Introduction

History of inguinal hernia is as old as history of surgery itself. Bassini in 1887 published his original description of inguinal hernia repair with a later modification to Shouldice repair in 1945. Two real revolutions which have changed the hernia repair completely are the Lichtenstein “tensionless” mesh repair in 1989 and the introduction of laparoscopic surgery to hernia repair in the early 1990s [1].

Shortly afterward, surgeons have not only published their early experiences on laparoscopic intraperitoneal mesh (IPOM) (Fig. 1) repair of inguinal hernia but also described two major modifications to it—the transabdominal pre-peritoneal repair (TAPP) and the totally extraperitoneal (TEP) repair. Such is the practice of modern science at a brisk pace [2].

Fig. 1
Image is an internal view of a part of some muscles. It has a white skin-like patch on the lower side.

Laparoscopic IPOM for inguinal hernia

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Transabdominal Pre-Peritoneal (TAPP) repair, as compared to its counterpart TEP, provides easy learning in correlation to peritoneal and pre-peritoneal anatomy. This technique involves a diagnostic laparoscopy followed by an incision on peritoneum, careful blunt dissection to create peritoneal flap, reduction of hernia sac, placement of mesh, and closure of peritoneal flap again [3, 4].

Indications

  • Reducible primary inguinal hernia (Figs. 2 and 3)

  • Recurrent inguinal hernia after previous open repair

  • Sliding inguinal hernia

  • Hernia with adhesions at hernia orifices

  • Alternative to difficult TEP

Fig. 2
Image is an internal view of a part of an organ. It has a small bulge on the right side of the image.

Right direct inguinal hernia

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Fig. 3
Image is an internal view of a part of an organ that seems swollen and has veins all over it. It has a small bulge on the left side of the image.

Left direct inguinal hernia

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Contraindications

  • Inability to tolerate general anesthesia

  • Clotting disorders

  • Peritonitis

  • Incarceration (relative)

  • COPD

  • Previous posterior mesh repair (relative)

  • Prostatectomy (relative)

  • Previous lower midline surgical incision (relative)

  • Previous pelvic surgery for TAPP

  • Ascites

Preoperative Preparation

  • Antibiotic prophylaxis

  • Empty bladder for primary unilateral inguinal hernia

  • Foley’s catheter for bilateral or recurrent inguinal hernia.

Operative Setup, Patient’s Position, and Trocars Placement

  • Monitor position: Position of monitor should be at patient’s foot end, contralateral to surgeon’s position. The Surgeon stand on the opposite side of the inguinal Hernia.

  • Instrumentation required

    • Veress Needle or Hasson’s Trocar for access

    • 30° telescope 10 mm

    • Atraumatic Graspers (2) 5 mm

    • Curved Scissors (1) 5 mm

    • Hook diathermy (1) 5 mm

    • Bowel Clamp (1) 5 mm

    • Suction/irrigation device

    • Endostaplers for mesh fixation 5 mm

    • Hemolock Clip applicator (1) 5 mm

    • Endoloop (1) (Optional)

  • Patient’s position

    • Patient should be in supine position with Trendelenburg position 15°

    • Surgeon stands on contralateral side of hernia and assistant stands behind or opposite to surgeon

    • Anesthetist should be reminding of endotracheal tubing positions due to the risk of collision of laparoscope cable with the tube.

  • Trocars size and position ( Fig. 4 )

    • 10–12 mm periumbilical trocar

    • 2 × 5 mm cannula are inserted on the right and left flank for a good triangulation

Fig. 4
A diagram of a human body in the centre, a structure below represents a monitor, 3 people on either side, one on the left and 2 on the right side. The left person is labeled C A, and the right side persons are labeled O S and S N. Few markings on the body, 3 small on the upper part and 1 large on the lower part of the body.

Patient’s and surgical team position; suggested trocars location

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Surgical Technique

  • General anesthesia with muscle relaxation is administered.

  • 1–2 cm infraumbilical incision is made. Peritoneal cavity is entered either by creating the pneumoperitoneum with Veress needle or using open technique by Hasson’ Trocar. Pneumoperitoneum is established with CO2 pressures at 10–12 mmHg

  • Two 5 mm trocars are inserted on either side of the camera port.

