Totally Extraperitoneal Approach in Inguinal Hernia Repair

Abstract

Inguinal hernia can be repaired endoscopically via three methods namely total extraperitoneal (TEP), transabdominal pre-peritoneal (TAPP), and the less common intraperitoneal onlay mesh (IPOM) repair. The first two are widely utilized for the obvious advantages of lower recurrence and complication rates, and better outcome (less pain, less analgesic reqirement, less surgical site infection, reduced length of hospital stay, early return to daily activity, etc.) when compared to the open repair while covering all the potential hernia site in the myopectineal orifice with a large prosthesis [1, 2]. The TEP approach has a lower risk of intra-abdominal injury to organs and postoperative adhesions. On the other hand, in the TAPP approach, the contralateral side can be examined for occult or undiagnosed hernia and it can be useful as a diagnostic tool in an emergency hernia repair of irreducible cases.

Introduction

Inguinal hernia can be repaired endoscopically via three methods namely total extraperitoneal (TEP), transabdominal pre-peritoneal (TAPP), and the less common intraperitoneal onlay mesh (IPOM) repair. The first two are widely utilized for the obvious advantages of lower recurrence and complication rates, and better outcome (less pain, less analgesic reqirement, less surgical site infection, reduced length of hospital stay, early return to daily activity, etc.) when compared to the open repair while covering all the potential hernia site in the myopectineal orifice with a large prosthesis [1, 2]. The TEP approach has a lower risk of intra-abdominal injury to organs and postoperative adhesions. On the other hand, in the TAPP approach, the contralateral side can be examined for occult or undiagnosed hernia and it can be useful as a diagnostic tool in an emergency hernia repair of irreducible cases.

Indications

• Patient with primary or recurrent reducible inguinal hernia

• Fit for general anesthesia

Contraindications

• Not fit for general anesthesia

• Acute abdomen with strangulated and infected bowel

• Respiratory distress

• Pediatric patients

Relative Contraindications

• Irreducible Hernia

• Sliding Hernia

• Inguino-scrotal Hernia

• Previous prostatectomy or pelvic surgery

• Previous TEP/TAPP Repair

Previous lower abdominal surgery is a relative contraindication. Adhesions can pose difficulty for the attending surgeon, and thus a surgeon who is attempting this should be skilled in doing both TEP and TAPP. But it should be explained to the patient that there is also a possibility that the operation can be converted to an open approach as deemed necessary by the surgeon. Previous open appendectomies are usually not a problem but requires one to be more careful during the lateral dissection.

Recurrent hernia from a previous TEP is a relative contraindication. This can still be done through TEP depending on the expertise of the surgeon.

Large inguinoscrotal hernia is also a relative contraindication depending on the experience of the surgeon since there would usually be a distorted anatomy and limited working space in this kind of inguinal hernias.

Preoperative Preparation

A thorough history and physical examination are necessary to assess the patient including the fitness for general anesthesia. If there is any doubt in the diagnosis of the inguinal hernia (large defect, sliding hernia, multiple recurrent, etc.) it may be prudent to do a preoperative imaging work-up by dynamic ultrasound or CT scan.

It should also be explained to the patient that there might be a risk of conversion to transabdominal pre-peritoneal (TAPP) inguinal hernia repair or open approach depending on the difficulty and safety of the procedure, which is based on the judgment of the operating surgeon. Risk for recurrence and complications should also be properly explained to the patient including vascular, nerve and vas injury, seroma, mesh infection, postoperative chronic pain, etc. [3].

Prophylactic antibiotic is recommended in the presence of risk factors for wound and mesh infection based on patient status (advanced age, recurrence corticosteroid use, immunosuppressive conditions, obesity, diabetes, and malignancy) or surgical factors (contamination, long operation duration, use of drains, urinary catheter) [4, 5].

Patient should also be advised to void prior to the procedure. However, in cases of complicated hernias (partially reducible, large defect, and/or the length of surgery more than 1.5 h) it is advisable to insert a urinary catheter, which can be removed at the end of the procedure.

Operating Theater Setup

Instruments

• 10 or 5 mm, 30° angled telescopes.

• Trocars

  • 10 mm Hasson’s trocar

  • 5 mm trocar

• Balloon dissector

  Based on the IEHS guidelines, it is recommended to use a balloon dissector when creating the preperitoneal space to decrease operative time, especially during the learning period, when it is difficult to identify the correct preperitoneal plane and space [5]. Once the learning curve is overcomed, to reduce the cost of the procedure, a blind dissection can be achieved by swiping the telescope along the midline. A self-made dissector balloon can be arranged using finger gloves over an irrigation device.

