Laparoscopic Total Extra Peritoneal Inguinal Hernia Repair

Laparoscopic Total Extraperitoneal Inguinal Hernia Repair Bruce Ramshaw, MD, FACS

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he laparoscopic approach for inguinal hernia repair was first reported by Ger, who performed a high ligation of the sac without mesh placement.1 In the early 1990s, a variety of trans-abdominal laparoscopic approaches were reported, with the trans-abdominal preperitoneal (TAPP) approach and the intraperitoneal onlay mesh (IPOM) techniques being the most common. Because of reports of high recurrence rates, the IPOM technique quickly fell out of favor. In 1993 the laparoscopic total extraperitoneal (TEP) approach was reported by McKernan.2 The TEP approach allows for mesh placement within the preperitoneal space, without entering the abdominal cavity. Another benefit of this approach is the avoidance of the incision and closure of the peritoneum typically required in the TAPP approach. I had the fortune of being a resident in Atlanta in 1993, allowing me to travel only a few miles to watch Barry McKernan perform several laparoscopic TEP hernia repairs. With the help of fellow residents and my attendings, we integrated this technique into all general surgery practices at Georgia Baptist Medical Center that year. Because it is an extremely difficult procedure to learn, it was advantageous to have over 10 surgeons helping each other learn the technique. On completing residency, the laparoscopic TEP approach became my procedure of choice for essentially all inguinal hernia repairs in my practice. Contraindications for performing the TEP technique include age (prepubertal children) and the inability to tolerate general or regional anesthesia. Relative contraindications include large scrotal hernias, previous lower midline abdominal surgery, and previous mesh placement in the preperitoneal space. I currently use a TAPP approach without reperitonealization, using mesh designed for intraabdominal placement, in these patients. The primary barrier to performing a successful laparoscopic TEP inguinal hernia repair is the difficulty associated with learning the technique. Once mastered, the repair can be performed faster, with better visualization and wider mesh

Division of General Surgery, University of Missouri Hospital & Clinics, One Hospital Drive, MC414 McHaney Hall, Columbia, MO. Address reprint requests to Bruce Ramshaw, MD FACS, Associate Professor of Surgery, Chief, Division of General Surgery, University of Missouri Hospital & Clinics, One Hospital Drive, MC414 McHaney Hall, Columbia, MO 65212. E-mail: [email protected]

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coverage than the commonly performed open tension-free inguinal hernia repairs, especially for bilateral and recurrent hernias. There are several barriers to learning the technique. First, access to the extraperitoneal space through a small infra-umbilical incision is not something a general surgeon has typically done. The extraperitoneal dissection of the lower abdomen, exposing the myopectineal orifice bilaterally, can be a daunting task. Balloon dissectors can significantly help a surgeon perform a safe, consistent extraperitoneal dissection, especially early in the learning curve. However, even with the balloon, accidental placement into the subcutaneous tissue, within the rectus muscle and inside the abdominal cavity has occurred. A laparoscopic view through the balloon helps ensure that it has been placed in the correct space. Usually, the pubis and Cooper’s ligament are the first structures visualized when the balloon is placed correctly. However, even when placed in the correct space, inflation of the balloon can injure the bowel or bladder, especially in patients with previous lower abdominal surgery. Directing the balloon more laterally toward the side of the defect and inflating it less than usual can minimize the likelihood of injury in these patients, including those who have undergone previous open prostatectomy. Another barrier is the variability of the initial presentation of the anatomy. Significant preperitoneal fat, presence of an unreduced direct hernia, bleeding from the balloon dissection, and previous lower abdominal surgery, can obscure the anatomy. Probably the most dangerous portion of the operation is the lateral dissection, where dissecting too far posteriorly can increase the risk of inadvertent iliac vessel injury. To minimize this dangerous complication, lateral dissection should be done near the anterior extraperitoneal plane, just posterior to the rectus muscle and inferior epigastric vessels. All structures posterior and lateral to the epigastric vessels should be carefully dissected posteriorly and medially to open up the lateral extraperitoneal space. Probably the most difficult dissection, even in experienced hands, is the reduction of a chronic, large indirect sac that is often adherent to the cord and surrounding structures. Reduction of the indirect sac can add several minutes to the procedure in experienced hands, and may necessitate conversion to an open approach for the surgeon early in the learning curve. Another barrier to learning the operation is the mesh manipulation. Manipulating and orienting a large mesh in a relatively small space can be challenging.

