The patient must be a suitable candidate for general anesthesia. Anticoagulation, aspirin, and antiplatelet drugs such as Clopidogrel Bisulfate (Plavix) must be discontinued in advance of the procedure in order to avoid postoperative hematoma formation. Preoperative antibiotics should be administered intravenously within one hour of the incision.
All laparoscopic repairs use some form of prosthetic material. These include synthetic mesh created from polypropylene (Marlex or Prolene), Dacron (Mersilene), or polyester (Parietex). Expanded polytetrafluoroethylene (e-PTFE) (Gortex) is supplied as an extruded sheet. Mesh is generally preferred to e-PTFE because the structure allows fibrous in growth and hence greater fixation to the surrounding tissues. E-PTFE, composite mesh, or biologic materials are preferred in situations in which the prosthetic would be in touch with the intestine or other intra-abdominal organs, as it promotes less of a fibrous response and lessens adhesions to these structures. In this regard, e-PTFE has been modified to have polypropylene on one side. This so-called “dual mesh” might be useful in cases in which the mesh cannot be completely covered by peritoneum.
Fixation of the mesh is necessary to prevent migration and the tendency for the mesh to shrink overtime. There are a variety of tacking devices that may be used including helical coils, shaped like a key ring, and anchors. They may be absorbable or nonabsorbable metal. Most are delivered with 5-mm disposable instruments.
General endotracheal anesthesia is required.
The patient is placed in the supine position, and the arms are tucked. The operating room setup and port placements are shown in figure 1.
Skin hair is removed with a clipper. A catheter is placed in the bladder and removed at the end of the case.
Figure 1 shows the typical room setup for a left inguinal hernia repair by either TAPP or TEP. The surgeon stands contralateral to the hernia. The camera operator is next to the surgeon and the assistant directly across. One or two monitors may be positioned at the foot of the operating table. In this chapter, a left indirect inguinal TAPP is shown with the surgeon on the patient’s right side, whereas the TEP repair shown in Chapter 113 demonstrates a right direct inguinal repair where the surgeon would be positioned on the patient’s left side.
Figures 3 to 7 illustrate a TAPP for a left indirect inguinal hernia. The Hasson technique as described in Chapter 11 is used to gain access to the peritoneal cavity. A supraumbilical incision is made for placement of the Hasson trocar. The patient is placed in a gentle Trendelenburg position. A 10-mm 30-degree laparoscope is passed. Two 5-mm trocars are placed under direct laparoscopic vision in the right and left midabdomen at the level of the umbilicus (figure 1). A diagnostic laparoscopy is performed and the hernia spaces inspected for additional hernias. Utilizing the two lateral trocars, a peritoneal flap is created using laparoscopic scissors and electrocautery. The incision is begun lateral to the medial umbilical ligament, which should not be divided, as this may cause bleeding from a vestigial umbilical artery. An incision is made in the peritoneum 2 to 3 cm above the hernia sac and carried laterally to the anterior iliac spine. The preperitoneal space is entered and blunt dissection is carried out with a laparoscopic Kittner dissector in the avascular plane between the peritoneum and the transversalis fascia. For a direct hernia, the dissection is begun laterally to expose the cord structures and epigastric vessels. As the flap is dissected, the critical anatomic landmarks from medial to lateral include Cooper’s ligament, the inferior epigastric vessels, the vas deferens, and the lateral zone or fossa (figure 2). The sites of an indirect and direct hernia are shown. Care should be to avoid dissection in the area labeled the Triangle of Pain which contains sensory nerves (figure 2), injury to which may cause chronic pain in the inguinal region, testicle, or thigh. Likewise care is exercised to avoid dissection in the Triangle of Doom (figure 2), the area which contains the major vascular structures. A corona mortis, a branch of the inferior epigastric may be seen on the lateral edge of Cooper’s ligament in 30% of patients (Chapter 111). This must be avoided when dissecting Cooper’s ligament or tacking the mesh in order to prevent troublesome bleeding. The left indirect sac is carefully teased and dissected away from the cord structures as it is brought back into the preperitoneal space. A small indirect sac may be completely reduced, but a larger sac that extends into the scrotum may need to be divided. Downward traction on the cord structures facilitates dissection of fatty tissue in the spermatic cord (cord lipoma). The iliopubic tract is identified (figure 3). The peritoneal flap is developed inferiorly. Care is taken to avoid injury to the genital branch of the genitofemoral nerve and the lateral femoral cutaneous nerve (Chapter 111). After an inferior flap is created, the following structures are identified: the inferior epigastric vessels, the symphysis pubis, and the rectus abdominis. Dissection is then carried medially to the contralateral pubic tubercle to allow sufficient overlap for the mesh placement to cover all of the potential hernia spaces. Figure 3 demonstrates the final peritoneal flap and space.
For bilateral hernias, the space of Retzius is dissected through two lateral incisions avoiding division of the urachus. This creates a large common space connecting the two sides.
The mesh is introduced through the 10-mm trocar (figure 4). For a unilateral repair, the mesh can either be a preformed one or a sheet that is at least 15 × 10 cm in size. Although not shown in the illustrations for a bilateral repair, two similar sheets of mesh or one large (30 × 15 cm) may be employed. For the unilateral repair, the mesh is placed over the peritoneal opening so that it covers all of the hernia spaces (direct, indirect, and femoral). A wide overlap is necessary and extends from the contralateral pubic tubercle medially to the ipsilateral anterior iliac spine. The mesh is unrolled and positioned with generous overlap in all directions. A slit may be made for the cord structures. Tacking devices are applied medially to the superior edge and inferior one edge. This is facilitated by direct counter-pressure by the surgeon’s nondominant hand. The lateral edge aspect of the mesh is usually not tacked into place because of potential nerve injury (lateral femoral cutaneous and the femoral branch of the genitofemoral nerve). The mesh is secured medially to the tissues immediately adjacent to the contralateral and the ipsilateral pubic tubercle and Cooper’s ligament (figure 6). Any redundancy in the inferior edge of the mesh should be trimmed in order to avoid rolling up.
The next step is to close the redundant peritoneum over the mesh. The mesh needs to be completely covered. Once the mesh is in place, the patient is taken out of the reverse Trendelenburg position. Desufflation to 10 mm Hg is accomplished. The peritoneal flap is then tacked to the anterior abdominal wall or sutured closed (figure 7).