• Graspers and atraumatic graspers

• Scissors, Hook

• Prosthetic mesh

  It is advisable to use a large pore polypropylene or multifilament polyester mesh with a size of at least 10 × 15 cm. Using a smaller mesh will increase the risk of recurrence. However, for larger defects of more than 3–4 cm (L > 3 according to EHS classification [4, 5] it is recommended to use a larger mesh (12 × 17 cm)

• Tackers and Fixation devices

  According to the IEHS Guidelines, fixation of the mesh is required only in particular cases like large hernia defect (>3–4 cm) especially in direct hernia to avoid translation of the mesh and to reduce the risk of recurrence [5]. Today either absorbable or permanent staplers/tackers are utilized to fix the mesh to the Cooper’s ligament and to the rectus muscle. Sealants in the form of Fibrin Glue (Tisseel or Tissucol, Baxter USA) or synthetic glue (Liquiband, AMS UK; Histoacryl, BBraun, Germany; etc.) are also available and several studies have shown their efficacy and benefits.

• Endoloops

  Pre-made loop sutures are useful for closure of inadvertent tears in the peritoneum and ligation of the hernia sac. Based on the IEHS guidelines, it is recommended to close any peritoneal tears to decrease the risk of adhesions which may lead to bowel obstruction. If not available, the loop can be made using a 50–70 cm absorbable suture and an extracorporeal Roeder’s knot.

Patient and Surgical Team Positioning

The patient is in a supine position under general anesthesia. The operating table is in a slight Trendelenberg position (10–15°) with both arms tucked at the sides. The attending surgeon stands at the opposite side of the hernia defect and the assistant stands beside the attending surgeon at the cephalad side of the patient (Fig. 1). The nurse then stands on the same side as the surgeon, near the feet of the patient. The monitor and video equipment are then placed at the caudal end of the operating table which can be midline or slightly ipsilateral to the defect. Monitors mounted on the boom arm will be helpful in improving visual space.

Fig. 1

Surgical team position

Surgical Technique

Entering and Creating the Preperitoneal Space

There are a few techniques to enter and create the preperitoneal space:

A 10 mm vertical/horizontal infraumbilical incision is first done. Subcutaneous tissue is bluntly dissected to expose the anterior rectus sheath using (2) S-retractors. The anterior rectus sheath is then incised, lateral from the midline, on the ipsilateral side of the hernia. This will avoid the linea alba and accidentally enter the peritoneal cavity. Then the rectus muscles are retracted laterally to expose the posterior rectus sheath.

Once the preperitoneal plane is entered, there are few techniques to create the space: (1) the optical balloon dissector; (2) the Veress’ needle technique; and (3) the most common blunt dissection. Using the trocar with an optical balloon dissector, the space is created by inflating the balloon under vision (Fig. 2). This is the plane one should maintain and create up to the symphysis pubis using a gauze, finger, or a dissecting balloon depending on the preference and expertise of the surgeon. A Hasson’s trocar is then inserted, and the plane is confirmed by inserting a 30° trocar. The rectus muscle should be visualized at the anterior area to be in the right plane. Insufflation is done with carbon dioxide at 8–12 mmHg.

Fig. 2

Ballon dissector

Two 5 mm trocars are then inserted at the midline under direct vision to prevent any injury to the bladder, peritoneum, or bowels. The first 5 mm trocar is placed three fingerbreadths above the symphysis pubis. The second 5 mm trocar is then placed in between the Hasson’s trocar and the first 5 mm trocar (Fig. 3).

Fig. 3

Trocar placement

Medial Dissection (Retzius or Pre-vesical Space)

Once all the working ports are inserted, using two atraumatic graspers, the dissection is conducted along the midline, below the rectus muscle and towards the pubis arch. The first landmark, cooper’s ligament should be identified and is an excellent starting point for dissection. Dissection should follow the preperitoneal plane. Fatty tissue present in the preperitoneal space should be kept in contact with the inguinal floor and not with the peritoneum. The dissection should go 2 cm beyond the symphysis pubis till the obturator fossa to avoid missing any obturator hernia and to allow the medial lower corner of the mesh to be fixated once the space is deflated (Fig. 4). The limits of the dissection are medial, 1–2 cm beyond the midline and below the pubis arch; inferiorly till the peritoneal reflection is identified at the border with the retroperitoneal space.

