Laparoscopic inguinal hernia repair

TAPP Laparoscopic Repair

• Trans-abdominal pre-peritoneal patch repair
• Incise peritoneum only and create a flap to do repair, and then close peritoneum over this again
• Pre-peritoneal space is then entered by incising the peritoneum transversely from the region of the median umbilical ligament laterally
• Anterior to the hernial defect
• Peritoneal flaps then developed
• Direct and small indirect sacs fully reduced
• Larger indirect sacs are part dissected and having freed the cord structures posteriorly, circumcised
• 15 x 10 cm mesh fashioned and inserted
• Medial border of mesh adjacent to symphysis pubis
• Posterior part placed well behind internal ring
• Stapled in place
• Staples applied to the pubic bone and Cooper’s ligament
• Further staples placed into muscle layers anteriorly
• None into or posterior to the iliopubic tract
• Peritoneum then reconstituted (running suture)

TEP Laparoscopic Repair

• Total Extra-Peritoneal Repair
• Good for – Recurrent, bilateral
• Becoming more common for primary hernias
• Earlier return to work with less pain
• But ? More complications and recurrence
• Contraindicated if:
  • Hernia still irreducible once anaesthetised
  • Previous complicated pelvic surgery
  • Significant cardiovascular disease or severe COPD

Anatomy

• Space created in pre-peritoneal plane
• Safe places to staple
  • Pubic tubercle
  • Cooper’s ligament
  • Above Iliopubic tract laterally

Technique

• Entry
  • Sub-umbilical incision
  • Dissect onto rectus sheath
  • Mobilise laterally opposite to hernia side
  • Vertical incision over muscle 2cm long ≈ 2cm from midline
  • Mobilise rectus laterally
  • Finger dissection into preperitoneal space
  • Can usually reach down to symphysis
  • Insert Hasson - inflate (or insert inflation balloon to create space)
    • 20x inflate under vision, wait with tamponade, then release
  • Insert 2x 5mm ports in midline
• Disection
  • Identify & preserve inferior epigastrics, keep on superficial aspect
  • Blunt dissection to reveal & identify
    • Symphysis pubis
    • Develop retroprostatic space
    • ASIS
    • Inguinal ligament
    • Identify position of iliac vessels
    • Identify deep ring
  • Direct hernia will often reduce spontaneously
  • Indirect
    • Tease out from cord
  • Careful of perforation of peritoneum
  • Unequivocal identification of vas & vessels — Reduce sac fully or divide
• Mesh
  • Roll 10x15cm mesh on grasper, (cut 1 corner) & insert through 10mm port
  • Roll out, use cut corner for orientation
  • Staple to pubic bone (above pubic bone not directly into), Cooper’s ligament, 2cm above Iliopubic tract & laterally
  • Keep sac on peritoneal side, vessels on wall side
  • Deflate under vision - Keep mesh in position
• Remove ports
  • Close with 1 vicryl UR6 to sheath & 3-0 monocryl to skin