fixation device. Adhesions are taken down as necessary. Both inguinal regions are inspected and the median umbilical ligament (remnant of the urachus), the medial umbilical ligament (remnant of the umbilical artery), and the lateral umbilical fold (peritoneal reflection over the inferior epigastric artery) are identified. The internal inguinal ring and cord structures are immediately evident. Commonly, the inferior epigastric vessels and the vas deferens can be seen through the intact peritoneum as shown in Figure 1.
Laparoscopic TAPP Herniorrhaphy
7 The peritoneum is incised (using scissors) approximately 2 cm above the superior edge of the hernia defect. Occasionally, the median umbilical ligament is divided if it appears to compromise exposure. The peritoneal flap extends from the median umbilical ligament to the anterior superior ifiac spine. The flap is mobilized inferiorly using blunt and sharp dissection.
8 The inferior epigastric vessels are exposed using gentle blunt dissection. Next, the pubic symphysis and lower portion of the rectus abdominis muscle need to be identified.
Robert J. Fitzgibbons, Jr
9 Cooper~s ligament is then dissected to its junction with the femoral vein. The iliopubic tract is identified, and dissection is continued inferiorly with care taken to avoid injuring the femoral branch of the genitofemoral and lateral femoral cutaneous nerves, which enter the lower extremity just below the iliopubic tract. Finally, skeletonizing the cord structures from the peritoneum completes the dissection. (Reprinted with permission from Fitzgibbons RJ Jr, Filipi CJ, Ryberg AA: Transperitoneal approach to inguinal hernia, in Toouli J, Gossot D, Hunter JG (eds): Endosurgery. New York, NY, Churchill Livingstone, 1996, pp 961-975.)
Laparoscopic TAPP Herniorrhaphy
10 For a direct hernia, the sac and preperitoneal fat are reduced from the hernia orifice by gentle traction, separating the peritoneal sac from the thinned-out transversalis fascia, which lines the abdominal wall portion of the hernia defect. This characteristic layer is sometimes referred to as the "pseudosac." It is important that this layer be teased away from the hernia sac and allowed to retract back into the defect, because needless bleeding will be the result of an attempt to resect it. Some surgeons feel that the pseudosac should be tacked or stapled to Cooper's ligament to decrease the incidence of seroma with large direct hernias. For indirect hernias, there are two options. A small sac is easily mobilized from the cord structures and reduced back into the peritoneal cavi~ A large sac may be difficult to mobilize because of dense adhesions between the sac and the cord structures caused by chronicity of the hernia, resulting in undue trauma to the cord if an attempt is made to remove the sac in its entirety. In this situation, the sac can be divided just distal to the internal ring leaving the distal sac in situ, with dissection of the proximal sac away from the cord structures. The division of the sac is most easily accomplished by opening the sac on the side opposite the cord structures. The division of the sac can then be performed from the inside. (Reprinted with permission from Fitzgibbons RJ Jr, Filipi CJ, Ryberg AA: Transperitoneal approach to inguinal hernia, in Toouli J, Gossot D, Hunter JG (eds): Endosurgery. New York, NY, Churchill Livingstone, 1996, pp 961-975.)
Robert J. Fitzgibbons, Jr
1 1 The mesh has been fixed in place and trimmed to fit perfectly in the preperitoneal space. (Reprinted with permission from Camps JNA, Nguyen NXNA, Annibali RNA, et al: Laparoscopic inguinal herniorrhaphy: Current techniques, in Arregui MR, Fitzgibbons RJ Jr, McKernan JB, et al (eds): Principles of Laparoscopic Surge~ New York, NY, Springer-Verlag, 1995, pp 400-408.)
12 The peritoneal flap is pulled over the mesh and stapled in order to isolate the prosthesis from intra-abdominal viscera.