Fig. 4

Space of Retzius

Lateral Dissection (Lateral Space of Bogros)

Moving towards the anterior superior iliac spine (ASIS), in a surgical plane that is below the inferior epigastric vessels (IEV) and above the peritoneum, the lateral dissection is made. This plane is confined by the two layers of the fascia transversalis. The dissection is continued by pushing down the peritoneum until the psoas muscle can be seen. The lateral space of Bogros is delineated and cleaned all the way up to the anterior superior iliac spine. Attention should be made to avoid dissecting further laterally, beyond the lumbar fascia in the so-called lateral triangle of pain. This will prevent injury of the latero-cutaneous and genitofemoral nerves. The thin layer of fat covering the lateral fascia should be preserved and not skeletonized, similar energy and diathermy should not be used at this level (Figs. 5 and 6). Limits of the lateral dissection are inferiorly the psoas muscle, superiorly the ASIS, and cranially the arcuate line.

Fig. 5

Triangle of pain and triangle of doom

Fig. 6

Lateral cutaneous nerve at the Space of Bogros

Hernia Sac Identification and Reduction

Once the medial and lateral dissections are completed (Fig. 7), we should be able to identify all the hernia defects followed by a proper hernia sac reduction and repair. This will allow the surgeon to visualize all the anatomical landmarks, lessen the risk of injuries, have a wider space for placing the prosthesis and in case of

Fig. 7

Anatomic Landmarks in Endo-laparoscopic inguinal hernia repair

inadvertent tear of the peritoneum to continue to work safely without being affected by the pneumoperitoneum.

The exposure of the whole Myopectineal Orifice should be made after a complete medial and lateral dissection followed by the hernia sac reduction (Fig. 8).

Fig. 8

Myopectineal orifice, left

Hernia Reduction

Medial or Direct Hernia

In endo-laparoscopic approach, a defect medial to the inferior epigastric hernia and at the level of the Hesselblack triangle is a direct hernia. The reduction can be easily achieved by identifying and holding the hernia “pseudosac” and dividing it from the preperitoneal lipoma and peritoneum. When dissecting the direct hernia, the surgeon must remain in the correct plane in order to avoid injuring the bladder if it is part of the hernia. Careful dissection is done at the level of the pubis arch to avoid injury of the “corona mortis” and laterally of the iliac vessels and vas deferens. The pseudosac is grabbed, and the hernia contents are then reduced.

Femoral Hernia

The reduction of the hernia sac and content is achieved by gentle traction keeping in mind that the vessels hide behind the content (Fig. 9).

Fig. 9

Femoral hernia, right

If the content is not reducible by traction due to the small size of the defect, it may be necessary to widen the femoral defect by using a hook diathermy ONLY on the medial-upper side (Fig. 10). This will facilitate the hernia sac reduction.

Fig. 10

Widening of the femoral ring using a hook diathermy at the medial-upper side

Obturator Hernia

In the same canal where the obturator vessels are, it is possible that preperitoneal fat and/or hernia sac is within. Gentle traction will allow the reduction of the hernia sac (Fig. 11).

Fig. 11

Obturator hernia, left

Indirect Hernia

Lateral to the IEV, lies the deep ring and the indirect hernia. The standard approach to indirect hernia repair requires the spermatic structures to be separated from the hernia sac. This can be achieved using the medial approach and four simple steps: (1) Separate the whole sac and spermatic cord from the iliac vessels; (2) Slim the sac at the level of the deep ring with a partial reduction of both cord structures and sac; (3) Separate the cord structures from the sac on the inferior edge of the sac; and (4) Sac reduction by simple traction. Transection of the sac may be necessary in cases of long or complete sac to minimize injury to the testis by overtraction. It is suggested to divide the sac using diathermy to reduce the risk of hematoma and to ligate the proximal part using pre-made suture loop. Lipoma of the cord should be fully reduced.

Parietalization of the elements of the cord is considered sufficient when the peritoneum is dissected inferiorly until at least at the level at which the vas deferens crosses the external iliac vein and the iliopsoas muscle is identified.

In women, round ligament of the uterus is usually adherent to the peritoneum. Transection of the round ligament is then recommended, at least 1 cm proximal to the deep ring to avoid injury of the genital branch of the genitofemoral nerve at this location.