Laparoscopic total extraperitoneal inguinal hernia repair

Operative Technique

Figure 1 (A–C) The skin incision is made at the inferior aspect of the umbilicus. Dissection is carried down to the anterior fascia of the rectus muscle just lateral to the midline. If the incision is made away from the hernia, there will be less dissection of that groin by the balloon (more dissection in the ipsilateral groin). However, there will be more room to work because the 10 mm trocar and scope will be farther away from the groin with the hernia defect. If the hernia is bilateral, I usually place the incision on the side away from the larger hernia defect, to allow more room to work there. If, however, there is previous lower abdominal surgery on one side or the other (a previous RLQ appy scar for example), I will direct the balloon to the contralateral side, away from the previous scar to minimize the chance of tearing the peritoneum. (Color version of figure appears online.)

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Figure 2 (A–D) Following the anterior fascia incision, I use my finger to sweep the rectus muscle off the posterior fascia from the midline. This is important to ensure proper balloon dissector placement. If this space cannot be entered, or if the peritoneum is injured, the same dissection may be performed on the contralateral side. There are advantages and disadvantages of placing the balloon dissector on the side of the hernia. The dissection is better; however, the balloon may dissect the inferior epigastrics off the anterior abdominal wall, making the repair more difficult. Also, with the laparoscope closer to the ipsilateral groin, there is a smaller space in which to work. (Color version of figure appears online.)

Laparoscopic total extraperitoneal inguinal hernia repair

Figure 3 (A–C) The balloon dissector is placed in the space between rectus muscle and posterior fascia, and directed down to the pubis. The canula is removed and the zero degree, 10 mm laparoscope is used. The dissector is inflated while the space is viewed laparoscopically. The pubis and Cooper’s ligaments should be identified as well as rectus muscle fibers, which are seen anteriorly, not posteriorly, through the balloon. After appropriately dissecting the preperitoneum, the balloon is left in place briefly for tamponade and then deflated and removed. (Color version of figure appears online.)

Figure 4 A 10 mm balloon tip or other Hassan type trocar is placed, and the extraperitoneal space is insufflated to a maximum pressure of 10 to 12 mmHg. Two 5 mm trocars are placed in the low midline between the rectus muscles. I usually place the first trocar about one finger breadth above the pubis and the final trocar halfway between the end of the 10 mm trocar and the suprapubic 5 mm trocar. (Color version of figure appears online.)

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Figure 5 (A–D) Medial dissection is usually accomplished by the balloon dissector. However, an unreduced direct hernia will obscure the medial anatomy. Careful reduction of the hernia sac and counter traction of the weakened transversalis fascia with graspers will allow for complete reduction and exposure of the medial anatomy. Hernias may also be reduced from the femoral space, between the iliopubic tract and Cooper’s ligament, and the obturator space, posterior to Cooper’s ligament. (Color version of figure appears online.)

Laparoscopic total extraperitoneal inguinal hernia repair

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Figure 5 Continued

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Figure 6 (A,B) The lateral anatomy is usually not exposed by the balloon dissection and it is important to attempt to identify inferior epigastic vessels to guide initial lateral dissection. The vessels should be retracted anteriorly and all cord contents should be carefully dissected off of the anterior and lateral abdominal wall to expose the lateral anatomy. The transversus arch fibers join the iliopubic tract to form the lateral border of the indirect space. The iliopubic tract travels laterally, parallel and deep to the inguinal ligament. The cutaneus nerves (lateral femoral cutaneous, femoral branch of the genitofemoral and their branches) usually travel on the psoas muscle and leave the extraperitoneal space at or near the level of the iliopubic tract. For this reason, fixation lateral to the cord and posterior to iliopubic tract is avoided. However, it is possible, because of previous surgery or anatomic anomaly, for nerves to course anterior to the iliopubic tract. Therefore, fixation anterior to the iliopubic tract should be approached with caution. (Color version of figure appears online.)

Laparoscopic total extraperitoneal inguinal hernia repair

Figure 7 (A,B) Once the lateral dissection is complete, the cord is explored for an indirect sac and/or a lipoma of the cord. The indirect hernia sac will usually be located on the anteriomedial portion of the cord and may be more difficult to reduce than a direct hernia. A lipoma of the cord is usually found at the end of the sac anteriolaterally on the cord. Fatty tissue within the cord vessels or fat posterior to the iliopubic tract will bleed if grasped and reduced, but a lipoma of the cord will usually reduce easily from the internal ring, with minimal or no bleeding. (Color version of figure appears online.)

