What are the approach considerations in laparoscopic inguinal hernia repair?

Updated: Apr 16, 2020
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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Answer

A number of considerations should be kept in mind in the performance of laparoscopic inguinal repair, whether via the totally extraperitoneal (TEP) approach or via the transabdominal preperitoneal (TAPP) approach.

Extreme care must be exercised in placing the mesh fixation tacks. This point cannot be overstated. A nerve injury caused by an errant tack can be truly debilitating to the patient and very challenging to treat. Tacks should be placed only above the iliopubic tract. [90] Proper placement may be ensured by drawing a line from the pubic tubercle to the anterior superior iliac spine (ASIS) at the start of the procedure. Before firing each tack, carefully palpate the tacker head through the abdominal wall to ensure that it is above this line.

Violation of the peritoneum during TEP repair causes loss of insufflation from the preperitoneal space into the peritoneal cavity, which, in turn, causes the preperitoneal space to collapse to some degree. This collapse can make the procedure more difficult to complete; in addition, it places intra-abdominal organs at risk for injury and may lead to adhesion formation.

Accordingly, efforts should always be made to avoid tearing the peritoneum if at all possible. If the rent is small, endoscopic clips can be placed to close the defect and minimize the leak. Otherwise, conversion to a TAPP repair or an open repair may be necessary. Another option is to place a Veress needle through a stab incision into the abdominal cavity to drain the carbon dioxide.

Trocar placement should always be done under direct vision. To prevent bleeding and hematoma formation, the trocars should be placed exactly in the midline so as to avoid tearing the fibers of the rectus abdominis.

During preperitoneal dissection, the inferior epigastric artery and vein sometimes become separated from the abdominal wall and then hang down into the operative field. Clipping and dividing these vessels may be required in order to complete the procedure.

It is very helpful to place the mesh in such a way as to facilitate its subsequent flush deployment. This may be accomplished by folding the mesh in half lengthwise, grasping it by the fold, and advancing it through the trocar toward the ASIS. When the grasper is released, the natural memory of the mesh causes it to spring open in a properly oriented position, without any need for time-consuming manipulation.

Vascular injury is a relatively uncommon but nonetheless potentially disastrous adverse event. It can be avoided by respecting the proximity of the femoral vessels, particularly when the mesh is being tacked to the Cooper ligament. [91]

Recurrence of the hernia is a significant concern. The key to minimizing the recurrence rate is to use an ample-sized piece of mesh. The mesh must be large enough to extend 2 cm medial to the pubic tubercle, 3-4 cm above the Hesselbach triangle, and 5-6 cm lateral to the internal ring.

If the patient is male, the surgeon should always remember to pull the testes gently back down to their normal scrotal position at the end of the procedure.


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