Laparoscopic TAPP Herniorrhaphy
obstruction may result. Decreasing the pneumoperitoneum before closing the peritoneal flap may aid the closure. To reduce postoperative discomfort, a long-acting local anesthetic is injected into the preperitoneal space before completing the closure of the peritoneum and prior to deflating the abdomen. Similarly, local anesthetic is used in all trocar sites. Cannula sites greater than 5 m m should be closed at the fascial level. Otherwise, an excessive rate of trocar-site herniation will be observed (see 13). Direct suture is difficult, especially in obese patients, but there are a variety of reusable or disposable devices available to facilitate fascial closure. Finally, the pneumoperitoneum is released and the skin of all trocar sites is closed with absorbable, intracuticular sutures. Bilateral hernias can be repaired using one long transverse-peritoneal incision extending from one anterior-superior iliac spine to another. We prefer to use the same peritoneal incision and preperitoneal dissection used for a unilateral hernia on either side, preserving the peritoneum between the medial-umbilical ligaments. The symphysis pubis is completely dissected so that both preperitoneal dissections communicate with each other. This allows the placement of one large prosthesis (usually 8 by 30 cm or larger) essentially covering the entire lower pelvis, similar to Dr Stoppa's procedure performed conventionally, By not incising the peritoneum between the two medial-umbilical ligaments, one avoids the theoretical complication of dividing a patent urachus. Some surgeons prefer two separate pieces of mesh to avoid placing the mesh in front of the bladder. Also, it is easier to manipulate two pieces separately and tailor them more accurately to fit the preperitoneal space on either side.
On completion of the dissection, a large piece of mesh, at least 6 by 11 cm, is placed over the myopectineal orifice so that it completely covers the direct, indirect, and femoral spaces. The mesh can either be simply laid over the cord structures, or a slit can be made in the mesh to wrap the mesh around the cord structures. Most surgeons now avoid the slit in the prosthesis because recurrences have been noted through these slits even when they have been repaired around the cord. The use of a large prosthesis allows the intra-abdominal pressure to act uniformly over a large area, thus preventing its herniation through one point (ie, the hernial defect). The medial edge is stapled or tacked to the contralateral pubic tubercle and the symphysis pubis. The medial, inferior border is secured to Cooper's ligament. Next, the mesh is stapled along the superior border to the posterior rectus sheath and transversalis fascia, at least 2 cm above the hernia defect. To further decrease the incidence of neuralgia, staples are placed horizontally for the superior border of the prosthesis to correspond to the direction of the ilioinguinal and iliohypogastric nerves. 'They are placed vertically when stapling laterally because this is the direction of the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve. It is again emphasized that, to avoid neuralgias involving the lateral cutaneous nerve of the thigh or the femoral branch of the genitofemoral nerve, staples or tacks should never be placed below the iliopubic tract when lateral to the internal spermatic vessels. A useful maneuver during fixation is to palpate the head of the stapler through the abdominal wall with the nondominant hand. This ensures that stapling is done above the iliopubic tract (see Fig 3). A point just medial to the anteriorsuperior iliac spine is the preferred location for the lateral edge of the prosthesis, completing coverage of the myopectineal orifice with a wide overlap. After the complete fixation, redundant mesh on the inferior border can be trimmed in situ to tailor it to the preperitoneal space (see Fig 11). The purpose of trimming the mesh is to prevent "roll-up" of the inferior border when closing the peritoneum. See Figure 12 for peritoneal closing. We do not feel that linear approximation of the peritoneum is necessary for all patients, especially if the result is tenting of the peritoneum caused by excessive tension required to approximate the two edges. The tenting effect may leave a space between the peritoneal flap and the prosthesis, a potential area into which the bowel might migrate, resulting in bowel obstruction. Occasionally, it is necessary to simply cover the prosthesis with the inferior flap, leaving exposed the transversalis fascia. Excessive gaps between the staples should also be avoided because the bowel may herniate between these gaps, or may adhere to the exposed mesh. In either situation, small bowel
Postoperative Care and Follow-up
Most patients are discharged home the day of the operation. Patients who have persistent nausea, vomiting, or pain that is not well controlled with oral medication are admitted for overnight observation. Light duty work with lifting restriction as dictated by pain tolerance can be resumed as soon as the patient desires. Patients return for follow-up at 1 week, 6 weeks and then as needed.
Complications A s s o c i a t e d With Laparoscopic Herniorrhaphy
The potential advantages of laparoscopic herniorrhaphy must be interpreted in the light of the disadvantages of a laparoscopic approach. These include complications related to the laparoscopy such as bowel perforation or
Robert J. Fitzgibbons, Jr
13 Left-lower abdominal-quadrant trocar-site hernia involving the sigmoid colon. We now recommend that all trocar sites greater than 5 mm in size be closed at the fascial level.
major vascular injury, potential adhesive complications at sites where the peritoneum has been breached or prosthetic material has been placed, the apparent need (at least at the present time) for a general anesthetic, and increased cost because of the expensive equipment necessary. Table 4 summarizes possible complications of laparoscopic herniorrhaphy by dividing them into three groups: (1) those related to the laparoscopy, (2) those related to the patient (ie, general complications), and (3) those related to the herniorrhaphy. Except for complications unique to laparoscopy, the incidence of other complications is similar for both the laparoscopic and conventional procedures.
