Laparoscopic Trans Abdominal Pre Peritoneal Inguinal Hernia Re

Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair Michael J. Rosen, MD

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hen considering a laparoscopic approach for repairing inguinal hernias, the surgeon has several options. Initially laparoscopic repairs involved an intraperitoneal onlay mesh. Using this technique, the surgeon placed a large piece of mesh in an intraperitoneal position, similar to a laparoscopic ventral hernia repair. This approach has largely been abandoned secondary to high recurrence rates and the drawbacks of intraperitoneal mesh. The remaining two techniques include a totally extraperitoneal (TEP) and a transabdominal preperitoneal (TAPP) approach. The main difference between these two techniques is the sequence of gaining access to the preperitoneal space. In the TEP approach, the dissection begins in the preperitoneal space with a balloon dissector. In the TAPP approach, the preperitoneal space is accessed after initially entering the peritoneal cavity. Each approach has its own merits. Using the TEP approach, the preperitoneal dissection is quicker, and the potential risks of intraperitoneal visceral damage are minimized. However, the use of dissection balloons can be costly, the working space is more limited, and in the case of prior preperitoneal surgery or mesh the space may be impossible to create. Additionally, if large tears in the peritoneal flap are created during a TEP, the potential working space can become obliterated necessitating conversion to a transabdominal approach. For these reasons, knowledge of a transabdominal technique is essential when performing laparoscopic inguinal hernia repairs. The transabdominal approach allows immediate identification of the groin anatomy before extensive dissection and disruption of natural planes. The larger working space of the peritoneal cavity can make early experience with the laparoscopic approach safer and easier. The TAPP is the preferred approach of the author and will be described herein. There are no absolute contraindications to laparoscopic inguinal hernia repair other than the inability to tolerate general anesthesia. Patients who have had extensive prior lower abdominal surgery can require significant adhesiolysis and may be best approached anteriorly. In particular patients who have had a radical retropubic prostatectomy with the preperitoneal space previously dissected can make accurate safe dissection challenging.

Department of Surgery, University Hospitals of Cleveland, Case Western Reserve School of Medicine, Cleveland, OH. Address reprint requests to Michael J. Rosen, Assistant Professor of Surgery, Department of Surgery, University Hospitals of Cleveland, Euclid Ave, Cleveland, OH 44106. E-mail: [email protected]

1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2006.04.008

Preoperative Routine use of Foley catheterization is not performed. The patients are instructed to empty their bladder before entering the operating room. A single dose of a first generation cephalosporin is given and sequential compression devices are applied. The patient is placed under general anesthesia, both arms are tucked at the patients’ side, and the abdomen and groin are sterilely prepped. The surgeon stands on the side opposite the hernia and the first assistant stands on the ipsilateral side of the hernia along with the scrub nurse. The laparoscopic tower is positioned at the foot of the table (Fig. 1).

Trocar Positioning The abdomen is accessed via an open Hasson technique through an infraumbilical incision. The abdomen is insufflated to 15 mmHg. A 5 mm 30 degree laparoscope is then inserted and a general inspection of the abdominal cavity is performed. The pelvic floor is evaluated and the pathology of the inguinal anatomy is examined (Fig. 2). Two additional 5-mm ports are placed in line with the umbilicus and just lateral to the inferior epigastric vessels. These trocars should remain above the umbilicus to avoid interference with the preperitoneal flap dissection. Additionally, placing these trocars too far laterally can result in difficulty navigating instruments across the abdominal viscera (Fig. 3). Using an angled 5-mm laparoscope, the surgeon can stand on the opposite side of the hernia and use the middle trocar as a working port. The camera operator uses the lateral 5-mm port ipsilateral to the defect for visualization.

Peritoneal Flap Dissection The patient is placed in a slight Trendelenberg position. The dissection begins at the ipsilateral medial umbilical fold. The preperitoneal flap is raised from a medial to lateral direction using the curved scissors with monopolar cautery. It is important to begin this dissection rather cephalad on the abdominal wall to leave enough space for reduction of the hernia and placement of an appropriately sized piece of mesh (Fig. 4). Additionally, as the initial incision is carried laterally, one should avoid the temptation to drift inferiorly toward the inguinal canal, again compromising the eventual space necessary for mesh placement. The proper incision carries transversely across the ab45

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Figure 1 Patient positioning and operating room setup for left inguinal hernia. Surgeon stands on opposite side of hernia using middle and lateral trocar working ports. First assistant stands on ipsilateral side of hernia with camera. Arms are tucked bilaterally at sides, with monitor at foot of bed.

dominal wall toward the anterior superior iliac spine. When traversing across the plane, one must be cautious and avoid the epigastric vessels. Achieving the appropriate dissection plane is critical to the success of the operation. Although the dissection is typically below the arcuate line there tends to be an attenuated

transversalis fascia that is adherent to the rectus muscle. The appropriate plane is just superficial to the peritoneum. By grasping the inferior cut edge of the peritoneum and retracting cephalad the preperitoneal space is created by gently pushing away and dividing the loose filmy attachments (Fig. 5). The first struc-

Transabdominal preperitoneal inguinal hernia repair

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Figure 2 Inguinal anatomy of the right side. Location of indirect and direct space in relation to the inferior epigastric vessels.

ture identified is Cooper’s ligament. By sweeping down the bladder staying high on the anterior abdominal wall one eventually encounters this white firm ligament. Even in unilateral hernias, I routinely sweep the bladder far medially past the midline to provide adequate mesh overlap. Cooper’s ligament is cleared off laterally until a fairly constant crossing vessel is identified. This so-called “aberrant” obturator vessel is present in over 75% of patients. Next, the lateral dissection is begun. Unlike the medial dissection plane which typically can be developed bluntly allowing the preperitoneal fatty tissue to divide in its natural plane, the appropriate plane for the lateral dissection is directly on the peritoneum which can typically be quite thin. The lateral dissection is carried medially until the spermatic vessels and then the vas deferens are encountered. One must use extreme caution when using electrocautery in the preperitoneal space, as a loop of intestine can be just below the peritoneal flap with energy easily transmitted through the flap.

