INGUINAL HERNIA - acreditacion-fmc.org · of inguinal hernias. In addition to describing current...

I N G U I N A L H E R N I A

Fadi T. Hamadani, MD, and Simon Bergman, MD, MSC, FACS, FRCSC*

In the United States, approximately 1,000,000 abdominal wall herniorrhaphies are performed each year, of which almost 80% are for inguinal or femoral hernias.1 Worldwide, some 20 million groin hernias are repaired each year.2 The lifetime risk of having to undergo an inguinal hernia repair is 27% for men and 3% for women.3 In male patients, indi-rect inguinal hernias are the most common type (more often located on the right), occurring approximately twice as fre-quently as direct inguinal hernias; femoral hernias account for a much smaller percentage. In female patients, indirect inguinal hernias are also the most common type, but femo-ral hernias are seen more frequently than direct hernias, which are rare in this population. Femoral hernias account for fewer than 10% of all groin hernias; however, 40% pres-ent as emergencies (i.e., with incarceration or strangulation), and mortality is higher for emergency repair than for elec-tive repair. A two-peak theory has been described, stating that a new diagnosis of an inguinal hernia is most likely in patients younger than 1 year and in patients older than 55 years, although hernias can be diagnosed across any given age group.4

Numerous classifi cation schemes for groin hernias have been devised, and the variety of classifi cations in current use indicates that the perfect system has yet to be developed.5 The main problem in developing a single classifi cation scheme suitable for wide application is that it is impossible to eliminate subjective measurements so as to ensure consis-tency from observer to observer. The advent of laparoscopic herniorrhaphy has further complicated the issue in that some of the measurements needed cannot be obtained via a laparoscopic approach. At present, the Nyhus system enjoys the greatest degree of acceptance [see Table 1].

In what follows, we discuss open and laparoscopic repairs of inguinal hernias. In addition to describing current opera-tive techniques, we address inguinal surgical anatomy, pre-operative planning, and complications. Finally, we review selected trials measuring the results of laparoscopic repair against those of open repair.

Anatomy

muscular layers of the abdominal wall

External Oblique

The obliquely arranged anteroinferior fi bers of the exter-nal oblique aponeurosis fold back on themselves to form the

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inguinal ligament, which attaches laterally to the anterosu-perior iliac spine [see Figure 1]. In most people, its medial insertion is dual: one portion of the ligament inserts on the pubic tubercle and the pubic bone, whereas the other portion, the lacunar ligament, is fan-shaped and spans the distance between the inguinal ligament proper and the pec-tineal line of the pubis. It blends laterally with the Cooper ligament. The more medial fi bers of the aponeurosis of the external oblique muscle divide into a medial crus and a lateral crus to form the external or superfi cial inguinal ring, through which the spermatic cord or round ligament passes. The inguinal ligament forms the base of the Hesselbach triangle. The edge of the rectus abdominis and the inferior epigastric vessels forms its medial and superolateral borders, respectively.

Internal Oblique

Located beneath the external oblique muscle, the internal oblique fi bers orient themselves inferomedially toward the pubis to run parallel to the external oblique aponeurotic fi bers. These fi bers arch over the round ligament or the spermatic cord, forming the superfi cial part of the internal inguinal ring.

Transversus Abdominis

Deep to the internal oblique muscle, the transversus abdominis arises from the inguinal ligament, the inner side of the iliac crest, the endoabdominal fascia, and the lower six costal cartilages and ribs. The medial aponeurotic fi bers of the transversus abdominis contribute to the rectus sheath. Infrequently, these fi bers are joined by a portion of the inter-nal oblique aponeurosis to form the conjoined tendon.

Table 1 Nyhus Classifi cation System for Groin Hernias

Type Description

1 Indirect hernia with normal internal abdominal ring. This type is typically seen in infants, children, and small adults.

2 Indirect hernia in which internal ring is enlarged without impingement on the floor of the inguinal canal. Hernia does not extend to the scrotum.

3A Direct hernia. Size is not taken into account.

3B Indirect hernia that has enlarged enough to encroach on the posterior inguinal wall. Indirect sliding or scrotal hernias are usually placed in this category because they are commonly associated with extension to direct space. This type also includes pantaloon hernias.

3C Femoral hernia

4 Recurrent hernia. Modifiers A, B, C, and D are sometimes added to type 4, corresponding to indirect, direct, femoral, and mixed, respectively.

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gastrointestinal tract and abdomen

* This chapter is a combination and update of two previous chapters on inguinal hernia repair. The authors acknowledge Liane S. Feldman, MD, FACS, FRCSC, Robert J. Fitzgibbons Jr, MD, FACS, Alan T. Richards, MD, FACS, Thomas H. Quinn, PhD, Marvin J. Wexler, MD, FACS, and Shannon A. Fraser, MD, for their contributions to the previous chapters on which this update is based.

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gastro inguinal hernia — 2

Internal Oblique Muscle

TransversusAbdominis Muscleand Aponeurosis

TransverseFascia

SuperficialInguinalRing Spermatic Cord

InferiorEpigastric Vessels

ReflectedExternalObliqueAponeurosis

External ObliqueMuscle

Figure 1 Shown is the relationship of the great muscles to the groin.

Transversalis Fascia

The transversalis fascia lies just superfi cial to the perito-neum and forms the iliopectineal arch, the iliopubic tract, and the crura of the deep inguinal ring. The latter forms a sling around the deep inguinal ring. This sling has function-al signifi cance in that as the crura of the ring are pulled upward and laterally by the contraction of the transversus abdominis, a valvular action is generated that helps pre-clude indirect hernia formation. The iliopubic tract is the thickened band of the transversalis fascia that courses paral-lel to the more superfi cially located inguinal ligament. It is attached to the iliac crest laterally and inserts on the pubic tubercle medially. The insertion curves inferolaterally for 1 to 2 cm along the pectineal line of the pubis to blend with the Cooper ligament, ending at the midportion of the superior pubic ramus.

Rectus Abdominis

The rectus abdominis is the central anchoring mass of the abdominal wall. It arises from the fi fth through seventh costal cartilages and inserts on the pubic symphysis and the pubic crest.

Femoral Area

Inferior to the iliopubic tract, midway along the inguinal ligament, is the femoral sheath, containing the femoral artery and branch of the genitofemoral nerve, the femoral vein, and the femoral canal. The latter is a 1 to 2 cm blind pouch that begins at the femoral ring and extends to the level of the fossa ovalis. The femoral ring is bordered by the superior pubic ramus inferiorly, the femoral vein laterally,

and the iliopubic tract (with its curved insertion onto the pubic ramus) anteriorly and medially. The femoral canal, which normally contains preperitoneal fat and lymph nodes, is the site of femoral hernias when a peritoneal sac protrudes through its ring.

nerves

The seventh through 12th intercostal nerves and the fi rst and second lumbar nerves provide most of the innervation for the anterior wall muscles and overlying skin [see Figure 2].

Genitofemoral Nerve

Arising from the fi rst and second lumbar nerves, the genitofemoral nerve pierces the psoas muscle and fascia at its medial border, descends under the peritoneum on the psoas major, and divides into a medial genital and a lateral femoral branch. The femoral branch descends lateral to the external iliac artery and spermatic cord, passing posteroin-ferior to the iliopubic tract and into the femoral sheath to supply the skin over the femoral triangle. The genital branch crosses the lower end of the external iliac artery and enters the inguinal canal through the internal inguinal ring with the testicular vessels. This branch supplies the coverings of the spermatic cord down to the skin of the scrotum. The genitofemoral nerve is the most visible of the cutaneous nerves and is sometimes confused with the testicular vessels if the latter are not well appreciated in their more medial position.

Ilioinguinal and Iliohypogastric Nerves

These nerves arise from the 12th thoracic and fi rst lumbar nerve roots, run subperitoneally, and emerge from the lateral psoas border to pierce the transversus abdominis near the iliac crest. They course between the external and internal oblique muscles above the internal inguinal ring. The ilioinguinal nerve runs parallel to the spermatic cord and innervates a small cutaneous area near the external genitals, whereas the iliohypogastric nerve pierces the external oblique muscle to innervate the skin above the pubis.

Lateral Cutaneous Nerve of the Thigh

Arising from the second and third lumbar nerves, the lateral cutaneous nerve descends deep to the peritoneum on the iliac muscle and comes to lie in a superfi cial position only 3 cm below the anterosuperior iliac spine. It innervates the front and lateral aspects of the thigh.

preperitoneal space

Deep to the transversalis fascia and superfi cial to the peri-toneum, the preperitoneal space is known as the space of Retzius in the midline behind the pubis and the space of Bogros, laterally. This is the space that is accessed for laparoscopic repairs [see Figure 3]. The surgical perspective on the pelvic anatomy from the intraperitoneal view has been elegantly described by Skandalakis and colleagues6 and Spaw and colleagues,7 whose work forms the basis of the descriptions we present in this chapter. Excellent descriptions of the preperitoneal space by Wantz8 and Condon9 are also worthy of review.

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Figure 2 Shown are the (a) important nerves of the lower abdominal wall and (b) anatomy of the nerves in the inguinal region as seen during the open anterior approach.

Quadratus LumborumMuscle

lliohypogastricNerve

L3

Genitofemoral Nerve

Sympathetic Trunk

Psoas Muscle

Genital Branchof GenitofemoralNerve

Iliohypogastric Nerve

Ilioinguinal Nerve

ExternalSpermatic NerveFemoral Branch

of GenitofemoralNerve

Lateral FemoralCutaneous Nerve

llioinguinalNerve

a b

External SpermaticVessels

IlioinguinalNerve

Genital Branch ofGenitofemoral Nerve

Internal ObliqueMuscle andAponeurosis

External ObliqueAponeurosis

Iliohypogastric Nerve

Medial Umbilical Ligament

The medial umbilical ligament is an unfamiliar but some-times prominent structure that is seen in the transabdominal preperitoneal (TAPP) approach. It courses along the anterior abdominal wall toward the umbilicus, often with an appar-ent mesentery. It is most prominent in the region of the medial inguinal space. This ligament is most readily identi-fi ed when the umbilical laparoscope is directed toward the pelvic midline, where the ligament’s bilateral structure is best seen as it is oriented toward the umbilicus. Medial retraction of this structure is usually necessary for full exposure of the medial aspect of the inguinal canal.

