Laparoscopic surgery represents a historical
surgical watershed ushering a new era of technology dependent surgery. Laparoscopy today is firmly established in the armamentarium of surgeons worldwide. Once the technology and tools were available, there was a quantum jump in the application of laparoscopic techniques to include diverse therapeutic surgical procedures, which included the inguinal hernia repair.
The initial enthusiasm for laparoscopic herniorrhaphy was driven by dissatisfaction with the pain, disability and recurrence following traditional anterior hernia repairs. The first laparoscopic approach to the problem of groin hernia is credited to Ger who intraabdominally stapled the neck of a hernial sac in 1982. Schwartz in 1990 described a plug repair. Arregui has described the transperitoneal repair whereas Mckernan and Phillips developed the totally extraperitoneal repair. The intraperitoneal onlay mesh repair was developed by Franklin and Rosenthal.1
Principle of Laparoscopic Repair
Over the past decade, laparoscopic hernia repair has changed from an operation in evolution to several well defined techniques of transperitoneal or totally extraperitoneal approaches. Almost all laparoscopic repairs are now based on the principle of Stoppa’s repair. All accomplish a posterior reinforcement of the myopectineal orifice of Fruchaud with prosthetic material thus taking care of existing and potential hernial sites (direct, indirect and femoral).2 Effectiveness of this type of repair has been well established by the open operation of Nyhus and Stoppa. The laparoscopic approach mimics this and can be considered as a new method of performing an old established open operation.
There are two techniques available for preperitoneal herniorrhaphy – the Total extraperitoneal repair (TEP) and Transabdominal preperitoneal repair (TAPP). These two procedures differ in their approach to the preperitoneal space. In TAPP approach, the preperitoneal space is reached through the abdominal cavity whereas TEP repair is carried out without breaching the peritoneum.
Laparoscopic hernia repair is preferred in patients with bilateral and recurrent hernias.
Anterior repair of a recurrent hernia is technically demanding operation and is associated with a much higher risk of regional nerve injury and testicular ischaemia. Laparoscopic herniorrhaphy provides a posterior approach so that the previously dissected tissue is avoided, thereby reducing the chance of regional nerve injury and vascular compromise of the testis.2
Bilateral inguinal hernias are an ideal indication for laparoscopic repairs. The ability to avoid bilateral inguinal incisions, dissection and postoperative disability is a significant advantage that should not be minimized.2
Laparoscopic hernia repair is performed for primary unilateral hernia as well.
The absolute contraindication is a strangulated hernia. Patients with history of extensive intra-abdominal pelvic infections, history of pelvic irradiation, surgery in the space of Retzius are not suitable for laparoscopic herniorrhaphy. Similarly patients with severe cardiopulmonary insufficiency are not suited for laparoscopic approach.
The relative contraindications based on the experience of the surgeon are obstructed hernia, complete irreducible hernia, patients who are obese and those with a history of previous lower abdominal surgery.
Choice of procedure
It is important for surgeons to understand both TAPP and TEP. Although TEP is indicated for the treatment of majority of hernias, TAPP can help the surgeon approach large scrotal, incarcerated and complex recurrent hernias with a higher margin of safety and ease.2 TEP avoids the large peritoneal incisions of TAPP that can result in either adhesive or incarcerated small bowel obstruction. TEP allows better visual control in the medial part of the operative field where it is important to ensure that the mesh crosses the midline. Patients with previous transverse pelvic incisions and in whom concomitant diagnostic laparoscopy is required are better treated with TAPP approach. Similarly patients with a recurrence following TEP are treated by TAPP.2
TAPP vs TEP
The TAPP method is simpler to learn and therefore more frequently performed. However, we do not agree in principle to a transabdominal approach routinely for groin hernia repair as it necessitates violation of the peritoneal cavity. For over a decade we have been following the TEP technique for repair of groin hernias and a TAPP repair is performed only in patients who have had extensive lower abdominal surgery. In a study by Sergio Roll et al from Brazil comparing TAPP and TEP, it was observed that TEP repair was associated with the lowest risk of intraoperative and postoperative complication related to the male genitalia.3 Similarly a study by Felix et al has shown that TEP has fewer complications and equivalent if not superior recurrence rates.4
Technique of TEP
Extraperitoneal access is achieved through an infraumbilical 12 mm transverse incision. After incising the rectus sheath a space is created between the rectus muscle and posterior rectus sheath. We use our indigenous balloon prepared using two fingerstalls of a size 8 latex surgical glove for preperitoneal dissection. A 10 mm Hasson cannula is introduced in the preperitoneal tunnel. Two working ports are placed in the preperitoneal space in the midline. Dissection of the extraperitoneal space begins in the midline. The aim is to identify the pubic bone. Dissection then proceeds inferiorly and laterally and the Cooper’s ligament is identified. In the case of a direct hernia it may become difficult to identify Cooper’s ligament as this area may be occluded by the hernia sac. The direct hernial sac is then reduced by traction on the peritoneal extrusion and counter traction on the abdominal wall. The anatomical landmarks that would now become visible are Cooper’s ligament, iliopubic tract femoral ring and the inferior epigastric vessels.