Our group analyzed the videotapes of 13 patients eventually suffering a recurrence after laparoscopic herniorrhaphy and identified several mechanisms as the cause of the recurrence. These included: (1) incomplete dissection of the preperitoneal space, which leads to poor overall assessment of the groin floor, missed hernias, insufficient delineation of important landmarks, and inadequate space for the inferior border of the prosthesis to lay flat causing it to roll up; (2) a prosthesis that is too small, leading to incomplete coverage and overlap of all the potential hernia sites of herniation through the myopectineal orifice; (3) migration of the mesh prosthesis; (4) mesh slitting, which may be the source of a future recurrence; (5) folding or invagination of the mesh into the defect; and (6) displacement of mesh by hematoma. We feel a thorough dissection of the preperitoneal space with identification of all the landmarks followed by fixation of a large size mesh that adequately covers and overlaps the entire myopectineal orifice without slitting or folding is the best way to avoid recurrence. Slitting of the prosthesis remains controversial. Although we feel it is unnecessary, some surgeons think it aids in fixation and is acceptable providing the slit is adequately repaired around the cord structures. Conclusion Laparoscopic inguinal herniorrhaphy will only be successful if it is performed safely by well-trained surgeons. It is
Table 4. Complications
Related to Laparoscopy Bleeding Abdominal wall Intra-abdominal Retroperitoneal Visceral injury Bowel perforation Bladder perforation Bowel obstruction Trocar or peritoneal closure site hernia Adhesions Diaphragmatic dysfunction Wound infection Hypercapnia Related to the Patient Urinary Ileus Aspiration pneumonia Cardiovascular and respiratory insufficiency Nausea and vomiting Related to the Herniorrhaphy Neurological Cord and testicular hydrocele Wound infection Prosthetic infection Seroma Retroperitoneal hematoma Foreign body reaction to mesh
Laparoscopic TAPP Herniorrhaphy
i4. Rubio PA: Laparoscopic intraperitoneal hernioplast3z. Int Surg 79:293-295, 1994 15. Felix EL, Michas CA, Gonzalez MHJr: Laparoscopic hernioplasty. TAPP vs TER Surg Endosc 9:984-989, 1995 16. Ferzli G, Kiel T: Evolving techniques in endoscopic extraperitoneal herniorrhaphy. Surg Endosc 9:928-930, 1995 17. Kald A, Smedh K, Anderberg B: Laparoscopic groin hernia repair: Results of 200 consecutive herniorraphies. Br J Surg 82:618-620, 1995 18. Kavic MS: Laparoscopic hernia repair. Three-year experience. Surg Endosc 9:12-15, 1995 19. Phillips EH, Arregui M, Carroll BJ, et al: Incidence of complications following laparoscopic hernioplasty. Surg Endosc 9:16-21, 1995 20. Ramshaw BJ, Tucker JG, Mason EM, et al: A comparison of transabdominal preperitoneal (TAPP) and total extraperitoneal approach (TEPA) laparoscopic herniorrhaphies. Am Surg 61:279283, 1995 21. Voeller GR, Mangiante EC Jr, Williams C: Totally preperitoneal laparoscopic inguinal herniorrhaphy using balloon dissection. Surg Rounds 18:107-112, 1995 22. BatoffiJ, Kelemen O, Vizsy L, et al: Transabdominal preperitoneal herniorraphy: technique and results. Acta Chir Hung 36:18-21, 1997 23. Litwin DE, Pham QN, Oleuiuk FH, et al: Laparoscopic groin hernia surgery: The TAPP procedure. Transabdominal preperitoneal hernia repair. CanJ Surg 40:192-198, 1997 24. Schmidt P, Antal A: The totally extraperitoneal (TEP) laparoscopic hernia repair. Acta Chir Hung 36:320-322, 1997 25. Sievers D, Barkhausen S, Scheer H, et al: Laparoscopic transperitoneal inguinal hernia repair (TAPP)--Complications and results of a prospective study. Langenbecks Arch Chir Suppl Kongressbd 114:1116-1118, 1997 26. Barry MK, Donohue JH, Harmsen WS, et al: Transabdominal preperitoneal laparoscopic inguinal herniorrhaphy: Assessment of initial experience. Mayo Clin Proc 73:717-723, 1998 27. Bittner R, Kraft