Spermatic Cord Structures

The testicular artery and vein descend from the retroperi-toneum, travel directly over and slightly lateral to the external iliac artery, and enter the internal spermatic ring posteriorly. These vessels are covered only by the peritone-um and are usually well visualized as fl at structures in the abdominal cavity that assume a cordlike appearance when joined by the vas deferens immediately before entering the internal spermatic ring. The vas deferens is best identifi ed where it joins the spermatic vessels. From there, the vas deferens can be traced back medially as it courses over the pelvic brim and falls into the pelvis and behind the bladder.

Inferior Epigastric Vessels

The inferior epigastric artery and vein lie on the medial aspect of the internal inguinal ring and ascend the deep surface of the rectus abdominis. In the TAPP approach, these vessels may be diffi cult to visualize, particularly in obese patients. They are best identifi ed by locating the internal inguinal ring at the junction of the vas deferens and the

testicular artery and vein. At this location, the vessels exit the medial margin of the internal ring. However, they can quickly fade from view as they travel superiorly and medi-ally along the anterior abdominal wall. Corona mortis is a vascular communication between the obturator artery and the inferior epigastric artery found in 20% of patients [see Figure 4].

Cooper Ligament

The Cooper ligament is a condensation of the transversalis fascia and the periosteum of the superior pubic ramus lat-eral to the pubic tubercle. It can be seen only in the preperi-toneal space. With the peritoneum intact, it is often easier to palpate the ligament than to see it, but once the ligament has been identifi ed and cleaned, its glistening white fi bers are apparent. Care must be taken during dissection to avoid the tiny branches of the obturator vein that often run along the ligament’s surface. The iliopubic tract inserts into the supe-rior ramus of the pubis just lateral to the Cooper ligament, blending into it.

Internal Inguinal Ring

The medial border of the internal inguinal ring is formed by the transversalis fascia and the inferior epigastric vessels. The inferior border is formed by the iliopubic tract and, anteriorly, is bordered by the transversus abdominis arch, which passes laterally over the internal ring and forms a very well-defi ned visible edge. The layers of the abdominal wall constituting the lateral border of the internal inguinal ring appear the same as when viewed from the exterior approach. An indirect hernia sac lies anterior and lateral to the spermatic cord at this level as opposed to the familiar medial cord position seen in the classic exterior groin approach to open herniorrhaphy.


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either anterior or superior to it. Conversely, femoral hernias occur below the tract, either posterior or inferior to it. Fibers of the iliopubic tract extend into the Cooper ligament medi-ally, where they become the medial margin of the femoral canal, also called the lacunar ligament.

Triangle of Doom

The lateral spermatic vessels and the medial vas deferens merge at the internal inguinal ring, where they form the apex of the so-called triangle of doom [see Figure 5]. Beneath this triangle lie the external iliac vessels. They are often poorly visualized, and extreme care must be taken not to extend dissection into this area.

Another area worthy of careful attention is the triangle of pain [see Figure 5], situated inferior to the iliopubic tract and bordered medially by the spermatic vessels. Using tacks within this triangle risks injury to the genital branch of the genitofemoral, iliohypogastric, and lateral cutaneous nerves of the thigh, a cause of postherniorrhaphy neuralgia.

Operative Planning

choice of anesthetic

The open approach to inguinal hernia repair lends itself well to many different anesthetic techniques. Depending on the setting and on patient and physician preferences, the procedure can be undertaken under general, regional (spinal or epidural), or local anesthesia. The need for pneumoperi-toneum and thus for general anesthesia in laparoscopic her-niorrhaphy is sometimes considered a major disadvantage. Nausea, dizziness, and headache are more common in the recovery room after TAPP repair than after Lichtenstein repair.10 It is not necessarily true, however, that local or regional anesthesia is safer than general anesthesia.11 For open repair, local anesthesia or general anesthesia with short-acting agents avoids the higher risk of urinary reten-tion associated with spinal anesthesia while maintaining the benefi ts of rapid recovery.12 If general or regional anesthesia is chosen, a local anesthetic is injected in the groin incision.

Figure 3 (a) Shown is the anatomy of the right groin from the posterior, or peritoneal, approach. (b) Shown is a laparoscopic view of the anatomy of the left groin with the peritoneum intact in a patient without a hernia. IEV = inferior epigastric vessels; IR = internal ring; MUL = medial umbilical ligament; TV = testicular vessels; VD = vas deferens.

Figure 4 Laparoscopic view of left groin. The corona mortis is demonstrated here coursing over Cooper ligament.

Iliopubic Tract

Frequently confused with the inguinal ligament, which is part of the superfi cial musculoaponeurotic layer and not seen posteriorly, the iliopubic tract is part of the deep layer. All inguinal hernia defects lie above the iliopubic tract,

Cooper LigamentCorona Mortis

Inferior Epigastric Artery

Transversus AbdominisAponeurosis Arch

TransverseFascia Sling

SpermaticCordSemicircular Line

Henle’s Ligament

Cooper LigamentExternal Iliac Vessels

Iliopubic Tract

a

b


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For open anterior repair, local anesthesia combined with intravenous (IV) infusion of a rapid-acting, short-lasting, amnesic, and anxiolytic agent (e.g., propofol) is a popular anesthetic option that may minimize many of the systemic side effects or complications. In addition to a fi eld block injected in the subcutaneous and deeper tissues in the area of the proposed incision, a nerve block is performed by injecting the anesthetic of choice 1 cm medial and 1 cm infe-rior to the anterosuperior iliac spine, as well as by injecting the areas of the pubic tubercle and the Cooper ligament.

choice of prosthetic mesh

For most abdominal wall hernias, the procedure of choice includes the use of a prosthetic mesh. A detailed discussion comparing various prosthetic materials is beyond the scope of this chapter; however, some general statements may be made. North American surgeons tend to favor polypropyl-ene, whereas Europeans are more likely to employ polyester mesh, although this distinction has begun to blur. The use of prosthetic mesh presupposes that the prosthesis can be isolated from the intra-abdominal viscera either by human tissue (e.g., peritoneum), by nonmesh material such as expanded polytetrafl uoroethylene (ePTFE), or by an added adhesive coating barrier [see Table 2]. The standard technique in inguinal hernia repair includes the use of tension-free mesh, which has been shown to minimize recurrences.13 On the other hand, chronic postoperative pain and dysesthesia remain problematic. Effi cacy of mesh repair is based on strengthening of weakened abdominal wall tissue by a strong mesh aponeurosis scar tissue (MAST) complex,14 through a mesh-induced infl ammatory response. The fi rst-generation polypropylene meshes contained too much for-eign tissue and led to chronic pain and stiffness in and around the site of foreign mesh placement. This led to the

development of lightweight mesh as new studies suggest a correlation between the polypropylene amount, structure of meshes, and postoperative quality of life.15 Lightweight meshes are associated with less scar tissue, less restriction of abdominal wall movement, and less postoperative pain.16 The concern with the use of lightweight meshes has been a reported higher recurrence rate. A recent meta-analysis compared the outcome of lightweight mesh and heavy-weight mesh in the repair of inguinal hernia and concluded that there was no difference in the incidence of seroma, infection, and testicular atrophy.17 There was no statistical difference in overall postoperative recurrence between light-weight and heavyweight mesh in inguinal hernia repair according to this meta-analysis, although it was noted that in large indirect and direct hernias, use of lightweight mesh did result in a higher recurrence (six times higher incidence of recurrence with lightweight mesh). This was attributed to the insuffi cient friction and stiffness of the lightweight mesh, which caused the mesh to slip in larger hernias. The authors of this study pointed out that for larger hernias, reduction of recurrence with the use of lightweight mesh was possible if more fi xations were employed. Finally, lightweight mesh was also associated with less chronic postoperative pain and feeling of a foreign body.18

Operative Techniques

There are a great deal of described techniques for inguinal hernia repair, both open and laparoscopic, and a degree of controversy remains regarding the ideal approach to and outcome for inguinal hernia repair. The evidence supports the use of mesh as it is associated with a signifi cant reduc-tion in the risk of recurrence between 50 and 75%.19 With the evolution of the open anterior approach to tension-free

TransversusAbdominis Muscle

Internal Ring Inferior Epigastric Vessels

Rectus AbdominisMuscle

Iliopubic Tract

Pubic Tubercle

Femoral Ring

Cooper Ligament

External Iliac Artery

TRIANGLE OFDOOM

TRIANGLE OFPAIN

External Iliac Vein

HESSELBACHTRIANGLE

Vas Deferens

Testicular Artery

Testicular Vein

Iliacus Muscle

Psoas MajorMuscle

Figure 5 Shown is the left inguinal region with the peritoneum removed, as seen during laparoscopic inguinal hernia repair. The “triangle of doom” contains the external iliac vessels. The “triangle of pain” is an area that must be paid attention to during repair as multiple sensory nerves run in this area and may cause signifi cant postoperative neuralgia if injured.


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prosthetic mesh repair, determining which patients will benefi t signifi cantly from laparoscopic herniorrhaphy has become increasingly important. Patients are well served when a surgeon has several approaches at his or her com-mand that can be applied to and, if necessary, modifi ed for individual circumstances.

