Chapter 8B

The transabdominal preperitoneal (TAPP) and the totally extraperitoneal repair (TEP) are the two most commonly performed types of laparoscopic inguinal hernia repairs. The intraperitoneal onlay mesh (IPOM) repair, the only truly minimally invasive laparoscopic hernia repair (because a radical dissection of the preperitoneal space is avoided), is rarely performed. Over the last decade, surgeons have become proficient in these procedures and an increasing number of laparoscopic repairs are being performed. Long-term follow-up data is now available, which shows that laparoscopic hernia repair has similar success rate as the conventional repair, with early return to work and possibly decreased overall cost.

Laparoscopic inguinal hernia repair requires that the surgeon appreciate the anatomy of the myopectineal orifice from a perspective opposite to that of the conventional anterior repair. Consequently, a detailed understanding of the anatomy of the deep inguinal region and the posterior aspect of the anterior abdominal wall is necessary to perform a laparoscopic inguinal hernia repair. The major nerves (five in number) in the region of the myopectineal orifice are all located lateral to the deep inguinal ring. The nerves, from lateral to medial, include the lateral femoral cutaneous nerve, anterior femoral cutaneous nerve, femoral nerve, femoral branch of the genitofemoral nerve, and the genital branch of the genitofemoral nerve. These nerve branches may be quite variable in their course and lie in the so-called triangle of pain, bordered medially by the gonadal vessels, anteriorly and inferiorly by the iliopubic tract, and laterally by the iliac crest.

On the other hand, the important vascular structures are located infero-medial to the deep ring. In some individuals, a vessel or vessels, which are usually referred to as “aberrant,” arise from the inferior epigastric system, arching over Cooper's ligament to join the normal obturator vessels, thereby completing a vascular ring. This is referred to as the corona mortis. Bleeding can be quite significant from it if attention is not paid during the dissection in this region. The internal spermatic vessels and the ductus deferens approach the deep inguinal ring from different directions, forming the apex of the triangle of doom, so called because the external iliac vessels, deep circumflex iliac vein, genital branch of the genitofemoral nerve, and the femoral nerve lie in this region.1

A tension-free open mesh repair is still the gold standard for the treatment of inguinal hernia and is usually performed under local anesthesia with sedation. Compared with this, the laparoscopic approach requires general anesthesia, is associated with higher in-hospital costs, and has a long learning curve. More importantly, the laparoscopic approach has the remote potential for a fatal complication such as major vascular or bowel injury.

Certain hernia types are better served by the laparoscopic approach. These include, bilateral hernias because both sides can be repaired from the same access ports, thereby pushing the risk/benefit ratio in favor of laparoscopy; recurrent hernias assuming the preperitoneal space has not been previously ...

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