K, Schmedt CG, et al: Update: What is left for laparoscopic hernia repair? Dig Surg 15:167-171, 1998 28. Cohen RV,Morrel AC, Mendes JM, et al: Laparoscopic extraperitoneat repair of inguinal hernias. Surg Laparosc Endosc 8:14-16, 1998 29. Felix E, Scott S, Crafton B, et al: Causes of recurrence after laparoscopic hernioplasty. A mnlticenter study. Surg Endosc 12:226-231, 1998 30. Ferzli G, Sayad P, Huie F, et al: Endoscopic extraperitoneal herniorrhaphy. A 5-year experience. Surg Endosc 12:1311-1313, 1998 31. Hussein MK, Khoury GS, Taha AM: Laparoscopic inguinal hernia repair. Int Surg 83:253-256, 1998 32. Kiruparan P, Pettit SH: Prospective audit of 200 patients undergoing laparoscopic inguinal hernia repair with follow-up from 1 to 4 years. J R Coll Surg Edinb 43:13-16, 1998 33. Sayad P, Hallak A, Ferzli G: Laparoscopic herniorrhaphy: Review of complications and recurrence. J Laparoendosc Adv Surg Tech A 8:3-10, 1998 34. Toouli J, Baldini E, Casaccia M, et al: Outcome of laparoscopic transabdominal preperitoneal inguinal hernia repair. Surg Laparosc Endosc 8:223-226, 1998 35. Stoker DL, Spiegelhalter DJ, Singh R, et al: Laparoscopic versus open inguinal hernia repair: Randomised prospective trial. Lancet 343:1243-1245, 1994 36. Col-nell RB, Kerlakian GM: Early complications and outcomes of the current technique of transperitoneal laparoscopic herniorrhaphy and a comparison to the traditional open approach. Am J Surg 168:275-279, 1994
an excellent alternative to conventional herniorrhaphy in selected circumstances. The best indications are: (1) recurrent hernia after a conventional inguinal hernia repair (CIHR), because the operation is performed in normal, nonscarred tissue; (2) bilateral hernias, as both sides can easily be repaired using the same small laparoscopy incisions; and (3) the presence of an inguinal hernia in a patient who requires a laparoscopy for another procedure (ie, a laparoscopic cholecystectomy), assuming the gram stain of the bile is negative. A more contentious issue is the use of laparoscopic inguinal hernia repair (LIHR) for the uncomplicated, unilateral hernia. Large prospective, randomized trials will be needed to definitvely settle the question of whether the added risks and costs are worth the benefits. The potential for severe, life-threatening complications is greater with LIHR than CIHR, although the overall incidence of complications between the two procedures is similar. The question becomes does the benefit of LIHR justify the increased risk of severe complications? We feel it should be part of the armamentarium of surgeons offering comprehensive hernia therapy.
1. Wantz GE: Giant prosthetic reinforcement of the visceral sac: The Stoppa groin hernia repair. Surg Cin NAmer 78:1075-1087, 1998 la. CorbittJDJr: Laparoscopic herniorrhaphy. A preperitoneal tensionfree approach. Surg Endosc 7:550-555, 1993 2. Arregui ME, Navarette J, Davis CJ, et al: Laparoscopic inguinal herniorrhaphy. Techniques and controversies. Snrg Clin North Am 73:513-527, 1993 3. Hawasli A: Laparoscopic inguinal herniorrhaphy: Classification and i year experience. J Laparoendosc Surg 2:137-143, 1992 4. Begin GF: Laparoscopic extraperitoneal treatment of inguinal hernias in adults. A series of 200 cases. Endosc Surg Allied Technol 1:204-206, 1993 5. Fitzgibbons RJ Jr, Camps J, Cornet DA, et al: Laparoscopic inguinal hernia: Results of a multi-center trial. Ann Surg 221:313, 1995 6. Geis WP, Crafton W-B, Novak MJ, et al: Laparoscopic herniorrhaphy: Results and technical aspects in 450 consecutive procedures. Surgery 114:765-772, 1993 7. Himpens JM: Laparoscopic inguinal hernioplasty. Repair with a conventional vs a new self-expandable mesh. Surg Endosc 7:315318, 1993 8. Newman L 3rd, Eubanks S, Mason E, et al: Is laparoscopic herniorrhaphy an effective alternative to open hernia repair? J Laparoendosc Surg 3:121-128, 1993 9. Quilici PJ, Greaney EM Jr, Quilici J, et al: Laparoscopic inguinal hernia repair results: 131 cases. Am Surg 59:824-830, 1993 10. Wheeler KH: Laparoscopic inguinal herniorrhaphy with mesh: An 18-month experience. J Laparoendosc Surg 3:345-350, 1993 11. Felix EL, Michas CA, McKnight RL: Laparoscopic herniorrhaphy. Transabdominal preperitoneal floor repair. Surg Endosc 8:100103, 1994 12. Paget GW: Laparoscopic inguinal herniorrhaphy. A personal audit of 222 hernia repairs. MedJ Aust 161:249-253, 1994 13. Panton ON, Panton RJ: Laparoscopic hernia repair. Am J Surg 167:535-537, 1994
