Inguinal Hernia Repair by TEP

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Inguinal region

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    Posterior aspect of the inguinal region: (1) Inferior epigastric artery and vein, (2) Medial orifice = direct inguinal hernia, (3) Femoral hernia orifice, (4) Pectineal ligament (Cooper), (5) Spermatic duct, (6) External iliac artery and vein, (7) Testicular artery and vein, (8) Iliopubic tract, (9) Lateral orifice = indirect inguinal hernia

    The inguinal region (where the anterior abdominal wall transitions to the lower extremity) possesses several weak spots where a hernia sac (with or without contents) may protrude through the abdominal wall (femoral hernias are more frequent in women, while inguinal hernias are more common in men). Inferior to the inguinal ligament the septum of the iliopectineal arch divides the inguinal canal into a vascular and muscular compartment – lacuna vasorum and lacuna musculorum respectively.

    Vascular compartment

    • Both the external iliac artery and vein (→ femoral artery and vein; with the artery lateral to the vein) course through the vascular compartment which is lateral to the pubic bone. In addition, the femoral branch of the genitofemoral nerve passes through the very lateral part of this compartment, while the deep inguinal lymph nodes (Rosenmueller nodes) are located inferomedially. In femoral hernias the lacuna vasorum is the deep weak spot (through the femoral septum along the femoral vein).

    Muscular compartment

    • Lateral to the lacuna vasorum, the muscular compartment is traversed by the psoas major and iliacus muscles (together they comprise the iliopsoas muscle), the femoral nerve, and lateral femoral cutaneous nerve.
  • Anterior abdominal wall

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    • During testicular development the tubular structure of the inguinal canal is formed by the externalization of the testicles, which are pulled into the scrotum by the gubernaculum testis. The peritoneum pulled along during this descent remains in the inguinal canal as a pouch (processus vaginalis testis). Thus, the layers of the abdominal wall turn into the corresponding sheaths in this pouch:
    • Transversalis fascia → internal spermatic fascia,
    • Internal oblique → cremaster,
    • Fascia of external oblique → external spermatic fascia,
    • No investment by the transversus abdominis since it terminates more cephalad.
    • The blood vessels (testicular artery and vein), spermatic duct (ductus deferens) and nerves (ilioinguinal nerve originating from the lumbar plexus) are also pulled into the scrotum, and together they form the spermatic cord. When the processus vaginalis closes, it obliterates the connection with the peritoneal cavity, typically leaving behind only the vestige of the vaginal process. In the female embryo the pull of the gubernaculum does not result in a complete descent of the ovaries, which remain close to the uterus, but rather the remains of the original gubernaculum persist in the inguinal canal as the round ligament of uterus. Incomplete obliteration of the processus vaginalis is a weak spot in the abdominal wall and therefore a possible starting point for inguinal hernia.
    • The approximately 4 cm long oblique inguinal canal, slanting downwards and medially, parallels the inguinal ligament immediately superior to it, with the cephalic end of the canal originating at the deep inguinal ring and the opening to the external abdominal wall at the superficial inguinal ring.

    Deep inguinal ring

    • Halfway between the pubic symphysis and the anterior superior iliac spine in the inner abdominal wall, lateral to the inferior epigastric artery and vein (within the lateral umbilical fold).

    Superficial inguinal ring

    • Superior to the pubic tubercle in the fascia of the external oblique, superior edge pointing cephalad, lower edge formed by inguinal ligament, sides = medial and lateral crus with stabilizing intercrural fibers.
  • Walls of the inguinal canal

    • Anterior wall

    Fascia of the external oblique, with lateral augmentation by fibers of the internal oblique → inguinal ligament and → cremaster

    • Posterior wall

    Transversalis fascia, with medial augmentation by the conjoint tendon (= tendon of the transversus abdominis and internal oblique).

    • Superior wall

    Transversus abdominis and internal oblique (fibers running from inguinal ligament to the medial conjoint tendon)

    • Inferior wall

    Medial inguinal ligament (= reflected ligament) and a trough for the spermatic cord formed by the external oblique.

  • Contents of the inguinal canal

    • In men: Spermatic cord (funiculus spermaticus) with the spermatic duct; deferential artery (branch of the inferior vesical artery) and testicular artery (from the aorta); venous pampiniform plexus; cremasteric artery and vein; genital branch of the genitofemoral nerve; sympathetic nerve fibers; and lymphatic vessels. All invested by the internal spermatic fascia, cremasteric fascia, and external spermatic fascia.
    • In women: Round ligament of uterus passing from the uterus through the deep inguinal ring into the inguinal canal and then on through the superficial inguinal canal to the labia majora; lymphatic vessels; and in both sexes sometimes the ilioinguinal nerve.
  • Types of hernias