Practical considerations do not allow a description of every single named inguinal hernia repair in the literature. The nonprosthetic named repairs alone number more than 70.20 Rather than address every known variant, we describe the major repairs appropriate for adults on which these variants are based.

general indications for surgical repair

The general indications for inguinal hernia repair are the same as for open and laparoscopic approaches, with the alternative to surgical management being watchful waiting. Many surgeons consider the presence of an inguinal hernia to be reason enough to operate; however, recent studies have shown that the presence of a reducible, asymptomatic inguinal hernia in males is not an indication to operate as the incarceration rate is less than 1%.21 Two trials were conducted to study the effects of watchful waiting for asymptomatic hernias and found that after long-term follow-up, there was no signifi cant difference in hernia-related symptomatology.22,23 Another long-term follow-up study determined that most patients with an asymptomatic groin hernia eventually develop symptoms and should be offered surgical repair if they are medically fi t.24

For laparoscopic repair options, the National Institute for Health and Clinical Excellence (NICE) of the United Kingdom’s National Health Service has offered a set of guidelines for the use of laparoscopic inguinal hernia repair. Their specifi c indications for laparoscopy over open repair are recurrent hernias, bilateral hernias, the need for earlier return to full activities, the patient’s medical fi tness to with-stand anesthesia, the personal choice of the patient, and the surgeon’s experience.25 In choosing between open and laparoscopic surgery, the following are considered:

• The suitability of the individual for general anesthesia• The nature of the presenting hernia

• The suitability of the particular hernia for a laparoscopic or open repair

• The experience and comfort level of the surgeon in the available technique options

anterior herniorrhaphy

Step 1: Initial Incision

Traditionally, the skin is opened by making an oblique incision between the anterosuperior iliac spine and the pubic tubercle. For cosmetic reasons, however, many sur-geons now prefer a more horizontal skin incision placed in the natural skin lines. In either case, the incision is deepened through Scarpa fasciae and the subcutaneous tissue to expose the external oblique aponeurosis. The external oblique aponeurosis is then opened through the external inguinal ring. If a prosthesis is to be used, a space is created beneath the external oblique aponeurosis from the anterior rectus sheath medially toward the anterosuperior iliac spine laterally. The iliohypogastric, ilioinguinal, and genital nerves should be identifi ed and protected. Efforts to mobilize these structures out of the operative fi eld may increase postopera-tive groin pain.20 Although identifi cation of the nerves is important, routine division of the iliohypogastric and ilioin-guinal nerves does not seem to be consistently associated with postoperative groin pain either way.26

Step 2: Mobilization of the Cord Structures

The cord structures are bluntly dissected away from the inferior fl ap of the external oblique aponeurosis to expose the inguinal ligament (shelving edge) and the iliopubic tract. This dissection is continued over the pubic tubercle and onto the anterior rectus sheath. The cord structures are then lifted with the fi ngers of one hand at the pubic tubercle so that the index fi nger can be passed underneath to meet the ipsilat-eral thumb or the fi ngers of the other hand. Mobilization of the cord structures is completed by means of blunt dissec-tion, and a Penrose drain is placed around them so that they can be retracted during the procedure. The cremasteric muscle is then opened longitudinally rather than completely divided; this reduces the chances of damage to the cord and prevents testicular descent.

Step 3: Management of the Hernia Sac

The indirect hernia sac, if present, is located anterior and medial to the cord structures. The sac is dissected free of the cord structures by peeling away or dividing the adhesions between them. The sac can then be ligated and divided but, in adults, is preferably simply reduced into the peritoneal cavity. Proponents of sac inversion believe that this measure results in less pain (because the richly innervated peritone-um is not incised) and may be less likely to cause adhesive complications. Furthermore, sac eversion in lieu of excision protects intra-abdominal viscera in cases of unrecognized incarcerated sac contents or sliding hernia. For large ingui-nal scrotal hernial sacs, it may be preferential to divide the sac in the middle of the inguinal canal once it is clear that no abdominal contents are present rather than persist at full removal of the sac from the scrotum. The anterior wall of the distal sac is opened as far as possible, and the proximal sac is closed and reduced into the peritoneal cavity.

Table 2 Commercially Available Synthetic Prostheses for Inguinal Hernia Repair

Polypropylene/polyesterBard Composix E/X Mesh (PPL + ePTFE)Sofradim Parietene (PPL + hydrophilic collagen)Sofradim Parietex (PPL + hydrophilic collagen)Genzyme Sepramesh (PPL + Seprafilm)Ethicon Prolene Soft Mesh (PPL)Ethicon Proceed (PPL + PDS + ORC)Ethicon Ultrapro (PPL + poliglecaprone 25)Ethicon Vicryl Knitted MeshGore-Tex Soft Tissue Patch (ePTFE)Gore-Tex DualMesh (ePTFE)Gore-Tex DualMesh Plus (ePTFE + silver + chlorhexidine)Gore-Tex MycroMesh (ePTFE)

ePTFE = expanded polytetrafl uoroethylene; ORC = oxidized regenerated cellulose; PPL = polypropylene.


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Direct hernia sacs are separated from the cord and other surrounding structures and reduced into the preperitoneal space. Dividing the superfi cial layers of the neck of the sac circumferentially—thereby, in effect, opening the inguinal fl oor—usually facilitates reduction and helps maintain it while the prosthesis is being placed. The opening in the in-guinal fl oor also allows the surgeon to palpate for a femoral hernia. Sutures can be used to maintain reduction of the sac, but they have no real strength in this setting.

Step 4: Repair of the Inguinal Floor

Methods of repairing the inguinal fl oor differ signifi cantly among the various anterior herniorrhaphies and thus are described separately below.

Step 5: Closure

Closure of the external oblique fascia serves to reconstruct the superfi cial (external) ring. The external ring must be loose enough to prevent strangulation of the cord structures yet tight enough to ensure that an inexperienced examiner will not confuse a dilated ring with a recurrence. Scarpa fascia and the skin are closed with resorbable sutures.

tissue repairs

Bassini Repair

After performing the initial dissection and the reduction or ligation of the sac, the transversalis fascia is opened from the internal inguinal ring to the pubic tubercle, thereby exposing the preperitoneal fat, which is then bluntly dis-sected away from the undersurface of the superior fl ap of the transversalis fascia [see Figure 6a].

A relaxing incision was not part of Bassini’s original description but now is commonly added. The incision is made through the anterior rectus sheath, extending superi-orly from the pubic tubercle for a variable distance, as determined by the degree of tension present. A so-called hockey-stick incision oriented laterally at the superior end is a common choice. The posterior rectus sheath is strong enough to prevent future incisional herniation. The relaxing incision works because as the anterior rectus sheath sepa-rates, the various components of the abdominal wall are displaced laterally and inferiorly.

The fi rst stitch in Bassini’s repair includes the triple layer (comprising the transversalis fascia, the transversus abdom-inis, and the internal oblique muscle) superiorly and the periosteum of the medial side of the pubic tubercle, along with the rectus sheath. In current practice, however, most surgeons try to avoid the periosteum of the pubic tubercle so as to decrease the incidence of osteitis pubis. The repair is then continued laterally, and the triple layer is secured to the refl ected inguinal ligament (Poupart ligament) with nonabsorbable sutures. The sutures are continued until the internal ring is closed on its medial side [see Figure 6b].

Concerns about injuries to neurovascular structures in the preperitoneal space and to the bladder led many surgeons, especially in North America, to abandon the opening of the transversalis fascia. The unfortunate consequence of this decision is that the proper development of the triple layer is severely compromised. In lieu of opening the fl oor, a forceps (e.g., an Allis clamp) is used to grasp tissue blindly in the hope of including the transversalis fascia and the transver-sus abdominis. The layer is then sutured, along with the

Figure 6 Bassini repair. (a) The transversalis fascia has been opened and the preperitoneal fat stripped away to prepare the deepest structure in the Bassini triple layer (comprising the transversalis fascia, the transversus abdominis, and the internal oblique muscle). (b) The triple layer superiorly is approximated to the inguinal ligament, beginning medially at the pubic tubercle and extending laterally until the deep inguinal ring is suffi ciently narrowed.

TransversusAbdominis

TransversalisFascia

Internal ObliqueMuscle

a b


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internal oblique muscle, to the refl ected inguinal ligament as in the classic Bassini repair.

Shouldice Repair

The initial steps proceed as per the Bassini repair, includ-ing division of the transversalis fascia and relaxing incision. A continuous nonabsorbable suture (traditionally monofi la-ment steel wire) is used for the repair. Eventually, four suture line layers are placed. The repair starts at the pubic tubercle by approximating the iliopubic tract laterally to the undersurface of the lateral edge of the rectus abdominis [see Figure 7a]. The suture is continued laterally, approximating the iliopubic tract to the medial fl ap, which is made up of the transversalis fascia, the internal oblique muscle, and the transversus abdominis. The continuous suture is extended to the internal ring, where the lateral stump of the cremaster muscle is picked up to form a new internal ring. Next, the direction of the suture is reversed back toward the pubic tubercle, approximating the medial edges of the internal oblique muscle and the transversus abdominis to the Poup-art ligament, and the wire is tied to itself and then the fi rst knot [see Figure 7b]. Thus, two suture lines are formed by the fi rst suture.

A second suture is started near the internal ring, approxi-mating the internal oblique muscle and the transversus abdominis to a band of external oblique aponeurosis super-fi cial and parallel to the Poupart ligament. This third suture

line ends at the pubic crest. The suture is then reversed, and a fourth suture line is constructed in a similar manner, superfi cial to the third line.

Although the Shouldice clinic has outstanding results, a major criticism of this operation is that the results may not be reproducible in general practice because surgeons may fi nd it hard to identify the various layers in the medial fl ap reliably—a step that is crucial for developing the multiple suture lines.

