Abdominal Wall: Minimally Invasive (Laparoscopic/Robotic) Inguinal Hernia Repair

Basics

• Mesh Placed in Preperitoneal Space
  • Also Prevents Femoral Hernias
  • May Not Be Possible if Prior Surgery Has Obliterated the Preperitoneal Space (Such as Prostatectomy)
• Absolute Contraindications:
  • Active Infection
  • Strangulation (Not Incarceration)
  • Unable to Tolerate Pneumoperitoneum
• Avoid Tacking in Triangles of Doom & Pain
  • Inferior to Iliopubic Tract
  • Lateral to Epigastrics

Critical View of the Myopectineal Orifice (MPO)

• The Appropriate Exposure of the Anatomical Area Viewed Prior to Mesh Placement During MIS Hernia Repair
• 9 Steps to Establish:
  • Identify and Dissect the Pubic Tubercle Across the Midline and Cooper Ligament (CL). For Large, Direct Hernias, Extend the Dissection to The Contralateral CL.
  • Rule Out A Direct Hernia. Visualize Anatomy Through the Inflated Balloon During Totally Extraperitoneal And Extended Totally Extraperitoneal Repairs to Detect A Direct Hernia Before Dissection. Remove Unusual Fat in The Hasselbach Triangle.
  • Dissect At Least 2 cm Between CL and The Bladder to Facilitate Flat Placement of The Medial and Inferior Edge of Mesh Toward the Space of Retzius, Thereby Avoiding Mesh Displacement Caused by Bladder Distention.
  • Dissect Between CL and The Iliac Vein to Identify the Femoral Orifice and Rule Out A Femoral Hernia.
  • Dissect the Indirect Sac and Peritoneum Sufficiently to Parietalize The Cord’s Elements. This Step Is Often Not Completed, Especially in A Small Surgical Field. To Ensure Compliance with This Requirement, Continue to Dissect Until the Cord’s Elements Lie Flat. Then, Visualize the Psoas Muscle and Iliac Vessels, Pull the Sac and Peritoneum Upward Without Triggering Movement of The Cord’s Elements, And Dissect Between the Cord’s Elements to Avoid Missing A Tail of The Sac.
  • Identify and Reduce Cord Lipomas (Which May Appear Small and Unimportant Until Reduced). Usually Lateral to The Cord’s Elements, They Should Not Be Confused with Lymph Nodes (Which Are Generally Spared). Most Lipomas Do Not Require Removal, But Should Be Placed Above the Mesh to Help Prevent Mesh Rolling Upward.
  • Dissect Peritoneum Lateral to The Cord’s Elements Laterally Beyond the Anterosuperior Iliac Spine (ASIS), Sweeping It Back Inferiorly Well Behind the Mesh’s Inferior Border.
  • Perform the Dissection, Provide Mesh Coverage, And Ensure That Mesh and Mechanical Fixation Are Placed Well Above an Imaginary Inter-ASIS Line and Any Defects, Thereby Avoiding Recurrence and Nerve Injury, Especially to The Ilioinguinal Nerve.
  • Place the Mesh Only When Items 1 to 8 Are Completed and Hemostasis Has Been Verified. Mesh Size Should Be At Least 15×10 cm, Although A Larger Piece of Mesh Is Sometimes Required to Cover The MPO. Preferably, Choose Mesh That Adapts to the Contour of The Space and the Cord’s Elements. It Should Not Have Undue Memory. Place It Without Creases or Folds. Avoid Splitting the Mesh. Ensure That Its Lateroinferior Corner Lies Deep Against the Wall and Does Not Roll Up During Space Deflation (Use Glue or Careful Suturing If Necessary).

TAPP vs TEP Comparison

• Comparison:
  • Overall Equivalent Operative Time, Cost, Complications, Pain & Recurrence
  • Possible Trends:
    • TAPP: Higher Visceral Injuries
    • TEP: Higher Vascular Injuries
  • In General Decision is Based on Surgeon’s Skill & Training
• Indications for TAPP:
  • Large Scrotal Hernia – Able to Visualize Herniated Viscera in Both Preperitoneum & Peritoneum
  • Significant Scarring of Preperitoneal Field
    • History of Lower Abdominal Surgery/Midline Laparotomy
    • History of Prostatectomy
    • History of Plug & Patch Repair
  • Uncertain Diagnosis when Laparoscopy Could Benefit
• Indications for TEP:
  • Bilateral Inguinal Hernias