Chapter 115: Repair of Inguinal Hernia, Laparoscopic Transabdominal Preperitoneal

INDICATIONS

The indications for inguinal hernia repair have been described in preceding chapters. The techniques that remain to be described include the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP). Laparoscopic repair may be applied to indirect, direct, or femoral hernias. Laparoscopic inguinal herniorrhaphy is contraindicated in the presence of intraperitoneal infection and irreversible coagulopathy and in patients who are poor risks for general anesthesia. Relative contraindications include large sliding hernias that contain colon, long-standing irreducible scrotal hernias, ascites, and previous suprapubic surgery. For totally extraperitoneal repairs, specific relative contraindications include incarceration and bowel ischemia. A thorough knowledge of the anatomy of the inguinal region is essential when it is approached posteriorly using a laparoscope. The view of this area as seen from the intraperitoneal perspective in the transabdominal preperitoneal repair, as well as the one from the preperitoneal perspective in the totally extraperitoneal repair, is shown in Chapter 114. In addition, proficiency with laparoscopic skills or mentored experience with this type of hernia repair is strongly recommended.

A. TRANSABDOMINAL PREPERITONEAL REPAIR

PREOPERATIVE PREPARATION

Patients must be suitable candidates 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 1 hour of the incision.

EQUIPMENT AND SUPPLIES

All laparoscopic repairs use some form of prosthetic material. Typically, bare permanent synthetic mesh is used. In situations where the peritoneum is unable to cover the mesh, a barrier-coated mesh is used with its visceral surface facing the bowel.

Fixation of the mesh is usually used to prevent migration and the tendency for the mesh to shrink over time. There are a number of absorbable and nonabsorbable tacks that may be used. Most are delivered with 5-mm disposable instruments. Self-gripping meshes and fibrin glue also have been employed to minimize the use of mechanical fixation if desired.

ANESTHESIA

General endotracheal anesthesia is required.

POSITION

Patients are placed in the supine position, and the arms are tucked. The operating room setup and port placements are shown in FIGURE 1.

OPERATIVE PREPARATION

Skin hair is removed with a clipper. A catheter is placed in the bladder if deemed necessary by the surgeon and, if so, is usually removed at the end of the case. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

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 holder is next to the surgeon and ...