McVay Cooper Ligament Repair

This operation is similar to the Bassini repair, except that it uses the Cooper ligament instead of the inguinal ligament for the medial portion of the repair. Interrupted sutures are placed from the pubic tubercle laterally along the Cooper ligament, progressively narrowing the femoral ring; this constitutes the most common application of the repair—namely, treatment of a femoral hernia [see Figure 8]. The last stitch in the Cooper ligament is known as a transition stitch and includes the inguinal ligament. This stitch has two purposes: (1) to complete the narrowing of the femoral ring by approximating the inguinal ligament to the Cooper liga-ment, as well as to the medial tissue, and (2) to provide a smooth transition to the inguinal ligament over the femoral vessel so that the repair can be continued laterally (as in a Bassini repair). Given the considerable tension required to bridge such a large distance, a relaxing incision (as described

Figure 7 Shouldice repair. (a) The fi rst suture line starts at the pubic tubercle by approximating the iliopubic tract to the undersurface of the lateral edge of the rectus abdominis. The suture is continued laterally, approximating to the medial fl ap (made up of the transversalis fascia, the internal oblique muscle, and the transversus abdominis). (b) The second suture line begins after the stump of the divided cremaster muscle has been picked up. The direction of the suture is reversed back toward the pubic tubercle, approximating the medial edges of the internal oblique muscle and the transversus abdominis to the Poupart ligament. Two more suture lines will be constructed by approximating the internal oblique muscle and the transversus abdominis to a band of the inferior fl ap of the external oblique aponeurosis superfi cial and parallel to the Poupart ligament—in effect, creating a second and a third artifi cial Poupart ligament.

a b


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A slit is made on the lateral side of the prosthesis to create two tails: a wider one (approximately two thirds of the total height) above and a narrower one below. The tails are positioned around the cord structures and placed beneath the external oblique aponeurosis laterally to about the anterosuperior iliac spine, with the upper tail placed on top of the lower. A single interrupted suture is placed to secure the lower edge of the superior tail to the lower edge of the inferior tail and the inguinal ligament—thereby, in effect, creating a shutter valve. This step is considered important for preventing indirect recurrences. The maneuver provides a cradling effect as well, preventing direct contact between the cut edges of the prosthesis and the cord structures, which could result in damage when linear approximation is used. The suture also incorporates the shelving edge of the ingui-nal ligament so as to create a domelike buckling effect over the direct space, thereby ensuring that there is no tension, especially when the patient assumes an upright position.

Two interrupted sutures are placed to attach the superior aspect of the mesh to the internal oblique aponeurosis and rectus fascia. Care is taken to tie these loosely and to avoid placing them laterally so as to minimize the risk of damag-ing the intramuscular and therefore invisible portions of the important nerves. The prosthesis should be sutured with enough laxity to allow for the difference between the supine and upright positions and, more importantly, to account for contraction of the mesh.

in the Bassini repair) should always be used. In the view of many authorities, this tension results in more pain than is noted with other herniorrhaphies and predisposes to recur-rence. For this reason, the McVay repair is rarely chosen today, the main exception being for treatment of a patient with a femoral hernia or a patient with specifi c contraindica-tions to mesh repair.

tension-free repairs

Lichtenstein Repair

This operation is the current standard for inguinal herni-orrhaphy. The initial preparation of the inguinal fl oor does not differ substantially from that carried out in a nonpros-thetic repair. The transversalis fascia is not opened—a prac-tice that has occasionally been criticized on the grounds that it might cause an occult femoral hernia to be missed. To date, however, an excessive incidence of missed femoral hernias has not been reported in men. The situation may be different in women in that femoral recurrence is much more common than one might assume when the entire myopec-tineal orifi ce is not addressed (as is the case with the McVay procedure or any of the preperitoneal operations).27

The key to the operation is the placement of a large pros-thesis (at least 15 × 10 cm for an adult) extending from a point 2 cm medial to the pubic tubercle (to prevent the commonly seen pubic tubercle recurrences) to the anterosu-perior iliac spine laterally. The medial end is rounded to correspond to the patient’s particular anatomy, and a continuous suture of either nonabsorbable or long-lasting absorbable material is begun between the prosthesis and the anterior rectus sheath 2 cm medial to the pubic tubercle [see Figure 9]. The suture is continued laterally, securing the prosthesis to either side of the pubic tubercle (not into it) and then to the shelving edge of the inguinal ligament. The suture is tied at the internal ring.

Figure 8 McVay Cooper ligament repair. The lateral stitch is the transition stitch to the femoral sheath and the inguinal ligament.

lliohypogastricNerve

Genital Nerve

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llioinguinalNerve

Figure 9 Lichtenstein repair. A mesh prosthesis is positioned over the inguinal fl oor to extend approximately 2 cm medial to the pubic tubercle. A slit is made in the mesh to accommodate the cord struc-tures, and the two tails are secured to each other and to the shelving edge of the inguinal ligament with a single interrupted suture. The superior and medial aspects of the prosthesis are secured to the internal oblique muscle and the rectus fascia with a few interrupted sutures.


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Plug-and-Patch Repair

The mesh plug technique was fi rst developed by Gilbert and subsequently modifi ed by Millikan and colleagues and Rutkow and Robbins, among others [see Figure 10].28–30 The groin is entered via a standard anterior approach. The hernia sac is dissected away from surrounding structures and reduced into the preperitoneal space. A sheet of poly-propylene mesh is formed into a cone, tied, inserted in the defect, and secured with interrupted sutures to either the internal ring (for an indirect hernia) or the neck of the defect (for a direct hernia).

A prefabricated prosthesis that has the confi guration of a fl ower is commercially available and is recommended by Rutkow and Robbins.30 This prosthesis is tailored to each patient’s particular anatomy by removing some of the “petals” to avoid unnecessary bulk. Many surgeons consider this step important for preventing erosion into surrounding structures (e.g., the bladder); indeed, such complications have been reported, albeit rarely.

Millikan and colleagues further modifi ed the procedure by recommending that the inside petals be sewn to the ring of the defect.29 For an indirect hernia, the inside pedals are sewn to the internal oblique portion of the internal ring; this forces the outside of the prosthesis underneath the inner side of the defect and makes it act like a preperitoneal underlay. For direct hernias, the inside petals are sewn to the Cooper ligament and the shelving edge of the inguinal ligament, as well as to the conjoined tendon; this, again, forces the outside of the prosthesis to act as an underlay.

The patch portion of the procedure is optional and involves placing a fl at piece of polypropylene in the conven-tional inguinal space so that it widely overlaps the plug, much as in a Lichtenstein repair. The difference with a plug-and-patch repair is that only one or two sutures—or, some-times, no sutures—are used to secure the fl at prosthesis to the underlying inguinal fl oor. Some surgeons, however, place so many sutures that they have, in effect, performed a Lichtenstein operation on top of the plug.

The plug-and-patch repair, in all of its varieties, is fast and easy to teach, which has made it popular in both private and academic centers. A randomized, controlled trial has shown it to be equivalent to the Lichtenstein repair in terms of recurrence and morbidity.31 However, case reports in the literature have described removal of plugs for pain, migra-tion, or erosion, and, as a result, the benefi ts of the plug-and-patch repair compared with those of the Lichtenstein repair have been scrutinized.

Femoral Hernia Repair

Femoral hernias in females can be approached using a groin incision with dissection beneath the inguinal ligament without opening the external oblique fascia. To facilitate reduction of the contents of the hernia, the femoral canal may need to be opened by dividing the inguinal ligament and/or lacunar ligament. The defect can be closed with sutures or with a mesh plug from below the inguinal liga-ment [see Figure 11]. Larger femoral hernias in females and femoral hernias in males are better repaired using a McVay Cooper ligament repair.

posterior (preperitoneal) herniorrhaphy

A key technical issue in a preperitoneal hernia repair is how the surgeon chooses to enter the preperitoneal space. In fact, within this general class of repair, the method of entry into this space constitutes the major difference between the various procedures as all the repairs involve placement of a large prosthesis in the preperitoneal space. The theoretical advantage of this measure is that whereas in a conventional repair, abdominal pressure might contribute to recurrence, in a preperitoneal repair, the abdominal pressure would help fi x the mesh material against the abdominal wall, thereby adding strength to the repair.

The preperitoneal space may be entered using an open or laparoscopic approach. The two principal laparoscopic techniques are the TAPP and total extraperitoneal (TEP) laparoscopic repairs. Although the laparoscopic repairs are the most prevalent posterior repairs at this time, the major open approaches are also described.

TAPP Repair

Step 1: trocar placement Pneumoperitoneum is estab-lished through a small infraumbilical incision. We generally prefer an open technique, in which a blunt-tipped 12 mm tro-car is inserted into the peritoneal cavity under direct vision. CO2 is then insufflated into the abdomen to a pressure of 12 to 15 mm Hg. The angled laparoscope is introduced, and both inguinal areas are inspected. Two 5 mm ports are placed, one at the lateral border of each rectus abdominis at the level of the umbilicus.

Figure 10 Gilbert plug-and-patch repair. Depicted is the mesh plug technique for repair of an inguinal hernia. A sheet of polypropylene mesh is formed into a cone (as shown here), inserted into the defect, and secured to either the internal ring (arrow) (for an indirect hernia) or the neck of the defect (for a direct hernia) with interrupted sutures. Prefabricated mesh plugs are also available.


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Figure 4]. In the TAPP approach, an indirect hernia, if pres-ent, will be immediately apparent and will have an obvious opening. The internal inguinal ring is then easily identified by the presence of a discrete hole lateral to the junction of the vas deferens, the testicular vessels, and the inferior epigastric vessels. Identification of a direct hernia can be more difficult. Sometimes a direct hernia appears as a complete circle or hole; at other times, it appears as a cleft, medial to the vas deferens–vascular junction; and at still other times, it is completely hidden by preperitoneal fat and the bladder and umbilical ligaments. Visualization can be particularly diffi-cult in obese patients, who may have considerable lipoma-tous tissue between the peritoneum and the transversalis fascia, or in patients whose hernia consists of a weakness and bulging of the entire inguinal floor rather than a distinct sac.

For adequate defi nition of this type of hernia and deeper anatomic structures, the peritoneum must be opened, a peritoneal fl ap developed, and the underlying fatty layer dissected.32 Traction on the ipsilateral testicle can demon-strate the vas deferens when visualization is obscured by overlying fat or pressure from the pneumoperitoneum.

Step 3: Creation of peritoneal flap The curved scissors or the hook cautery is used to create a peritoneal flap by making a transverse incision along the peritoneum, begin-ning several centimeters above the upper border of the inter-nal inguinal ring and extending medially above the pubic tubercle and laterally at least 5 cm beyond the internal ingui-nal ring or to the level of the ipsilateral trocar [see Figure 12]. Care must be taken to avoid the inferior epigastric vessels. Bleeding from these vessels can usually be controlled by cauterization, but application of hemostatic clips may be nec-essary on occasion. Another solution is to pass percutane-ously placed sutures above and below the bleeding point while applying pressure to the bleeding vessel so as not to obscure the field of vision. Division of the ipsilateral umbili-cal ligament may be useful in creating an appropriate medial space; however, the surgeon should be aware that the oblit-erated umbilical artery may still be patent and that use of the electrocautery or clips is prudent.

