Continuing Education Activity

Inguinal hernia repairs are one of the most common general surgical operations performed in the world. Diagnosis of inguinal hernias is typical performed using a thorough history, and physical and is typically signified by a bulge in the groin. This activity explores several treatment options for patients with inguinal hernias including watchful waiting, open primary repair, open tension-free repairs with the use of mesh prosthetics, and laparoscopic repairs which are typically performed with mesh prosthetics.

Objectives:

• Identify indications for laparoscopic inguinal hernia repair.
• Review the anatomy and anatomical pitfalls encountered when performing laparoscopic inguinal hernia repair.
• Describe complications associated with laparoscopic inguinal hernia repair.
• Explain why careful planning of the interprofessional team and discussion with other professionals involved in the management of the patient undergoing laparoscopic inguinal hernia repair will lower the associated morbidity and improve patient outcomes.

Introduction

Inguinal hernia repairs are one of the most common general surgical operations performed in the world. Diagnosis of inguinal hernias is typical performed using a thorough history, and physical and is typically signified by a bulge in the groin. There are many treatment options for patients with inguinal hernias including watchful waiting, open primary repair, open tension-free repairs with the use of mesh prosthetics, and laparoscopic repairs which are typically performed with mesh prosthetics.

Anatomy and Physiology

The anatomy of the inguinal canal can be quite complex and thorough knowledge of anatomy from the preperitoneal view is imperative to perform a good laparoscopic inguinal hernia repair. Several important landmarks include the inferior epigastric vessels (which help distinguish between a direct and indirect hernia), the pubic bone/Cooper's ligament, the vas deferens/cord structures/round ligament, and the iliopubic tract [1]. Surgeons performing laparoscopic inguinal hernia repair should also be aware of the triangle of pain and doom. The triangle of doom is a triangle bound by the vas deferens, testicular vessels, and the peritoneal fold. The importance of this triangle is in this area you can find the external iliac artery and vein. The triangle of pain is bound by the iliopubic tract, testicular vessels, and the peritoneal fold. This triangle holds the lateral femoral cutaneous nerve, the femoral branch of the genitofemoral nerve, and the femoral nerve. Secondary to the important structures located in these two triangles it has been strongly recommended to avoid traumatic fixation of mesh in these areas as it could cause major vascular injuries or nerve injury that could result in chronic pain.  

Indications

Laparoscopic inguinal hernia repair has become a valid option for repair of an inguinal hernia, although the primary indication for the use of laparoscopic inguinal hernia repairs has been for bilateral and recurrent inguinal hernias. As more experience has been gained with the laparoscopic techniques, it is now used for the repair of the primary/unilateral inguinal hernia[2]. Potential benefits of the laparoscopic approach include quicker postoperative recovery and possible decreased incidence of long-term groin pain[2].

Contraindications

There are no absolute contraindications to laparoscopic inguinal hernia repair except for the inability to tolerate general anesthesia. Patients at high risk for anethesia and unilateral inguinal hernia may be better served with an open repair under local anesthesia. Relative contraindications include large inguinoscrotal hernias (which should not be attempted early in the learning curve as they can be quite difficult operations) and patients on anticoagalation (secondary to the difficulty with dealing with posterative bleeding in the retroperitoneal space compared to dealing with bleeding after open surgery).

Equipment

The following is in general what is needed for a laparoscopic inguinal hernia repair. Specific instruments/equipment can be left to the discretion of the surgeon.

1. Laparoscopic equipment including a 30 degree 5mm or 10mm camera
2. Three laparoscopic trocars (2 5mm and one 10mm)
3. Laparoscopic scissors and grasper of choice. If planning on suturing mesh or peritoneum in TAPP then laparoscopic needle drivers
4. Mesh prosthetic of choice (in general an uncoated polypropylene or polyester mesh that is at least 10x12cm and in most cases larger)
5. Fixation method of choice (tackers (absorbable/nonabsorbable, glue, suture)
6. Closure sutures for fascial defect and skin

Personnel

The surgeon can be performed with a surgeon and assistant or resident. Ideally, the surgeon performs the surgery through 2 trocars, and the assistant holds the camera.

Preparation

Preparation for laparoscopic inguinal hernia is similar to any other surgical/laparoscopic procedure. Preoperative antibiotics and anticoagulation can be given as per hospital protocol/surgeon preference. The patient is placed under general anesthesia supine with both arms tucked and appropriately padded. Some surgeons place foley catheters routinely, and others place selectively or not at all, and this is left to surgeon discretion.