37. Brooks DC: A prospective comparison of laparoscopic and tension-free open herniorrhaphy. Arch Surg 129:361-366, 1994 38. Millikan KW, Kosik ML, Doolas A: A prospective comparison of transabdominal preperitoneal laparoscopic hernia repair versus traditional open hernia repair in a university setting. Surg Laparosc Endosc 4:247-253, 1994 39. Wilson MS, Deans GT, Brough WA: Prospective trial comparing Lichtenstein with laparoscopic tension-free mesh repair of inguinal hernia. BrJ Surg 82:274-277, 1995 40. PayneJHJr, Grininger LM, Izawa MT, et ah Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 129:973-979, 1994 41. Vogt DM, Curet MJ, Pitcher DE, et ah Preliminary results of a prospective randomized trial of [aparoscopic onlay versus conventional inguinal hernirrhaphy. AmJ Snrg 169:84-89, 1995 42. Lawrence K, McWhinnie D, Goodwin A, et ah Randomised controlled trial of laparoscopic versus open repair of inguinal hernia: early results. Br MedJ 311:981-985, 1995 43. Barkun JS, Wexler MJ, Hinchey EJ, et ah Laparoscopic versus open inguinal herniorrhaphy: Preliminary results of a randomized controlled trial. Surgery 118:703-709, 1995 44. Wright DM, Kennedy A, Baxter JN, et aL: Early outcome after open versus extraperitoneal endoscopic tension-free hernioplasty: A randomized clinical trial. Surgery 119:552-557, 1996 (abstr) 45. Liem MS, van der Graaf Y, van Steensel CJ, et al: Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N EnglJ Med 336:1541-1547, 1997 46. Aitola P, Airo I, Matikainen M: Laparoscopic versus open preperitoneal inguinal hernia repair: A prospective randomised trial. Ann Chir Gynaeco187:22-25, 1998
Robert J. Fitzgibbons, Jr 47. Champault GG, Rizk N, Catheline JM, et ah Inguinal hernia repair: Totally preperitoneal Iaparoscopic approach versus Stoppa operation: Randomized trial of 100 cases. Surg Laparosc Endosc 7:445-450, 1997 48. Dirksen CD, Beets GL, Go PM, et al: Bassini repair compared with laparoscopic repair for primary inguinal hernia: A randomised controlled trial. EurJ Surg 164:439-447, 1998 49. Khoury N: A randomized prospective controlled trial of laparoscopic extraperitoneal hernia repair and mesh-plug hernioplasty: A study of 315 cases. J Laparoendosc Adv Surg Tech A 8:367-372, 1998 50. Paganini AM, Lezoche E, Carle F, et al: A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair. Surg Endosc 12:979-986, 1998 51. Sarli L, Pietra N, Choua O, et al: Prospective randomized comparative study of laparoscopic hernioplasty and Lichtenstein tension-free hernioplasty (article in Italian). Acta Biomed Ateneo Parmense 68:5~10, 1997 52. Tanphiphat C, Tanprayoon T, Sangsubhan C, et ah Laparoscopic vs open inguinal hernia repair. A randomized, controlled trial. Surg Endosc 12:846-851, 1998 53. Wellwood J: Randomied controlled trial of laparoscopic versus open mesh repair for inguinal hernia: Outcome and cost. Br MedJ 317:103-110, 1998 54. Beets GL, Dirksen CD, Go PM, et al: Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia? A randomized controlled trial. Surg Endosc 13:323-327, 1999 55. Lucas SW, Arregui ME: Minimally invasive surgery for inguinal hernia. WorldJ Surg 23:350-355, 1999 56. Juul P, Christensen K: Randomized clinical trial of laparoscopic versus open inguinal hernia repair. BrJ Surg 86:316-319, 1999
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.