The incised peritoneum is grasped along with the attached preperitoneal fat and the peritoneal sac and is dissected cephalad with blunt and sharp instruments to create a lower peritoneal fl ap. Dissection should stay close to the abdomi-nal wall. A signifi cant amount of preperitoneal fat may be encountered, and this should remain with the peritoneal fl ap so that the abdominal wall is cleared. When the correct preperitoneal plane is entered, dissection is almost bloodless and is easily carried out.

Step 4: dissection of hernia sac The hernia sac, if pres-ent, is removed from the Hesselbach triangle or the spermat-ic cord and surrounding muscle through inward traction, countertraction, and blunt dissection with progressive inversion of the sac until the musculofascial boundary of the internal inguinal ring and the key deep anatomic structures are identified. In most cases, the hernia sac can be slowly drawn away from the transversalis fascia or the spermatic cord [see Figure 13]. The indirect sac may be visualized more easily if it is grasped and retracted medially; this step facilitates its dissection away from the cord structures.

a

b

c

Figure 11 Femoral hernia repair in females. The femoral canal is opened by dividing the inguinal ligament, the lacunar ligament, or both to allow for reduction of the hernia contents (a). The repair is then accomplished with sutures (b) or a mesh plug (c).

Step 2: Identification of anatomic landmarks Four important landmarks should be seen initially during laparo-scopic inspection of the inguinal region: the spermatic vessels, the obliterated umbilical artery (also referred to as the medial umbilical ligament or the bladder ligament), the inferior epigastric vessels (also referred to as the lateral umbilical ligament), and the external iliac vessels [see


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Spermatic cord lipomas usually lie posterolaterally and are extensions of preperitoneal fat. In the presence of an indirect defect, such lipomas should be dissected off the cord along with the peritoneal fl ap to lie cephalad to the internal inguinal ring and the subsequent repair so that pro-lapse through the ring can be prevented. A large indirect

Figure 12 Shown is the trocar placement for (a) laparoscopic transabdominal preperitoneal (TAPP) repair and (b) laparoscopic total extraperi-toneal (TEP) repair.

Figure 13 Laparoscopic inguinal hernia repair: transversalis fascia. The transversalis fascia is seen adherent to the hernia sac. The sac must be separated from the fascia and dissected cephalad.

hernia sac can be divided at the internal ring if it cannot be readily dissected away from the cord structures. This step may prevent cord injury that can result from extensive dissection.

The pubic tubercle is often more easily felt than seen. The Cooper ligament is initially felt and subsequently seen along the pectineal prominence of the superior pubic ramus as dissection continues medially and fatty tissue is swept off to expose the glistening white structure. Care must be taken to avoid the numerous small veins that often run on the surface of the ligament, as well as to avoid the occasional aberrant obturator artery. The iliopubic tract is initially identifi ed at the inferior margin of the internal inguinal ring, with the spermatic cord above, and is then followed in both a medial and a lateral direction. Minimal dissection is carried out inferior to the iliopubic tract so as to avoid neurovascular injuries.

Step 5: mesh placement A 15 × 10 cm sheet of polypro-pylene or polyester mesh is rolled into a tubular shape and introduced into the abdomen through the 10/12 mm umbili-cal trocar. The mesh is used to cover the direct, indirect, and femoral spaces (i.e., the entire inguinal floor). Some form of mesh fixation should be used, either tacks or fibrin glue. Our preference is to use absorbable tacks. Medially, tacks are placed in the Cooper ligament. A two-handed technique is recommended for lateral tack placement: one hand is on the tacker, and the other is on the abdominal wall, applying


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external pressure to place the wall against the tacker. Care must be taken not to force the tacker too deeply into the abdominal wall superolateral to the spermatic cord; doing so might lead to inadvertent entrapment of the sensory nerves. The tacker can be moved from the left to the right port, depending on which position more readily allows placement of the staples perpendicular to the mesh and the abdominal wall. Lateral to the cord structures, all tacks are placed supe-rior to the iliopubic tract to prevent subsequent neuralgias involving the lateral cutaneous nerve of the thigh or the branches of the genitofemoral nerve. If the surgeon can palpate the tacker through the abdominal wall with the nondominant hand, the tacker is above the iliopubic tract. The mesh should lie flat.

Step 6: closure The peritoneal flap, including the redun-dant inverted hernia sac, is placed over the mesh, and the peritoneum is reapproximated with tacks or sutures along its superior edge [see Figure 14]. Inferior epigastric vessels must be avoided. Reduction of the intra-abdominal pressure to 8 mm Hg, coupled with external abdominal wall pressure, facilitates a tension-free reapproximation. The peritoneal repair is inspected to ensure that no major gaps might result in exposure of the mesh and subsequent formation of adhesions. The trocars are then removed under direct vision, and the pneumoperitoneum is released. The fascia at the 10/12 mm port sites is sutured closed, and the skin is closed with 4-0 absorbable subcuticular sutures.

TEP Repair

The extra-abdominal preperitoneal approach to laparo-scopic hernia repair, developed by McKernan and Laws,33,34 attempts to duplicate the open preperitoneal repair described by Stoppa and colleagues35–37 and Wantz.8,38 In a TEP repair, the trocars are placed preperitoneally in a space created between the fascia and the peritoneum. Ideally, the dissection remains in the extra-abdominal plane at all times, and the peritoneum is never penetrated.

Step 1: creation of preperitoneal space With the patient in the Trendelenburg position, the anterior rectus fascia is

opened through a 1 cm infraumbilical transverse incision placed slightly toward the side of the hernia, which helps prevent inadvertent opening of the peritoneum. The rectus is retracted laterally and a narrow retractor is slid over the posterior rectus sheath. In this plane, a preperitoneal tunnel between the rectus muscles and the peritoneum is created in the midline by inserting a dissecting balloon to the level of the symphysis pubis. The preperitoneal working space is developed by gradual inflation of the balloon to a volume of 1 L or until the creases in the balloon are effaced. This is done under direct vision using a 30° or 45° laparoscope as the transparency of the balloon permits constant laparoscopic visualization throughout the distention process. The balloon is then withdrawn and replaced with a 10/12 mm balloon-tipped trocar. Maximal inflation pressure is 10 to 15 mm Hg to prevent disruption of the peritoneum or development of extensive subcutaneous emphysema. Blunt, gentle dissection with the laparoscope can be employed to develop the space sufficiently to allow placement of additional trocars [see Figure 15].

Step 2: trocar placement [see Figure 12] After the perito-neum is dissected away from the rectus abdominis, a midline 5 mm trocar is inserted under direct vision three finger-breadths below the infraumbilical port. A second 5 mm tro-car is then inserted another three fingerbreadths below the first 5 mm trocar. Placement of the working trocars away from the pubis facilitates mesh placement in that the bottom port is not covered by the top of the mesh and thereby ren-dered nonfunctional. Care must be taken not to penetrate the peritoneum during trocar placement. If the peritoneum is penetrated, the resulting pneumoperitoneum can reduce the already limited working space. If the working space is compromised to the point where the repair cannot continue (which is not always the case), the surgeon can either try to repair the rent with a suture or place a Veress needle or angiocath in the upper abdominal peritoneal cavity. If such maneuvers are unsuccessful, the loss of working space may necessitate conversion to a TAPP or open approach.

Step 3: dissection of hernia sac The inferior epigastric vessels, which help guide lateral dissection and identifica-tion of the internal ring, are identified first and are kept up against the abdominal wall during peritoneal dissection. The Cooper ligament is exposed first, during which care must be taken not to injure the obturator branch that crosses it. Wide lateral dissection of the preperitoneal space is then undertaken with blunt graspers in a two-handed technique by bluntly dividing the avascular areolar tissue between the peritoneum and the abdominal wall. Proper lateral dissection is crucial to optimal mesh placement.

If a direct hernia is present medial to the inferior epigas-tric vessels, it will often be reduced by the balloon dissector. If not, the sac and the preperitoneal contents are carefully dissected away from the fascial defect and swept cephalad as far as possible. Gentle traction is applied to expose and dissect away the attachment of the peritoneum to the transversalis fascia.

The indirect space is then exposed by sweeping off the tissue lateral to the inferior epigastric vessels until the peri-toneum is found. If a lipoma of the cord is present, it will be lateral to and covering the peritoneum and should be

Figure 14 Laparoscopic inguinal hernia repair: peritoneal fl ap. The peritoneal fl ap is placed so as to entirely cover the mesh in the preperitoneal space.


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dissected out of the internal ring in a cephalad direction to prevent it from displacing the mesh.39 If there is no indirect hernia, the peritoneum will be found cephalad to the inter-nal ring. To ensure secure mesh placement, the peritoneum is bluntly dissected off the cord structures and placed as far cephalad as possible. If an indirect hernia is present, the sac will be lateral and anterior to the cord structures. These must be clearly identifi ed and protected during dissection. A small indirect hernial sac is bluntly dissected off the sper-matic cord with a hand-over-hand technique and reduced until an area suffi cient for mesh placement is created. To prevent early recurrence, all attachments of the peritoneum

Figure 15 Laparoscopic inguinal hernia repair: total extraperitoneal (TEP) approach. Shown is the preperitoneal distention balloon (PDB) system. The balloon is introduced into the preperitoneal space (a). As it is tunneled inferiorly toward the pubis, the balloon is infl ated under laparoscopic vision (b). As the balloon is infl ated, the pubic bone and peritoneal edge come into view (line and arrows) (c). Once the preperito-neal space is created, the balloon is removed and replaced with a blunt-tipped trocar. The preperitoneal space is insuffl ated under low pressure, additional trocars are placed, and the repair is begun (d).

should be dissected cephalad to where the inferior edge of the mesh will be. If a large indirect sac is not easily reduced from the scrotum, it may be transected in its superolateral edge, dissected off the cord structures, and closed with clips or a ligating loop. The distal sac is then left in place without ligation.

Unlike a TAPP repair, in which any indirect hernia pres-ent is readily apparent at fi rst inspection, a TEP repair always requires that the space lateral to the inferior epigas-tric vessels be dissected to make sure that there is no indirect component. This dissection should be done even if a direct or femoral hernia is identifi ed.