Dissection of Hernia Sac At this point the hernia sac should be reduced (Fig. 6). If a direct defect is encountered, the hernia contents are grasped and the attenuated transversalis fascia is gently teased away. If an indirect hernia is identified, the sac is likewise grasped

and retracted while bluntly sweeping off attachments to the cord structures. Large chronic indirect sacs can be particularly challenging. In cases where the hernia sac cannot be completely reduced, it can be transected and either sutured or closed with an endoloop leaving the distal end open. Any cord lipoma typically located inferior and lateral to the cord structures should be completely reduced to avoid potential confusion as a recurrence. These lipomas do not need to be resected and can be left in the preperitoneal space. Once the hernia sac is completely reduced, the peritoneal flap should be dissected at least 3 cm off the vessels and cord structures to prevent any drag coefficient from allowing peritoneum to sneak under the mesh, predisposing to recurrence. The upper flap of peritoneum is then grasped and retracted cephalad to develop a larger pocket for the mesh.

Placement of Mesh At least a 12 ⫻ 14 cm piece of polypropylene mesh is utilized. We do not place a slit for wrapping around the cord structures as recurrences have occurred through these defects. The mesh is grasped at the medial aspect. We do not roll the mesh tightly as this just makes unraveling more difficult once inside the patient. The mesh is brought in through the

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Figure 3 Trocar positioning. Note two lateral ports are just lateral to the inferior epigastrics in line with the umbilicus.

10-mm trocar and tucked medially into the pocket. The superior medial corner of the mesh is grasped and brought anteriorly while the inferior instrument pushes the mesh against the abdominal wall. While some groups advocate no mesh fixation, we currently believe some form of mesh fixation is important to prevent migration. Once the mesh is situated we place one tack in Cooper’s ligament. By only placing one tack, the mesh can still be rotated to obtain ideal lateral placement. However, the mesh will not migrate during lateral retraction. We then place a spiral tack at the superior lateral aspect of the mesh. It is critical that the tip of the tacker can be palpated with the nondominant hand of the surgeon through the anterior abdominal wall before deploying any tacks. If the tacker can not be palpated it indicates that it is likely below the iliopubic tract and therefore the lateral femoral cutaneous, genital-femoral, or femoral nerve could be entrapped. We then place one tack just lateral to the inferior

epigastric and one at the superior medial border of the mesh. Finally, another tack is placed in Cooper’s ligament (Fig. 7). At the conclusion, the peritoneum is re-examined with particular concern over the vessels to ensure it is not encroaching underneath the mesh. No tacks can be placed in the “triangle of doom” bordered by the vas deferens medially and the spermatic vessels laterally which contains the iliac artery and vein.

Peritoneal Closure The peritoneal flap is then secured to the anterior abdominal wall. This can be completed with spiral tacks, staples, or suturing. Any defects in the peritoneum should be closed. Occasionally, the reduced hernia sac can be used to close these defects. If a large hole in the peritoneum is created, several maneuvers can aid closure. The peritoneal flap dis-

Transabdominal preperitoneal inguinal hernia repair

Figure 4 Dissection of peritoneal flap. The flap begins at the medial umbilical fold. Note the length above the inguinal structures high on the anterior abdominal wall. Care is taken to avoid the epigastric vessels.

Figure 5 The inferior flap is grasped and retracted while the loose filmy attachments of the preperitoneal space are dissected free. The medial dissection is completed clearly identifying Cooper’s ligament.

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Figure 6 The indirect hernia sac is carefully reduced off of the cord structures.

Figure 7 The mesh is secured to the anterior abdominal wall with spiral tacks. No tacks are placed below the iliopubic tract.

Transabdominal preperitoneal inguinal hernia repair section should be extended inferiorly to gain laxity for closure, the pneumoperitoneum pressures can be reduced to 8 to 10 mmHg to decrease tension, and the patient can be taken out of the Trendelenberg position. For left sided defects, the sigmoid colon can be released from its peritoneal attachments. The umbilical port is closed with a single figure of eight resorbable suture and the abdomen is desufflated.

Special Considerations In cases of bilateral hernias, we use two separate pieces of mesh that are secured together in the midline. The mesh is placed in the first hernia but the peritoneum is not closed

51 until the other side is completed in case the mesh is accidentally displaced. In cases of prior preperitoneal hernia repairs, occasionally the peritoneal flap is completely destroyed and in those cases one can consider an onlay technique.

Postoperative Care The patients are typically discharged home from the recovery room. The patients must void before discharge as urinary retention can be an issue especially in bilateral hernias. The patients are instructed to avoid heavy lifting for several weeks postoperatively. Patients are followed in the office at 2 and 6 weeks.