    • The deep inguinal ring is the weak spot for indirect hernias, while direct hernias originate in the middle inguinal fossa (medial to the deep inguinal ring and the inferior epigastric artery and vein).
    • Indirect inguinal hernia
    • More common; men > women; congenital (patent processus vaginalis) or acquired (also via the deep inguinal ring in the lateral inguinal fossa, mostly in adults); hernia sac passes lateral to the epigastric vessels into the scrotum and labia majora respectively
    • Direct inguinal hernia
    • Mostly acquired; in adults men > women; pouching of the peritoneum and transversalis fascia in the middle inguinal fossa (inguinal triangle, medial to the epigastric artery and vein); delimited medially by the transversus abdominis and inferiorly by the inguinal ligament; emerges most often through the superficial inguinal ring → scrotum/ labia majora.
    • Femoral hernia
    • Mostly acquired; in adults women > men; together with the femoral artery and vein through the femoral canal in the medial thigh (medial to the lacuna vasorum); femoral branch of the genitofemoral nerve; and lymphatic vessels.

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative Management

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date of publication: 15.09.2011

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  • Access to the preperitoneal space

    91-5

    1 cm subumbilical skin incision Split the fatty tissue with Langenbeck retractors and expose the fascia/anterior rectus sheath. About 1 cm paramedian scalpel incision on the side of the hernia. Pull the medial flap of the fascia anteriad with a sharp clamp. Slip the Langenbeck retractor below the rectus muscle and lift it anteriad.

    Tip: If the fascia is incised precisely in the midline, this will open the abdominal cavity and not the rectus sheath. In this case, close the fascia and incise more laterally.

  • Trocar insertion

    91-6

    With a long peanut sponge on the posterior lamina of the rectus sheath, bluntly dissect the preperitoneal space down retrosymphysially. Follow this with blunt insertion of the 10 mm trocar and then gas inflation at a pressure of 10 – 15 mmHg. Insert the laparoscope with the camera Under visual control insert a 5 mm trocar in the median plane exactly halfway between the umbilicus and pubic symphysis

    Tip: Note the epigastric vessels regularly seen here, before inserting the 5 mm trocar. Use trocars with a locking mechanism since otherwise they will slip and massively hinder any preparation!

  • Dissecting the preperitoneal space

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    Dissect the preperitoneal space, primarily with the scissors, through the 5 mm trocar. Starting retrosymphysially, clear the tissue in one anteroposterior sweep from the posterior aspect of the pubic symphysis down to the bladder. Small vessels traversing the field can be coagulated.

    Follow this by bluntly dissecting the lateral space in the same way until the lateral margin of the rectus sheath is seen. Transect it in small steps with the scissors up to the plane of the superior anterior iliac spine. Under visual control, insert the second 5 mm trocar about 2 cm medial to the iliac spine.

    Tip: Sharply transect the lateral margin of the rectus sheath as far anterior as possible since otherwise this would open up the abdominal cavity!

  • Hernia sac dissection in direct hernia

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    From now on work with the dissector and scissors through 5 mm trocars. Traction and counter-traction will provide thorough blunt dissection of the preperitoneal space.

    This example demonstrates dissection of a right-sided direct hernia. With both instruments bluntly pull the hernia sac and its contents back from the defect.

    Tip: Since the dissection is carried extremely close to the femoral vessels, care must be taken to spare venous branches which, when injured, tend to hemorrhage and require lots of patience and extensive experience in hemostasis!

  • Hernia sac dissection in indirect hernia

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    In this example the left-sided indirect hernia sac is located lateral to the epigastric vessels and spermatic duct and within the spermatic cord.

    With traction and counter-traction bluntly dissect the hernia sac off the spermatic cord and as far posteriad as possible. Preperitoneal lipomas can be managed in the same way.

    Then pull the tensing peritoneum off the spermatic cord as far posteriad as possible.

    Tip: There are always numerous lymph nodes lateral to the spermatic cord. Dissection by the inexperienced surgeon in this area may result in hard to control persistent bleeding!

  • Mesh placement

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    After having completed the dissection prepare the mesh whose corners are rounded off with the scissors. Tightly roll up the mesh, grab one end with the dissector and then insert it blindly through the 10 mm trocar of the laparoscope. Unfurl the mesh and place it such that it completely covers the medial and lateral hernial orifices. During posterior placement ensure that the hernia sac and peritoneum, as well as any preperitoneal lipoma, will end up anterior to the mesh and not posterior to it. If so desired place a Redon drain. Deflate the gas under visual control and note that the peritoneum will mold to the posterior aspect the mesh.

  • Closing the incisions

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    After closing the anterior rectus sheath the skin incisions are closed with interrupted sutures – if so desired, with absorbable monofilament sutures.

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  • Intraoperative complications

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  • Postoperative complications

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  • Städtisches Klinikum München Schwabing

    Dr. Anne Heiss

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  • Literature summary

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  • Reviews; Guidelines

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  • Ongoing trials on this topic

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