PDB

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Peritoneum

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Inflated PDB

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dc

ba

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Step 4: mesh placement A number of different prosthe-ses in a variety of contoured or flat configurations are avail-able, including various forms of polypropylene and several types of polyester. Whichever is chosen, it should be large enough (15 × 10 cm) to provide adequate coverage. A mark-ing suture is placed or a mark is made to identify the infero-medial aspect of the mesh to be placed against the Cooper ligament. The mesh is inserted through the umbilical trocar into the preperitoneal space. Once in the preperitoneal space, the mesh is manipulated to cover the pubic tubercle, the internal ring, the Cooper ligament, the femoral canal, and the rectus abdominis superiorly. The inferior edge of the mesh must be tucked behind the peritoneal reflection to prevent folding of the mesh. Tacks are placed into the Cooper liga-ment and on the superolateral edge of the mesh on the ante-rior abdominal wall. To prevent nerve injury, no tacks should be placed inferior to the iliopubic tract lateral to the internal ring.

Mesh fi xation options vary and depend on surgeon pref-erence: permanent tacks, absorbable tacks, biologic “glues,” or eliminating the use of fi xation all together. Early results of a large randomized, controlled trial studying laparoscop-ic inguinal hernia repair without use of mesh fi xation found that it was unnecessary in TEP repair of small hernial defects. Such a strategy was associated with lower operative costs and a lower incidence of chronic groin pain. The omis-sion of mesh fi xation did not increase the risk of early hernia recurrence.40 Another recent meta-analysis compared mesh fi xation using a fi brin sealant versus staple fi xation in lapa-roscopic TEP repairs and found less chronic pain and an equivalent recurrence rate in the former.41

Step 5: closure The operative site is inspected for hemo-stasis. The trocars are removed under direct vision. The insufflated CO2 is slowly released so that the mesh may be visualized as the preperitoneal fat and contents collapse back onto the mesh. The fascia at trocar sites 10 mm or larger is sutured closed, and the skin is closed with subcuticular sutures.

open posterior prosthetic repairs

For open access, the space can be entered either anteriorly or posteriorly. If an anterior technique is to be used, the initial steps of the operation are similar to those of a conven-tional anterior herniorrhaphy. If a posterior technique is to be used, any of several incisions (lower midline, para-median, or Pfannenstiel) will allow an extraperitoneal dissection. The preperitoneal space can also be entered transabdominally. This approach is useful when the patient is undergoing a laparotomy for some other condition and the hernia is to be repaired incidentally.

Read-Rives Repair

The posterior space is accessed directly through the groin; thus, the initial part of a Read-Rives repair, including the opening of the inguinal fl oor, is much like that of a classic Bassini repair. The inferior epigastric vessels are identifi ed, and the preperitoneal space is completely dissected. The spermatic cord is parietalized by separating the ductus def-erens from the spermatic vessels. A 12 × 16 cm piece of mesh is positioned in the preperitoneal space deep to the inferior epigastric vessels and secured with three sutures placed in

the pubic tubercle, in the Cooper ligament, and in the psoas muscle laterally. The transversalis fascia is closed over the prosthesis, and the cord structures are replaced.

Stoppa-Rignault-Wantz Repair (Giant Prosthetic Reinforcement of Visceral Sac)

Giant prosthetic reinforcement of the visceral sac (GPRVS) has its roots in the important contribution that Henri Fruchaud, who was Stoppa’s mentor, made to herniology. Instead of subdividing hernias into direct, indirect, and femoral and then examining their specifi c causes, Fruchaud emphasized that the common cause of all inguinal hernias was the failure of the transversalis fascia to retain the peri-toneum. This concept led Stoppa to develop GPRVS, which reestablishes the integrity of the peritoneal sac by inserting a large permanent prosthesis that entirely replaces the trans-versalis fascia over the myopectineal orifi ce of Fruchaud [see Figure 16] with wide overlapping of surrounding tissue. The technique has not gained routine acceptance in North America, however.

Step 1: Skin incision A lower midline, Pfannenstiel, or inguinal incision can be used. The inguinal incision is placed 2 to 3 cm below the level of the anterosuperior iliac spine but above the internal ring; it is begun at the midline and extended laterally for 8 to 9 cm.42

Figure 16 Depicted is the myopectineal orifi ce of Fruchaud. The area is bounded superiorly by the internal oblique muscle and the transversus abdominis, medially by the rectus abdominis and the rectu s sheath, laterally by the iliopsoas muscle, and inferiorly by the Cooper ligament. Critical anatomic landmarks (e.g., the inguinal ligament, the spermatic cord, and the femoral vessels) are contained within this structure.


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Step 2: preperitoneal dissection The fascia overlying the space of Retzius is opened without violation of the peritone-um. A combination of blunt and sharp dissection is contin-ued laterally posterior to the rectus abdominis and the inferior epigastric vessels. The preperitoneal space is com-pletely dissected to a point lateral to the anterosuperior iliac spine. The symphysis pubis, the Cooper ligament, and the iliopubic tract are identified. Inferiorly, the peritoneum is generously dissected away from the vas deferens and the internal spermatic vessels to create a large pocket, which will eventually accommodate a prosthesis. In the inguinal approach, the anterior rectus sheath and the oblique muscles are incised for the length of the skin incision. The lower flaps of these structures are retracted inferiorly toward the pubis. The transversalis fascia is incised along the lateral edge of the rectus abdominis, and the preperitoneal space is entered; dissection then proceeds as previously indicated.

Step 3: management of hernia sac Direct hernia sacs are reduced during the course of the preperitoneal dissection. Care must be taken to stay in the plane between the peritoneum and the transversalis fascia, allowing the latter structure to retract into the hernia defect toward the skin.

Indirect sacs are more diffi cult to deal with than direct sacs are in that they often adhere to the cord structures. Trauma to the cord must be minimized to prevent damage to the vas deferens or the testicular blood supply. Small sacs should be mobilized from the cord structures and reduced back into the peritoneal cavity. Large sacs may be diffi cult to mobilize from the cord without undue trauma if an attempt is made to remove the sac in its entirety. Accord-ingly, large sacs should be divided, with the distal portion left in situ and the proximal portion dissected away from the cord structures. Division of the sac is most easily accom-plished by opening the sac on the side opposite the cord structures. A fi nger is placed in the sac to facilitate its separation from the cord. Downward traction is then placed on the cord structures to reduce any excessive fatty tissue (so-called lipoma of the cord) back into the preperitoneal space. This step prevents the “pseudorecurrences” that may occur if the abnormality palpated during the preoperative physical examination was not a hernia but a lipoma of the cord.

Step 4: management of abdominal wall defect This step varies most from one author to another. In Nyhus’s approach, the defect is formally repaired, and only then is a tailored mesh prosthesis sutured to the Cooper ligament and the transversalis fascia for reinforcement. Rignault prefers to close the defect loosely to prevent an unsightly early postop-erative bulge.43 In Stoppa’s and Wantz’s techniques,36,38 the defect is usually left alone, but the transversalis fascia in the defect is occasionally plicated by suturing it to the Cooper ligament to prevent the bulge caused by a seroma in the undisturbed sac.

Step 5: parietalization of spermatic cord The term parietalization of the spermatic cord, popularized by Stoppa and Warlaumont,36 refers to a thorough dissection of the cord

aimed at providing sufficient length to permit lateral move-ment of the structure [see Figure 17]. In their view, this step is essential in that it allows a prosthesis to be placed without having to be split laterally to accommodate the cord struc-tures36; the keyhole defect created when the prosthesis is split has been linked with recurrences. In Rignault’s opinion,43 creation of a keyhole defect in the mesh to encircle the spermatic cord is preferable, the rationale being that this gives the prosthesis enough security to allow the surgeon to dispense with fixation sutures or tacks. Minimizing fixation in this area is important because of the numerous anatomic elements in the preperitoneal space that can be inadvertently damaged during suture placement.

Step 6: placement of prosthesis Stoppa’s technique is most often associated with a single large prosthesis for bilat-eral hernias.36 The prosthesis is cut in the shape of a chevron (24 cm in length), and eight clamps are positioned strategi-cally around the prosthesis to facilitate placement into the preperitoneal space.

Unilateral repairs use a prosthesis that is approximately 15 × 12 cm but is cut so that the bottom edge is wider than the top edge and the lateral side is longer than the medial side. In Wantz’s technique,38 three absorbable sutures are used to attach the superior border of the prosthesis to the anterior abdominal wall well above the defect [see Figure 18]. The sutures are placed from medial to lateral near the linea alba, the semilunar line, and the anterosuperior iliac spine.

Figure 17 Preperitoneal inguinal prosthetic herniorrhaphy. Illus-trated is parietalization of the spermatic cord. The spermatic vessels and the vas deferens are mobilized so that they move laterally. This step is carried out so that the surgeon can place a large prosthesis that widely overlaps the myopectineal orifi ce without having to slit the prosthesis to accommodate the cord structures.


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Three long clamps are then placed on each corner and the middle of the prosthesis of the inferior fl ap and used to direct the mesh deep into the preperitoneal space with the peritoneal sac pushed cephalad.

Step 7: closure of wound The surgical wound is closed anatomically once the surgeon is assured that there has been no displacement or roll-up of the prosthesis.

Kugel and Ugahary Repairs

The Kugel and Ugahary repairs were developed to com-pete with laparoscopic repairs. They require only a small (2 to 3 cm) skin incision placed 2 to 3 cm above the internal ring.44,45 In Kugel’s operation, the incision is oriented obliquel y, with one third of the incision lateral to a point halfway between the anterosuperior iliac spine and the pubic tubercle and the remaining two thirds medial to this

a

b

c

Figure 18 Unilateral giant prosthetic reinforcement of the visceral sac (Wantz technique). (a, b) The prosthesis is cut so that the inferior edge is wider than the superior edge by 2 to 4 cm and the lateral side is longer than the medial side. The width at the superior edge is approximately the distance between the umbilicus and the anterosuperior iliac spine minus 1 cm, and the height is approximately 14 cm. Anteriorly, three sutures are placed—near the linea alba, near the semilunar line, and near the anterosuperior iliac spine—from medial to lateral to fi x the superior border. (c) Three long clamps on the inferior edge are used to implant the prosthesis deep into the preperitoneal space with the peritoneal sac retracted cranially.