It is important to close all peritoneal holes/tears with absorbable suture loops or plastic clips (i.e., hem-o-lok, Teleflex Medical, USA) to prevent any internal herniation or adhesion formation with the mesh.

Mesh Repair

The final step is the hernia repair and it is achieved by covering all the myopectineal orifice with a synthetic large pore prosthesis of 10 × 15 cm. The mesh is rolled and inserted through the 10 mm trocar. A “no-touch technique” is mandatory to avoid mesh infection. The mesh is opened and inserted into the preperitoneal cavity avoiding any contact with the skin. The mesh is then placed horizontally and unrolled over the myopectineal orifice making sure to cover all the hernia sites. One-third of the mesh should be below the symphysis pubis, the upper margin reaching the lower trocar medially and laterally lining over the psoas muscle. In bilateral hernias, there should be a 1–2 cm overlap of the meshes at the midline. It is important to make sure that no part of the peritoneum is under the mesh to prevent any recurrence. The mesh should be placed without wrinkles or folds and should not be split to avoid chronic pain or recurrence.

The mesh is then anchored using tackers or sealant to prevent mesh migration and possible recurrence. Two to three point fixations are necessary: the Cooper’s ligament, medial to the inferior epigastric vessels at the rectus muscle and if necessary lateral to the inferior epigastric vessels. Avoid tackers or stapler fixations below the ilio-pubic tract and too laterally considering a 15–20% of abnormalities in the nerves path. This will help prevent any nerve injuries and consequent postoperative chronic pain.

An accurate hemostasis should be guaranteed if the correct surgical plane is identified. The carbon dioxide is then released while visualizing that the mesh is not rolled, and the peritoneum stays in front of the mesh to prevent any recurrence. The lateral inferior edge of the mesh can be held with a grasper, if necessary. The ports are then removed and the anterior rectus sheath incision at the 10 mm trocar site is sutured. The skin incisions are then closed with absorbable sutures or glue.

Postoperative Care

• Diet, as tolerated, is resumed

• Analgesia is given (etoricoxib 90 mg daily for 3 days)

• Patient is discharged on the same day once voiding freely

• Follow-up is at 1 week, 1, and 3 months

Complications

Complications can be categorized into intraoperative and postoperative complications. Intraoperative complications specific to TEP occur in about 4–6% of the cases and can be due to vascular, visceral, nerve, and spermatic cord structures injury [6,7,8]. Vascular injuries would include injury to the external iliac vessels, inferior epigastric vessels, spermatic vessels, or the vessels over the pubic arch including the corona mortis veins. The most common is the injury of the IEV and this can be avoided by using the midline approach and by inserting all the ports under direct vision. Injury to the major vessels are catastrophic, a correct lateral traction of the sac and spermatic structure with a medial approach may be helpful in avoiding it. Visceral injuries including but not limited to the bowels and urinary tract can be reduced by careful dissection and limiting the use of diathermy. Transmitted energy through the thin peritoneal layer may result in injury of the bowel underlying. Patients with previous pelvis surgery, sliding hernia, or large inguinoscrotal are at risk for bladder injury, in this case a urinary catheter may be necessary. In case of injuries, they can be managed by an endolaparoscopoic suture repair. Nerve injuries can be prevented by accurate lateral dissection, limiting the number of staplers/tackers if fixation is needed, and the use of absorbable tackers or sealant. Spermatic cord injuries can be lessened by properly identifying the anatomy and avoiding too much traction of the cord. Tears in the peritoneum can also occur especially during the early stage of the learning curve. All peritoneal tears should be closed by using suture loops or hem-o-loks.

Postoperative complication like seroma commonly occur in patients with large direct and indirect hernia, the seroma usuall appear after 7–10 days and do not require any treatment. It may be mistaken for an early recurrence. In principle, it should be treated conservatively and will be reabsorbed spontaneously within 4–6 weeks. However, if it is symptomatic and persists after 2 months it is advisable to drain by aspiration and in sterile condition. In cases of complex sero-hematoma, an excision after 4–5 months should be considered.

Early recurrence is usually due to inadequate surgical technique and can be due to wrong case selection for beginners, inadequate fixation of the mesh, inadequate mesh size, inadequate dissection of the myopectineal orifice, and failure to cover unidentified hernia defects [9].