Chapter 8B. Perspective on Hernias: Laparoscopic Inguinal Hernia Repair

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 dissected and hernias in women because of higher incidence of femoral recurrence with the usual anterior prosthetic repairs.2 Many laparoscopic surgeons believe that sliding hernias especially when reducible are more effectively approached laparoscopically than conventionally. Previous surgery in the retropubic space, intra-abdominal adhesions, scrotal hernia, incarcerated inguino-scrotal hernia, and the presence of ascites constitute relative contraindications.

Brooks and his colleagues have nicely described the basics of the surgical technique in the previous section. We would like to emphasize a few additional points. For the TAPP operation, it is important to dissect the entire symphysis pubis to the contralateral pubic tubercle for adequate coverage of the myopectineal orifice to prevent the all too common pubic tubercle recurrence. Additionally, it is very important to adequately mobilize the inferior peritoneal flap because the prosthesis tends to roll up in the limited space and may be a cause for recurrence. A large inguinal scrotal sac does not need to be removed in its entirety and can be divided at a convenient point along the cord structures with the proximal side ligated and the distal side left widely opened. This avoids an excessive incidence of hydrocele and the vascular disruption in the distal cord, which can lead to various testicular complications. Slitting the mesh to wrap around the spermatic cord is optional, and if done, care should be taken to adequately repair the mesh around the spermatic cord. Prosthesis fixation methods continue to be controversial with some authors in fact questioning the need to do so. Several methods of prosthetic fixation, including absorbable tacks and biologic tissue adhesives, have been evaluated in recent studies.3,4 Additionally, it has been hypothesized that if there is enough overlap of the myopectineal orifice, fixation should not be required. Nevertheless, we continue to fix the mesh and avoid placing tacks inferior to the iliopubic tract and lateral to the internal spermatic vessels as they have been implicated in posthernia repair groin pain, which can be debilitating.

The choice between TEP and TAPP repair is largely determined by the surgeon's training, experience, and personal preference. The literature generally favors TEP over TAP because of the avoidance of complications associated with entering the peritoneal cavity including visceral injury, vascular injury, adhesion formation, and trocar site hernias. In addition, peritoneal closure does not have to be performed since the dissection is extraperitoneal. However, these advantages are not universally embraced and in fact the largest series of laparoscopic inguinal hernia repairs in the world were largely TAPP repair.5

A large number of randomized control trials and meta-analyses have shown that patients who undergo laparoscopic hernia repair experience less pain in the early postoperative period, and have lower analgesic and narcotic requirements, better cosmesis, and early return to normal activities. Most comparative studies have shown equivalent complication rates between the tension-free repair and the laparoscopic approach. It is important to note here that most of these outcomes have been reported from specialized centers and may not be truly reflective of outcomes in the community. This was suggested by the often-quoted Veterans Administration (VA) cooperative trial comparing a laparoscopic preperitoneal inguinal herniorrhaphy (mostly TEP) with a standardized Lichtenstein approach.6 Recurrences were more common in the laparoscopic group (87 of 862 patients or 10.1%) than in the open group (41 of 834 patients or 4.9%) and this was statistically significant. The surgeons participating in this trial were well trained but did not have a specialty interest in hernia surgery. Thus, the selection of open versus laparoscopic has to be based on the expertise of the surgeon. Both the patient and the surgeon should weigh the risks and benefits of this approach before pursuing laparoscopic inguinal hernia repair. Although several studies in the past have tried to define the learning curve for laparoscopic hernia repair, the number of procedures recommended to gain proficiency continues to be variable.

The overall incidence of morbidity after laparoscopic inguinal hernia repair has been quite variable. Fortunately, serious complications are rare. These complications may be related to laparoscopy per se, the patient, the hernia, or the prosthesis. Over three quarters of the major vascular injuries occur during the insertion of the Veress needle or trocars. The risk of major vascular injury requiring operative repair is relatively low, around 0.8%.7 Despite the low prevalence, these injuries are associated with mortality up to 17%.8 Prompt repair of such injuries with formal laparotomy should be considered, as the true magnitude of the injury may not be truly appreciated laparoscopically. Occasionally, bowel or bladder injury occurs during the access phase of laparoscopy. Such injuries should be promptly repaired either laparoscopically or with laparotomy, depending on the experience and skills of the surgeon.

With improvement in laparoscopic skills and increased surgeon experience, the recurrence rates of laparoscopic hernia repair have become almost equivalent to those reported for conventional hernia repair. Chronic pain after hernia repair is an important adverse outcome and has been extensively discussed in the literature. Unfortunately, there is poor understanding of the pre-, intra-, and postoperative factors that cause the various pain syndromes. These pain syndromes could be somatic or visceral in nature (depending on the underlying cause) and can be difficult to treat. Initial treatment of all these pain syndromes is initially conservative with reassurance, anti-inflammatory medication, cryotherapy, and local nerve blocks. In case conservative measures fail to relieve patient's symptoms and other underlying causes have been excluded, groin exploration may be required. When exploring the groin in this situation, the surgeon must be prepared for possible mesh removal, which may be difficult because of the dense adhesions. Neurectomy, neurolysis, or neuroma excision should be reserved as a last resort. Occasionally, patients may develop infertility or the dysejaculation syndrome. These could be due to underlying injury to the vas deferens or extensive cicatrization around the vas deferens due to mesh-induced inflammation. These conditions, although rare, can be difficult to treat and usually have less than satisfactory outcomes.

The hospital cost for laparoscopic hernia repair is significantly higher than that for conventional hernia repair. However, when both direct and indirect costs are assessed in follow-up, there does not appear to be a significant cost difference. The direct operative costs appear to be compensated by the higher productivity attributable to earlier return to work.

In conclusion, laparoscopic inguinal hernia repair is an excellent alternative to conventional repair for the properly trained surgeon. Although appropriate for uncomplicated unilateral hernias, one must consider the risk/benefit ratio carefully because of the need for general anesthesia and the slight possibility of a disastrous laparoscopic accident that can be avoided with the conventional procedure. There is wide agreement that the risk/benefit ratio favors laparoscopy for patients with bilateral or recurrent inguinal hernias where the conventional space has been violated.