An indirect hernial sac is identified as a white glistening structure lying anterolateral to the cord. An incomplete sac is dissected of the cord and completely reduced. No attempt should be made to reduce a complete sac as excessive traction causes severe postoperative testicular oedema and pain. Such a sac should be separated from the cord, transected and ligated using a catgut endoloop. Complete reduction of the peritoneal extrusion is ensured by stripping the peritoneum over the cord till it is no more visible proximally. Adequate space has to be created lateral to the cord structures as the lateral extent of the mesh would lie in this space. The inferior extent of dissection in this space is the psoas muscle.
The minimum size of the polypropylene mesh to be used on either side should not be less than 15 x 15 cm. The mesh is laid from the midline and extended over the cord structures till the lateral abdominal wall. The free margin of the mesh is pushed into the retropubic space medially and lies over the psoas muscle laterally. The mesh is then fixed at two places – the pubic bone and cooper ligament using a 5 mm fixation device Protack TM (Autosuture). No fixation should be done laterally for fear of cutaneous nerve entrapment. The mesh is then unrolled to lie within the extraperitoneal space and CO2 is exsufflated ensuring that none of the edges of the mesh is partially rolled as this may lead to further rolling and the likelihood of future recurrence.
TEP vs Conventional repairs
The TEP repairs began at a time when Lichtenstein repair had become the standard of care with reported recurrence rates of less than 1%. The advantages of laparoscopic repair over open repair are 1) reduced postoperative incisional pain and disability, 2) the greater availability of space by the extraperitoneal approach facilitates the insertion of a much bigger mesh, 3) In recurrent hernia, it is ensured that the selected site was not previously operated upon thus the chances of nerve injury and vascular injury are reduced and 4) entire myopectineal orifice can be inspected bilaterally and repaired. The reported incidence of a contra lateral hernia in a patient presenting clinically with a unilateral hernia is up to 50%.5 TEP approach presents a major advantage in this regard as both sides can be repaired with the same approach. A large series of randomized controlled trials conducted all around the world have confirmed clearly the advantages of laparoscopic inguinal hernia repair compared to open technique in terms of operative complication, discomfort, analgesic use and return to work. In a study by Liem et al, using a validated quality of life measurement instrument, the laparoscopic patient group was found to have a significantly improved quality of life at 1 and 6 weeks after surgery.6
Primary inguinal hernia is a heterogeneous disease that with increasing age of the patient shows a rising incidence and also a tendency to bilaterality. The optimal surgical approach must be selected individually. Though no true gold standard exists, the TEP procedure is the main pillar of operative treatment which synergies the advantages of minimal access surgery, those of tension free mesh repairs and the Stoppa’s repair.
I am thankful to Dr. Venkat Subramanian, my colleague in the Department of Minimal Access Surgery for actively participating in the “ENDOSCOPIC SUTURING IN GASTROINTESTINAL & GENERAL SURGERY” project and preparing this article.
My sincere thanks to my colleagues in the Department of Minimal Access Surgery, Dr. Rajesh Khullar, Dr. Anil Sharma, Dr.Vandana Soni, Dr. Manish Baijal, Dr. Amit Goel for their constant, positive and supportive help in all the ongoing projects and progress made in the department.
I sincerely thank to Ms. Aenu Batra, Mr. Pankaj Gupta and Mr. Satish Jha for their excellent secretarial help and support.
- Chowbey PK. Endoscopic repair of abdominal wall hernias. First edition 2004, New Delhi. Byword Viva Publishers Pvt. Ltd.
- Davud L. Crawford ad Edward H Phillips. Laparoscopic hernia repair: Indications and contraindications. In: Bruce V, MacFadyen Jr, et al. Laparoscopic surgery of the abdomen, Springer Verlag, New York. pp 273– 81.
- Roll S, et al. Videoendoscopic inguinal hernioplasty: A comparison between transabdominal and totally extraperitoneal techniques. Retrospective study of 720 operated cases in 10 years. Surg Endosc 2003; 17 (Suppl) : S285.
- Felix et al. Laparoscopic hernioplasty. TAPP vs TEP. Surg Endosc 1995; 9 : 984-9.
- Crawdord DL, Hiatt JR, Phillips EH. Laparoscopy identifies unexpected groin hernias. Am Surg 1998; 64 : 976-8.
- Liem MSL, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal hernia repair. N Engl J Med 1997; 336 : 1541-7.