  • The first step is to identify key anatomical landmarks (Figs. 5 and 6) such as [5]:

    • the pubic bone,

    • the medial umbilical ligament

    • the inferior epigastric vessels (IEV)

    • the anterior superior iliac spine (ASIS) by external palpation

  • The definition of the type of hernia is in relation to the IEV (Fig. 7)

    • direct hernia: is medial to IEV

    • indirect hernia: is lateral to IEV

    • femoral hernia: is medial to the IEV and to the iliac vessels

  • The next step is to reduce the hernia content into the abdominal cavity (Fig. 8). An atraumatic grasper or a bowel clamp is preferred to minimize any trauma to the contents of the hernia. It is advisable to avoid traction over the bowel and should attempt graded external compression.

  • The peritoneal dissection starts laterally below the ASIS and about 5 cm above the upper limit of the hernia sac (Fig. 9a, b). The peritoneum is opened towards the midline by using diathermy hook or scissors and dissected inferiorly by blunt dissection. Peritoneal flap should be high enough to allow 2 cm overlap to avoid exposing the edge of the mesh. If incision is too low, then the surgeon may try to push the mesh down which may crumple the mesh and ultimately suboptimal positioning.

  • The indirect hernia sac is reduced and separated from the spermatic cord (Fig. 10).

  • Occasionally, large indirect sacs cannot be completely reduced, and in such cases, the sac can be divided, and the proximal end should be ligated with a preformed laparoscopic loop ligature (Fig. 11). Alternatively, the sac can be ligated with a suture after ensuring it is empty and then can be divided distal to the ligated site.

  • The final step is the mesh positioning and fixation. A rolled large pore polypropylene mesh (10 cm by 15 cm in size) is inserted through the 10 mm port, and with the use of graspers, the mesh is placed horizontally covering the myopectineal orifices from the midline of the pubis to lateral space of Bogros and inferiorly 2 cm below the pubic arch. The mesh is then anchored with laparoscopic absorbable tacks or staplers to Cooper’s ligament and lateral to the IEV high at the abdominal wall to avoid the cutaneous nerves. This will help to prevent any mesh migration especially in case of large direct or indirect hernia. Mesh fixation is not necessary in smaller inguinal hernia [6]. A selective fixation for large hernia should be adopted (EHS classification; hernia defect > L2 and M2). Tacking should be avoided below the ileopubic tract and laterally below the ASIS where the risk of injury to the genito-femoral nerve and lateral femoral-cutaneous nerve of thigh [7] (Fig. 12).

  • Mesh fixation is still a debatable topic. There is recommendation for fixation in patients with recurrent or large hernia (>3 cm). We suggest fixation in all large hernia during the early learning curve [8].

  • Fibrin glue has been advocated as an alternative method of fixation, comparable to tacker and several studies have shown similar results between stapler fixation and fibrin glue with reduced risk of postoperative chronic pain [9, 10].

  • Last step is adequate hemostasis and the closure of the peritoneum flap over the mesh by using:

    • Absorbable Tackers

    • Hemolocks

    • Continuous Absorbable suture (Fig. 13)

  • It is advisable to close the peritoneal flap with continuous absorbable sutures under direct vision instead of tackers or staplers which can cause injury to the neurovascular structures located behind the peritoneum and the mesh. Care must be taken to avoid leaving gaps during the closure, as it may expose the mesh to the bowel which may lead to future adhesion formation or even fistulation.

  • Fascia at the Infra umbilical 10 mm port site must be closed.

  • Skin at the two 5 mm port site are closed with absorbable sutures or glue.

Fig. 5
A graphical image for different types and positions of hernia. It has 3 regions for femoral hernia, direct inguinal hernia, and indirect inguinal hernia.

The anatomy and landmarks of the myopectineal orifice (MPO) of Fruchaud

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Fig. 6
A graphical image of anatomy and position of different components. It has labels for inferior epigastric vein, M M transverse abdominis, M M rectus abdominis, femoral branch, indirect hernia, direct hernia, cooper ligament, pubis, vas deferens, femoral hernia, laterocutaneous n, genito femoral n, supermatic vessel, and external iliac vessel.