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point. The incision is deepened through the external oblique fascia, and the internal oblique muscle is bluntly spread apart. The transversalis fascia is opened vertically for a distance of about 3 cm, but the internal ring is not violated. The preperitoneal space is entered, and a blunt dissection is performed. The inferior epigastric vessels are identifi ed to confi rm that the dissection is being done in the correct plane. These vessels should be left adherent to the overlying trans-versalis fascia and retracted medially and anteriorly. The iliac vessels, the Cooper ligament, the pubic bone, and the hernia defect are identifi ed by palpation. Most hernial sacs are simply reduced; the exceptions are large indirect sacs, which must sometimes be divided, with the distal sac left in situ and the proximal sac closed. To prevent recurrences, the cord structures are thoroughly parietalized to allow adequate posterior dissection.

The key to Kugel’s procedure is a specially designed 8 × 12 cm prosthesis. The construction of the prosthesis allows it to be deformed so that it can fi t through the small incision; once inserted, it springs open to regain its normal shape, providing a wide overlap of the myopectineal orifi ce. The prosthesis also has a slit on its anterior surface, through which the surgeon places a fi nger to facilitate positioning.

Ugahary’s operation is similar to Kugel’s but does not require a special prosthesis. In what is known as the grid-iron technique, the preperitoneal space is prepared through a 3 cm incision, much as in a Kugel repair. The space is held open with a narrow Langenbeck retractor and two ribbon retractors. A 10 × 15 cm piece of polypropylene mesh is rolled onto a long forceps after the edges have been rounded and sutures placed to correspond to various anatomic landmarks. The forceps with the rolled-up mesh on it is introduced into the preperitoneal space, and the mesh is unrolled with the help of clamps and specifi c movements of the ribbon retractors.

combined anterior and posterior (preperitoneal) herniorrhaphy

Bilayer Prosthetic Repair

The bilayer prosthetic repair involves the use of a dumbbell-shaped prosthesis consisting of two fl at pieces of polypro-pylene mesh connected by a cylinder of the same material. The purpose of this design is to allow the surgeon to take advantage of the presumed benefi ts of both anterior and posterior approaches by placing prosthetic material in both the preperitoneal space and the extraperitoneal space.

The initial steps are identical to those of a Lichtenstein repair. Once the conventional anterior space has been pre-pared, the preperitoneal space is entered through the hernia defect. Indirect hernias are reduced, and a gauze sponge is used to develop the preperitoneal space through the internal ring. For direct hernias, the transversalis fascia is opened, and the space between this structure and the peritoneum is developed with a gauze sponge. The deep layer of the pros-thesis is deployed in the preperitoneal space, overlapping the direct and indirect spaces and the Cooper ligament. The superfi cial layer of the device occupies the conventional anterior space, much as in a Lichtenstein repair. It is slit laterally or centrally to accommodate the cord structures and then affi xed to the area of the pubic tubercle, the middle

of the inguinal ligament, and the internal oblique muscle with three or four interrupted sutures.

Complications

recurrence

An analysis of nearly 18,000 herniorrhaphies in Sweden reported that 15% of operations were performed to treat recurrent hernias.46 This fi gure is remarkably consistent with the data from other large population-based series and is infl uenced by the type of repair, type of hernia (primary versus recurrent), patient characteristics, and surgeon char-acteristics (hernia specialist or not). The use of mesh is an important factor, with a Cochrane meta-analysis of open mesh inguinal hernia repair versus open nonmesh repair fi nding that tension-free mesh repair led to a signifi cant reduction in hernia recurrence of between 50 and 75%.19 Two randomized trials using the Lichtenstein repair as the control operation documented 2-year recurrence rates between 1 and 4%, setting a benchmark for primary inguinal hernia repair.47,48

Similar low recurrence rates have been demonstrated regardless of the technique of mesh placement, whether laparoscopic or open.49,50 On the other hand, a large, randomized, multicenter Veterans Affairs (VA) study found that for primary, unilateral hernias, the laparoscopic approach was associated with a higher overall recurrence rate at 2 years (10%) when compared with open mesh repair (4%).48 Most reported recurrences after laparoscopic hernior-rhaphy come at an early stage in the surgeon’s experience with these procedures and arise soon after operation.48,51 The majority can be attributed to (1) inadequate preperitoneal dissection; (2) use of an inadequately sized patch, which may migrate or fail to support the entire inguinal area, including direct, indirect, and femoral spaces; or (3) staple failure with TAPP repair.

pain

Chronic postoperative groin pain is one of the major complications facing patients undergoing inguinal hernia repairs. Although some degree of postoperative groin pain is experienced by as many as 53% of patients,52 signifi cant long-term pain is probably seen in 5 to 15% of patients,48,49,53 regardless of whether the nerves were divided or pre-served.54 Persistent pain and burning sensations in the ingui-nal region, the upper medial thigh, or the spermatic cord and scrotal skin region occur when the genitofemoral nerve or the ilioinguinal nerve is stimulated, entrapped, or unin-tentionally injured. When the lateral cutaneous nerve is involved, lateral or central upper medial thigh numbness is experienced and often lasts several months or longer. Unlike patients who undergo open anterior herniorrhaphy, in whom discomfort or numbness is usually localized to the operative area, patients who undergo laparoscopic repair occasionally describe unusual but specifi c symptoms of deep discomfort that are usually positional and are often of a transient, shooting nature suggestive of nerve irritation. Postoperative chronic pain is more likely to be observed in younger patients and in patients who report preoperative pain attributable to their hernia, but other risk factors have


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also been identifi ed. In general, patients seem to report less postoperative pain after laparoscopic repair.10,45–59

When confronted with this complication, recurrence must be ruled out. Usually, this can be done by physical examina-tion with or without the use of ultrasonography. A cord lipoma, sometimes left in place following laparoscopic repair, should be distinguished from a recurrence. If pain is felt to be neuropathic in origin, it is best treated initially with reassurance and conservative treatment, such as antiinfl am-matory medications and local nerve blocks. Reexploration is avoided in the fi rst year after the procedure to allow for the possibility of spontaneous resolution. The only exception to this rule is the patient with severe groin pain in the recovery room, who is best treated with immediate reexploration.60 When groin exploration is required, neurectomy and neu-roma excision, adhesiolysis, muscle or tendon repair, and foreign body removal are all possibilities, with less than satisfying results.

genitourinary tract complications

Urinary tract infection and hematuria may be seen, espe-cially if bladder catheterization was used. Urinary retention still occurs in 1.5 to 3% of patients.48 Spinal anesthesia and the administration of large volumes of IV fl uids may also predispose to retention.12

Ischemic Orchitis

Wantz believed that the most common cause of postop-erative testicular swelling, orchitis, and ischemic atrophy is surgical trauma to the testicular veins (i.e., venous conges-tion and subsequent thrombosis).61 Orchitis is defi ned as postoperative infl ammation of the testicle occurring within the fi rst 2 postoperative days. Testicular pain occurs in about 1% of patients after laparoscopic repair,62 an incidence com-parable to that seen after open repair.48,57 Patients experience painful enlargement and hardening of the testicle, usually associated with a low-grade fever; the pain is severe and may last several weeks but is usually self-limited. Because spermatic cord dissection is minimized with the laparoscopi c approach, the risk of groin and testicular complications resulting from injury to cord structures and adjacent nerves may be reduced.48 The vast majority of patients who experi-ence testicular complications go on to recover without atro-phy, which probably occurs in less than 0.04% of primary inguinal hernia repairs and less than 0.5% of recurrent hernia repairs.57

Vas Deferens Injuries

The risk of injury to the vas deferens appears to be much the same in laparoscopic repair as in open repair.49 If fertil-ity is an issue, the cut ends should be reapproximated if the injury is recognized intraoperatively.

Urinary Tract Injuries

Bladder injuries necessitating repair have been reported in only a handful of cases following laparoscopic herniorrha-phy.55,63,64 They are most likely to occur when the space of Retzius has been previously dissected (e.g., in a prostatec-tomy). In such cases, an in-dwelling catheter may be useful to help identify the bladder and avoid injuring it. Although

indwelling catheter drainage may constitute suffi cient treatment of a missed retroperitoneal bladder injury, intra-peritoneal injuries are best treated by direct repair. Bladder and ureteral injuries identifi ed intraoperatively should be repaired immediately. Often, however, these injuries are not apparent until the postoperative period, when they present as lower abdominal pain, renal failure, ascites, dysuria, or hematuria—all of which should be investigated promptly.

vascular injuries

Postherniorrhaphy bleeding is usually the result of delayed bleeding from the cremasteric artery, the internal spermatic artery, or branches of the inferior epigastric vessels. This bleeding is usually self-limited but can produce an impressive wound or scrotal hematoma, which usually resolves over time. Injuries to the deep circumfl ex artery or the external iliac vessels may result in a large retroperito-neal hematoma. During laparoscopic repairs, the most common vascular injuries occurring are those involving the inferior epigastric vessels and the spermatic vessels.49 The external iliac, circumfl ex iliac, profunda, and obturator ves-sels are also at risk. A previous lower abdominal operation is a risk factor.60 The source of any abnormal bleeding during the procedure must be quickly identifi ed. All vessels in the groin can be ligated except the external iliac vessels, which must be repaired.49 Conversion of a laparoscopic procedure for bleeding is rare and occurs in less than 3% of cases.60

mesh complications

Infection

Mesh infection is rare. In a 2003 Cochrane review of anti-biotic prophylaxis for nonmesh hernia repairs, the overall infection rate was 4.69% in the control group and 3.08% in the treatment group.65 Thus, to prevent one infection in 30 days, 50 patients would have to be treated, and these patients would then be at risk for antibiotic-associated com-plications. Laparoscopic repairs were excluded from this review; however, in a meta-analysis comparing postopera-tive complications after laparoscopic inguinal hernia repair with those after open repair, superfi cial infection was less frequent in the laparoscopic groups.49 Deep mesh infection was rare in both groups. Mesh infection usually responds to conservative treatment with antibiotics and drainage. On rare occasions, the mesh must be removed; this may be accomplished via an external approach. If, however, a pros-thesis composed of a hydrophobic material (e.g., expanded polytetrafl uoroethylene) becomes infected, it is very diffi cult to sterilize and virtually always must be removed. It is note-worthy that removal of the mesh does not always lead to recurrence of the hernia, a fi nding that may be attributable to the resulting fi brosis.66

