MIS hernia repair, golden

rules for safe surgery

Ammar Abusultan; orthopedic resident
History

• In 1990, Ralph Ger and collogues

introduced the first laparoscopic
hernia repair
• It was done on 15 beagle dogs
Robotic vs conventional laparoscopic
• The laparoscopic technique is still uncommon worldwide
• Does it require unattainable skills to achieve?
• For many surgeons, the robotic platform has made this much easier
and has initiated the recent rapid growth in MIS inguinal hernia
repair
 Robotic vs conventional laparoscopic
• Intraoperative complications 0.03%
• Conversion to open 0.14%
• Urinary retention 3.5%
• Seroma/hematoma 4.1%
• Overall complications 7.4%
• Hernia recurrence was 0.18%

Aiolfi A, Cavalli M, Micheletto G, Bruni PG, Lombardo F, Per- ali C, Bonitta G, Bona D (2019) Robotic inguinal
hernia repair: is technology taking over? Systematic review and meta-analysis Hernia 23(3):509–519
Standardized laparoscopic approach
• What makes a great surgeon is understanding the anatomy and the
anatomical landmarks

• Daes and Felix published a stepwise guide called the critical view of
the Myopectineal Orifice (MPO)

• Furthermore, Furtado et al. systematized the approach by introducing

the INVERTED Y AND 5 TRIANGLES CONCEPT
What if both concepts get combined?
• Claus et al. recently published the combined surgical technique
combining the critical view of the Myopectineal Orifice (MPO) and
inverted Y and the five triangles

Claus, C., Furtado, M., Malcher, F., Cavazzola, L. and Felix, E., 2020. Ten golden rules for a safe MIS inguinal
hernia repair using a new anatomical concept as a guide. Surgical Endoscopy, 34(4), pp.1458-1464.
The ten golden rules for a safe MIS inguinal hernia repair
using a new anatomical concept as a guide

Simply, it is 3 zones and 10 rules

The 3 zones
Rule 1: beginning of surgery
• Peritoneal incision should be at least 4 cm above the deep inguinal
ring border
• The opening flap should extend from the anterior–superior iliac spine
(ASIS) to the medial umbilical fold
Rule 2: Dissection should follow the peritoneal plane
• Fatty tissue present in the pre-peritoneal space should be kept in
contact with the inguinal floor and not with the peritoneum
• The plane that exposes the muscle should be avoided in order to
prevent damage of inferior epigastric vessels or injury to nerves
Rule 3: Dissection should extend to at least the pubic
symphysis and at least 2 cm below the pubis at Zone 2
• In order to create sufficient space to accommodate an adequately sized
mesh, that overlaps Direct and Femoral Triangles by at least 3-4 cm
Pay attention!
• If you face co-existing direct hernia, dissect it, and reduce hernia’s
contents and the attenuated fascia transversalis should be dissected
and kept distally
• When dissecting the direct hernia you must remain in the correct
plain in order to avoid injuring the bladder especially if it is part of
the hernia
Never forget to emphasize the ward nurse in
charge
• The bladder should be emptied before the operation, what is the
clinical significance?
- Narrowing the operative field and difficulty to dissect Zone 2.
- Pushing or folding the lower edge of the mesh during CO2 deflation

(potential risk for recurrence)

Rule 4: The external iliac vein should be visible
to avoiding a missed femoral hernia in zone 3
Rule 5: Parietalization of the elements of the cord is
considered sufficient when the peritoneum is dissected
inferiorly until at least the level at which the vas deferens
crosses the external iliac vein in Zone 3 and the iliopsoas
muscle is identified posteriorly at Zone 1
Rule 6: In large or inguino-scrotal hernias, it is
recommended to transect and abandon the distal
hernia sac within the scrotum
• Indirect hernial sac is usually dissected and reduced from the inguinal
canal
• When dealing with large hernial sacs or chronic and fibrotic ones,
you may transect the hernia sac only after safely identifying the
elements of the spermatic cord

This decision is made to avoid excessive dissection of the cord elements

thus avoiding injury to them
Rule 7: The deep inguinal canal should be explored
during Zone 3 dissection in search of lipoma of the cord

• Any lipoma must be dissected and reduced from the inguinal canal,
why?
• Untreated lipomas are a major cause of recurrence after laparoscopic
repair
Here we go!
Only if all anatomical elements have been recognized, the
steps of dissection described above have been completed
and hemostasis achieved

Green light to proceed with mesh placement.

Rule 8: A large mesh (10 × 15 cm) may be placed
covering the MPO (Indirect, Direct and Femoral triangles) with overlap of at
least 3–4 cm
• The peritoneum should not left behind the mesh to avoid folding or
rolling up of it during evacuation of the gas or peritoneal closure
• Medially: mesh should be positioned between the pubic bone and the
bladder into the Retzius space
• Laterally: mesh should lie next to the iliopsoas muscle and level of
ASIS
• The mesh should be placed without wrinkles or folds and should not
be splitted (to avoid chronic pain and recurrence)
Rule 9: Mesh fixation is not necessary
• Indications:
Large inguinal hernias
Direct hernias
• Recommendations:
1. Avoid bone structures
2. Avoid inferior epigastric artery
3. Consider 2 cm above the iliopubic tract for extra safety
4. 5 to 6 fixation points are sufficient to fix the mesh
5. Bimanual technique of palpating the abdominal wall, while placing penetrating
fixation should be used (cpuntertraction)
Your fixator choices:
• Tacks
• Glue
• Sutures
• Self-fixing mesh
Rule 10: Deflation under direct visualization
• At the end of TAPP:
• The mesh must not be elevated by the closure
• Attention should be paid to ensure that the peritoneum does not fold
the bottom edge of the mesh
• Suture closure of the peritoneum is recommended instead of tacking
(potential for nerve injuries)
•Thanks for listening my best seniors