The anatomy and landmarks of the myopectineal orifice (MPO) of Fruchaud

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Fig. 7
An interval view of a section of the body. 6 regions are marked by arrows, lateral umbilical fold or inferior epigastric vessel, medial umbilical fold or umbilical artery, median umbilical fold or urachus, indirect inguinal hernia, vas deferens, and testicular vessel.

Type of hernia in relation to IEV

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Fig. 8
An interval view of a section of the body. two operating devices resembling rods are in the operating section.

Reduction of hernia content

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Fig. 9
A, 6 regions, epigastric vessels, medial umbilical ligament, vas deferens, iliac artery, A S I, and testicular vessels. A mark for wide opening of the peritoneum. The text at the top reads first view colon 30-degree optic head down position, on right, the position of the peritoneal incision. B, 2 pictures, label reads recommendation colon grade d.

(a) Landmarks and incision of the peritoneal flap (black line). (b) Incision of the peritoneal flap using diathermy hook or scissor

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Fig. 10
Two images. Image A of an internal view. Two regions labeled inferior epigastric artery, and hernia sac separated and retracted from vas structures. A region marked with a triangle, labeled triangle of doom. Image B, Two graphical representations with regions marked as triangle of doom. The appearance of the content inside the triangle is different.

(a) Indirect hernia sac is reduced and separated from the spermatic cord. (b) Indirect hernia sac is reduced and separated from the spermatic cord Figure

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Fig. 11
An internal view of an object placed on a spot. The spot looks bulged. The text on the image reads, closing the peritoneal sac.

The Indirect hernia sac is divided and ligated using an endoloop

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Fig. 12
A view of an internal section of the body. A flap in the center with an object placed on it.

Placement of an anatomical mesh in pre-peritoneal space with TAPP

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Fig. 13
A view of an internal section of the body. An instrument holds a spot on the section. A small suture is on the section.

Continuous absorbable suture is utilized to close the peritoneal flap

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Postoperative Care

  • Standard Analgesia

  • Discharge the patient when the patient can ambulate and pass urine

  • Avoid activities that require straining for up to 2–4 weeks

Postoperative Complications and Management [5]

  • Seroma

    • Almost evident in majority

    • Size is important to determine the outcome

    • Avoid unnecessary dissection

    • Usually gets resolved spontaneously

  • Bleeding

    • Injury to inferior epigastric vessels, spermatic vessels, and iliac vessels

    • Stop anticoagulation before surgery

    • Careful identification of vessels and dissection

    • Avoid rough dissection

    • Small hematoma would resolve in weeks, larger hematoma may require aspiration or surgical drainage but preferably done few weeks later to avoid mesh infection

  • Acute urinary retention

    • Early mobilization

    • Preoperative counseling

    • Adequate analgesia

    • Foley’s catheter may be inserted if patient is unable to pass urine after several attempts

  • Injury to surrounding structures

    • Good knowledge of groin anatomy in the extraperitoneal plane is important

    • Injury to vas could be devastating, avoid holding vas and vessels

    • Care must be taken while parietalization of the peritoneum

    • Judicious use of surgical energy to avoid bladder and bowl injury

  • Postoperative pain

    • Careful dissection in triangle of pain

    • Avoid injury to nerves

    • Absorbable tacking instead of metallic tackers and avoid any fixation over the triangle of pain

    • Prefer glue over tackers

  • Mesh infection

    • Maintain sterility during the entire surgery

    • Non touch technique during handling the mesh

    • Prophylactic antibiotic

    • Careful inspection of surgical site after surgery

    • Early explanation of the mesh is advisable if mesh infection is suspected

  • Recurrence

    • Look for contralateral orifice where possible

    • Adequate dissection

    • Appropriate mesh size

    • Proper orientation of mesh placement

    • Adequate medial coverage and overlap

Conclusion

Both techniques of endo-laparoscopic inguinal hernia repair (TEP and TAPP) are comparable in terms of the surgical outcomes [11]. Tailored approach in groin hernia repair by considering patient factors and surgeon’s expertise is recommended.