Adhesions and Erosions

Tissue response, which is variable from person to person, can be so intense that the prosthetic material is deformed by contraction. This can lead to migration with subsequent hernia recurrence. In addition, erosion can result in intesti-nal obstruction or fi stulization, especially if there is physical


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contact between the intestine and the prosthesis, as is some-times the case when tears in the peritoneum leave the mesh partially uncovered following preperitoneal repairs.67,68 Such complications usually become apparent weeks to years after the initial repair, presenting as abscess, fi stula, or small bowel obstruction. Erosion into the cord structures and vas deferens obstruction have also been reported.69,70

peritoneal access complications

Most randomized trials comparing laparoscopic repair with open mesh repair have found the overall complication rate to be comparable between groups.48,49 In general, how-ever, the rate of serious perioperative complications, although still low, is increased with the laparoscopic approach.48 This is probably attributable to injuries related to peritoneal or preperitoneal access. Trocar injuries to the bowel, the bladder, and the vascular structures can occur during the creation of the initial pneumoperitoneum or the subsequent insertion of the trocars.49,63 Visceral injury rates reported for the laparoscopic approach, although quite low, are still about 10 times those reported for the open approach.49 Another complication related to trocar place-ment is incisional hernia,20 which can lead to postoperative bowel obstruction48,49,71; however, this complication can be minimized by using 5 mm trocars and a 5 mm laparoscope instead of the larger 10 or 12 mm instruments.

Outcomes

In addition to the differences in recurrence rates and post-operative pain discussed in the previous section, other important outcomes are worth mentioning when consider-ing the optimal hernia repair option for a particular patient. In summary, the potential benefi ts of using a laparoscopic approach include reduced postoperative pain, earlier return to normal activities, and a reduction in chronic pain and numbness. Laparoscopy is, however, associated with higher costs. Recurrence rates may be higher for the laparoscopic approach; recent studies are challenging this.25

cost-effectiveness

A study comparing costs at North American teaching hospitals found that TEP repair cost $852 more than Lichten-stein repair; however, this study could not quantify the cost savings arising from faster recuperation and earlier reentry into the workforce.72 On the other hand, some studies have demonstrated economic savings with the use of a laparo-scopic approach, in the form of fewer days of work missed and reduced worker’s compensation costs.56,63 Operating costs can also be reduced by avoiding the use of disposable instruments.50 In addition, operating time has been shown to decrease as the surgeon’s experience with the procedure increases.48,73,74

operating time

A Cochrane meta-analysis suggested that overall, the average operating time was 15 minutes longer with the laparoscopic approach; however, for bilateral hernias, lapa-roscopic repair required no more time than open repair.49 It has been shown that with more experience and greater specialization, the differences in operating time between

laparoscopic and open repair tend to decrease and become clinically unimportant.73,75

recovery time

The most signifi cant short-term outcome measure after hernia repair is recovery time, defi ned as the time required for the patient to return to normal activities. One of the most frequently cited benefi ts of laparoscopic herniorrhaphy is the patient’s more rapid return to unrestricted activity, including work. A Cochrane meta-analysis revealed that the recovery time was signifi cantly shorter after laparoscopic repair than after open mesh repair.49 In a cost comparison between TEP repair and Lichtenstein repair, the recovery time was 15 days after the former compared with 34 days after the latter.72 In the 2004 VA study, laparoscopic repair patients returned to their normal activities 1 day earlier.48

quality of life

The studies that have assessed quality of life immediately after hernia repair have tended to favor the laparoscopic approach, albeit marginally. Using the SF-36 (a widely accepted general health-related quality of life questionnaire), one group found that at 1 month, greater improvements from baseline were apparent in the laparoscopic group in every dimension except general health; however, by 3 months, the differences between the two groups were no longer signifi cant.10 Another group also found no differences in any SF-36 domains 3 months after operation.64 Yet another study, however, using the Sickness Impact Profi le, found some benefi t to the laparoscopic approach.76 In con-trast, no postoperative differences in SF-36 domains were found in the VA study.48

Procedure Selection

asymptomatic hernias

The natural history of an untreated, minimally symptom-atic inguinal hernia was addressed in a randomized, con-trolled trial in which 364 men were assigned to “watchful waiting” (WW) and 356 men underwent routine operation.48 Only two patients in the WW group required emergency operations for strangulation over the follow-up period of 2 to 4.5 years. This result translated into a rate of 1.8 per 1,000 patient-years (0.18%), or about one fi fth of 1% for each year that the hernia remains unrepaired. The two patients who required emergency operations recovered uneventfully. The question that remained to be answered was which group fared better overall: the WW group or the group whose hernias were repaired immediately in accordance with conventional teaching? The answer to this question was at variance with conventional assumptions. At the conclusion of the study, functional status, as measured by quality of life instruments and pain scales, was identical in the two groups. About one third of the patients in the WW group crossed over to undergo operative treatment, principally because of symptom progression. However, there appeared to be no penalty for delaying surgery. Before this study, most sur-geons assumed that a hernia would become harder to repair the longer it remained (because of enlargement and buildup of scar tissue) and that patients whose operations were


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delayed would experience more complications. The investi-gators found, however, that postoperative complication rates were the same in patients who underwent immediate surgery as in those who were assigned to WW but had to cross over to surgical treatment.

primary unilateral hernias

For unilateral primary hernias, the most important con-sideration in choosing an inguinal hernia procedure may well be the experience of the surgeon, with excellent results demonstrated after both open and laparoscopic mesh repairs in experienced hands. The next consideration should be to tailor the operation to the patient’s particular hernia. In infants and young children with indirect hernias, for whom repair of the posterior canal wall is unnecessary, high ligation of the sac via the anterior approach is a suffi cient procedure but is not adequate in most adults, where a mesh is recommended to decrease recurrence. Conventional ante-rior prosthetic repairs are particularly useful in high-risk patients because they can be readily performed with local anesthesia, a safer approach than laparoscopic surgery, for which the pneumoperitoneum could result in adverse events. Similarly, we do not treat acutely incarcerated hernias laparoscopically. Large indirect scrotal hernias are another category of challenging laparoscopic cases. Previous lower abdominal surgery, although not an absolute contra-indication, may make laparoscopic dissection diffi cult. In particular, with respect to TEP repair, previous lower abdominal wall incisions may make it impossible to safely separate the peritoneum from the abdominal parietes for entry into the extraperitoneal plane, and conversion to a TAPP repair or an open repair may be required. Previous surgery in the retropubic space of Retzius, as in prostatic procedures, is a relative contraindication that is associated with an increased risk of bladder injury60 and other compli-cations.77 Similarly, previous pelvic irradiation may preclude safe dissection of the peritoneum from the abdominal wall.42 If local or systemic infection is present, a nonprosthetic repair is usually considered preferable, although the newer biologic prostheses now being evaluated may eventually change this view. A recent meta-analysis of all randomized, controlled trials compared hernia recurrence and surgery-related morbidity between open inguinal hernia repair (OIHR) and laparoscopic inguinal hernia repair (LIHR) for primary unilateral inguinal hernia. The study concluded that TEP repair was associated with an increased risk of recurrence relative to OIHR (relative risk [RR] = 3.72, p = .001) but that TAPP was not (RR = 1.14, p = .001). On the other hand, TAPP repair was associated with increased risk of perioperative complications relative to OIHR. Overall, LIHR was found to cause less chronic groin pain and numbness. The study identifi ed risk factors for recurrence after TEP LIHR: surgeon age under 45 years, presence of postoperative pain, a short operating time, and procedural inexperience.78

recurrent hernias

In patients with recurrent hernias after previous anterior repair, a laparoscopic or other posterior approach allows the surgeon to avoid the scar tissue and distorted anatomy present in the anterior abdominal wall by performing the

repair through unviolated tissue, thereby potentially reduc-ing the risk of damage to the vas deferens or the testicular vessels. This is especially true when mesh has previously been placed anteriorly. Similarly, recurrence following a preperitoneal approach may be more favorably treated with an anterior herniorrhaphy.79

bilateral hernias

Laparoscopy allows simultaneous exploration of the abdominal cavity (TAPP repair) and diagnosis and treat-ment of bilateral groin hernias, as well as coexisting femoral hernias (which are often unrecognized preoperatively), potentially without added risk or disability. Bilateral hernias accounted for 9% of the hernias reviewed in the Cochrane database.49 The operating time was longer in the laparoscop-ic groups than in the open groups; however, the recovery time, the incidence of persistent numbness, and the risk of wound infection were signifi cantly reduced in the former. These results are consistent with those of a prospective, randomized, controlled trial that compared TAPP repair with open mesh repair for bilateral and recurrent hernias.80 In this study, TAPP repair not only was less painful and led to an earlier return to work but also was associated with a shorter operating time.

incarcerated and strangulated hernias

Strangulated groin hernia is a serious surgical emergency associated with high morbidity and mortality (up to 9%). The rate varies between 0.9 and 2.9%, and prompt clinical diagnosis is needed as a delay of 6 to 12 hours increases the likelihood of intestinal necrosis and requires bowel resection in up to 15% of cases.81 There is no consensus on the pre-ferred surgical approach. The basic surgical principles are as follows: (1) the approach that offers the most optimal exposure and access to the small bowel, should resection be required, should be used; ischemic bowel may be addressed through either the groin incision, a laparotomy, or laparo-scopically82; (2) the hernia sac should be reduced with mini-mal trauma to its contents; and (3) synthetic mesh should be avoided in the context of strangulated bowel to avoid mesh infections. Tissue repairs are preferable, and the higher risk of recurrence should not be a deciding factor in the emergency setting.

Financial Disclosures: None Reported.

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Acknowledgments

Figures 2a and 9 Christine Kenney


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