Technique or Treatment

There are two main ways to perform laparoscopic inguinal hernia repair - the Transabdominal Preperitoneal (TAPP) approach and the Totally Extraperitoneal (TEP) approach. The two techniques similar except in the TAPP approach the peritoneum is incised, and this requires closure after mesh placement. The laparoscopic port placements typically vary between the two techniques. In a TEP technique, the e ports are placed typically in a line from the pubic bone to the umbilicus. In the TAPP technique, the three ports are placed at the umbilicus and the area of the mid-clavicular line at the level of the umbilicus on the left and right side of the abdomen. With these port positions, the surgeon can fix bilateral inguinal hernias either using the TEP or TAPP technique. In the TEP approach, the preperitoneal space is entered at the level of the umbilicus and is not violated during the procedures. In the TAPP technique, the surgeon must open and close a peritoneal flap that usually starts at the medial umbilical ligament and is incised laterally towards the anterior superior iliac spine. It is recommended that the surgeon close the peritoneal flap after mesh placement and this may be either done with sutures or tack fixation. This allows the mesh to be preperitoneal and not in contact with the abdominal cavity and viscera. Laparoscopic inguinal hernia repair, either by the TAPP or TEP method, involves placing a large mesh prosthetic that covers the entire myopectineal orifice[3]. This allows for coverage of indirect, direct, and femoral hernias.

Complications

The complications related to laparoscopic inguinal hernia can be divided into operative complications and postoperative complications. Operative complications can be related to laparoscopic access (which possible could be minimized with the TEP technique) and injuries to the surrounding structures of the inguinal region including vascular structures and the bladder. Thorough knowledge of the pertinent preperitoneal inguinal anatomy and meticulous dissection can help ensure low intraoperative complication rates. Postoperative complications most commonly relate to hernia recurrence (which has been minimized with the use of mesh) and chronic groin pain. Placement of a wide mesh covering the entire myopectineal orifice and the use of atraumatic or carefully placed traumatic fixation away from the triangle of pain and doom can help minimize the risk of recurrence and chronic pain[2].

Clinical Significance

In general, outcomes related to laparoscopic inguinal hernia are similar to those of open inguinal hernia repair assuming the surgeon is adequately trained and competent in the technique. Several studies have reported the steep learning curve associated with a laparoscopic inguinal hernia, and it is important to understand this learning curve when evaluating outcomes associated with this procedure. When surgeons have overcome their learning curve, reported to be between 50 and 250 cases[4][5][6], potential benefits of the laparoscopic approach include quicker recovery and possible decrease incidence of long-term groin pain with equivalent recurrence rates to the open approach. Although there are many proponents of both the TAPP and TEP techniques, outcomes are similar, and the choice of method is left to the discretion of the surgeon[2]. Although there are subtle differences in some outcomes comparing laparoscopic and open inguinal hernia repair, in general, the outcomes are similar.

Controversies in Laparoscopic inguinal hernia repair

There remain several controversies related to laparoscopic inguinal hernia repair. As mentioned, many debate the ideal indications for the use of the laparoscopic approach and initial indications were restricted to recurrent and bilateral hernias. With improved education and research related to the laparoscopic approach it has become a well-accepted treatment options and in some case preferred for all inguinal hernias including unilateral hernias. There also remains a significant debate regarding ideal fixation methods of mesh for laparoscopic inguinal hernia repair. Options for mesh fixation include no fixation, glue, tacks, and suture fixation. The risk of recurrence and chronic pain must be carefully weighed when discussing mesh fixation. Recent guidelines have recommended atraumatic or no fixation in most cases, however, have recommended mesh fixation in patients with large direct hernias to prevent recurrence[2]. Another controversy relates to the type of mesh used. In general some form of polypropylene or polyester meshes are used and as there has been no convincing data on the efficacy of one type of product or material, the choice of mesh is typically left to the discretion of the surgeon and the size of the mesh and ability to cover all potential hernia spaces is likely more important than the material.  

Enhancing Healthcare Team Outcomes

Patients with an inguinal hernia may first present to the primary care provider, emergency department physician, nurse practitioner or the internist. Since all hernias have the potential to strangulate or become incarcerated, these patients should be referred to the general surgeon. Laparoscopic hernia repair is now often done for bilateral and recurrent inguinal hernia. The  technique results in faster recovery, less pain and earlier discharge. However, significant pain and recurrence still occur in a number of patients. Thus, education of the patient is key. Upon discharge the nurse should educate the patient on symptoms of recurrence and when to return to the hospital.