Transabdominal Preperitoneal Hernia Repair

Transabdominal preperitoneal approach requires entry into the abdominal cavity. The patient is asked to empty the bladder prior to operation, and general anesthesia is administered. A Foley catheter is not routinely used in either laparoscopic approach. The patient is placed supine, and the monitors placed at the foot of the table. The surgeon stands on the opposite side of the inguinal hernia, and the abdomen is prepped from xiphoid to inguinal region, including the hernia. The initial trocar is placed using an open technique at the level of the umbilicus. We prefer to use a 10-mm trocar at this site allowing for a 10 mm 30° laparoscope.

Angled scopes are mandatory when performing laparoscopic transabdominal preperitoneal.

The 10-mm port allows for easy introduction of prosthetic mesh into the abdominal cavity. The patient is placed in Trendelenburg position, and diagnostic laparoscopy performed. The defect is identified and characterized as to either a direct or indirect hernia. The opposite side is also evaluated to rule out a double hernia. Two additional 5-mm trocars are then placed below the level of the camera and lateral to the rectus muscle. The use of a 20-gauge needle attached to a 10-cc syringe with local anesthetic allows for excellent visualization of each trocar site and for instillation of anesthetic into the peritoneum for postoperative pain control. Trocar placement lateral to the rectus muscle prevents injury to the epigastric vessels.

Familiarity with pelvic anatomy is crucial to performing a successful operation. The medial umbilical ligament contains the obliterated umbilical arteries and the lateral umbilical ligament contains the inferior epigastric vessels. A direct hernia defect is identified medial to the epigastric vessels and an indirect defect is lateral to the vessels and follows the cord structures through the internal ring.

Incising the peritoneum medially from the medial umbilical ligament to the anterior iliac spine laterally begins the operation. This peritoneal flap is further developed by bluntly pushing the fat and epigastric vessels toward the "ceiling." A wide pocket is required for adequate mesh placement. A large piece of mesh is required to provide adequate defect coverage and reduce the chance of recurrence. Dissection is then continued medially toward the pubic tubercle and Cooper's ligament. These structures are exposed using careful blunt dissection because numerous small crossing veins may be encountered and easily injured. The tubercle lies in the midline and can be felt with the instruments. Dissection is then continued laterally to expose the iliopubic tract and internal ring. Direct defects do not require manipulation of cord structures because the defect is only of the inguinal floor. When exposing this defect, the surgeon must reduce the hernia sac into the abdominal cavity. This is accomplished by retracting inferiorly on the peritoneal flap until the pseudosac of the floor, a white line that runs parallel to the inguinal floor, can be identified. The principle is to completely reduce the inverted peritoneum into the abdominal cavity and allows for complete coverage of the defect by prosthetic mesh. The indirect hernia courses along the cord structures through the internal ring. The reduction of an indirect hernia requires careful identification of the ductus deferens, which runs over Copper's ligament from medial to lateral, and other cord structures. Exposure of the direct space is also achieved when repairing indirect hernias. Blunt atraumatic graspers are used to carefully separate and reduce the indirect hernia away from the cord structures.

The fat surrounding the cord structures, known as cord lipomas, should be identified and removed. If this is not accomplished, patients may feel a recurrence has occurred.

Once the hernia has been reduced, a prosthetic mesh is placed into the abdominal cavity through the umbilical trocar. A large piece of polyprolene mesh that measures 10 X15 cm is preferred. The mesh is orientated so there is complete coverage of the direct and indirect space, and, most importantly, to cover the pubic tubercle where most recurrences occur. There have been no studies showing a benefit to creating a "slit" in the mesh to encircle the cord structures, and some authors feel that this may lead to cord ischemia. The mesh is then in place using a spiral tacker. The first tack is medially placed on the pubic tubercle and then along Cooper's ligament laterally. Next, the mesh is fixed to the "ceiling" of the inguinal floor along the posterior aspect of the transversalis fascia and then laterally above the iliopubic tract. The peritoneal flap is then reapproximated and tacked in place. The trocars are removed and fascia closed at the umbilical site.

Recent studies have shown the decreased necessity of fixation of the mesh in the totally extraperitoneal repair. This may lead to decreased postoperative neuralgia and decreased cost of surgery while not incur any an increase incidence of hernia recurrence.

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