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Figure 8 The vas deferans lies posteriomedially and the vessels lie on the psoas muscle posteriolaterally. They join at the internal ring and form a triangle (with the peritoneal reflection forming its base) called the triangle of doom, where the iliac vessels are found posteriorly. Posteriolaterally, the peritoneal reflection should be taken back to the level of the umbilicus by gently peeling the peritoneum off the cord structures, psoas muscle, and lateral abdominal wall. Medially, the peritoneum should be dissected off the iliac vein and obturator foramen. Sometimes, a plug of preperitoneal fatty tissue may be reduced from the obturator space. This dissection will allow for appropriate placement of a large mesh and minimize the chance of herniation around the mesh edges. (Color version of figure appears online.)

Laparoscopic total extraperitoneal inguinal hernia repair

Figure 9 (A,B) With the TEP technique for inguinal hernia repair, there are traditionally two types of mesh preparation: a mesh with a slit or a mesh without a slit. The mesh that is slit is passed around the cord allowing the cord to hold the mesh down posteriorly, preventing herniation at the posterior edge of the mesh. The slit should be overlapped and fixed, attempting to prevent herniation through the mesh slit. If the mesh is not slit it is very important to make sure that the peritoneum does not protrude under the mesh with the cord. To avoid recurrence, the peritoneum is dissected to the level of the umbilicus, and the posterior edge of the mesh is held down with a grasper during deflation of the extraperitoneal space. There are now newer meshes with different shapes and designs, adapted for laparoscopic inguinal hernia repair. I currently use a mesh that is shaped to conform to the preperitoneal inguinal anatomy. It has a posterior flap with a velcro-like patch that is placed behind the cord. Another flap is then placed anterior to the cord and fixed to the velcro-like patch to provide fixation posteriolaterally where point fixation devices cannot be used. This mesh was designed to minimize the chance of herniation through a slit in the mesh, or from under the posterior edge of mesh. Other potential solutions include using an additional piece of mesh to completely cover the slit if a slit mesh is used or using a glue to fix the mesh posteriolaterally if a mesh without a slit is used. I continue to use minimal point fixation because of the possibility of mesh contraction or migration, and/or folding that may occur with any type of mesh material. Multiple animal studies appear to show that heavyweight polypropylene mesh is more likely to contract than polyester or lightweight polypropylene. I usually use three points of fixation in addition to the velcro-like fixation posteriolaterally. One is at the superiolateral corner of the mesh. This corner is located at the lateral abdominal wall above the iliac crest at the level of the umbilicus, well away from the nerves at risk for injury. The other two points of fixation are medial, to Cooper’s ligament posteriorly and anteriorly to the lower rectus muscle. For bilateral hernias, the mesh should overlap at the midline and the mesh overlap is fixed in two areas, one near the pubis and one at the lower rectus muscles. The mesh should cover all hernia and potential hernia defects and widely cover the myopectineal orifice. It is fixed well away from the nerves. (Color version of figure appears online.)

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Summary The patient is usually able to go home on the day of surgery and is allowed to return to activity as tolerated. A prescription for pain medicine is given to the patient and the patient is usually able to switch to antiinflammatories in the first few days. Bruising and swelling of the groin, penis, and scrotum is not uncommon and ice and/or a jockstrap may be used for comfort. Urinary retention in the first 24 hours and constipation in the first few days are also possible and management strategies should be discussed with the patient. Significant wound and mesh complications are extremely rare with the laparoscopic TEP inguinal hernia repair. Drainage from the 10 mm incision is the most common wound complication and usually only requires a dry dressing. After the repair of large hernias, seromas, and/or hematomas are possible as a result of serous fluid and/or blood collection in the space created by the hernia reduction. The patient should be educated and forewarned of this possibility and told that usually

no treatment is required. Rarely, aspiration may be considered if there are significant symptoms. In conclusion, the total extraperitoneal approach for laparoscopic inguinal hernia repair can be utilized for almost all adult inguinal hernias. The ability to visualize the entire groin bilaterally, widely cover the myopectoneal orifice, and securely fix the mesh to healthy abdominal wall tissue away from nerves will result in a highly effective repair.

Acknowledgments The author thanks Bill Winn (Medical Illustrator) and Brandy Stockton (Administrative Assistant).

References 1. Ger R, Monroe K, Duvivier R, Mishrick A: Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac. Am J Surg 159:370-373, 1990 2. McKernan JB, Laws HL: Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 7:26-28, 1993