Transabdominal Preperitoneal Inguinal Hernia Repair

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Clinical Anatomy

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  Inguinal anatomy is notoriously challenging for the most experienced surgeon. The presence of major neurovascular structures in the retroperitoneum can make safe dissection challenging, particularly for the novice surgeon.

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  This chapter provides a stepwise approach to dissecting an inguinal hernia during laparoscopic repair that provides careful identification and preservation of key anatomic structures during laparoscopic inguinal hernia surgery.

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  The exact anatomic relationship of the inferior epigastric vessel to the hernia is critical to ascertain before dissection.

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  Direct inguinal hernias occur medial to the inferior epigastric vessels in the Hesselbach triangle.

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  Indirect inguinal hernias occur lateral to the inferior epigastric vessels ( Fig. 22.1 ).

  

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  Femoral hernias occur below the iliopubic tract, and the lateral border is the femoral veins.

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Preoperative Considerations

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  Although all hernias can be approached using a laparoscopic technique, not all are best approached using this technique.

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  The laparoscopic approach requires general anesthesia; in elderly patients who cannot tolerate general anesthesia, an anterior open technique should be performed under local anesthesia.

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  Patients with very large incarcerated inguinal scrotal hernias can undergo laparoscopic repair, but the procedure is extremely difficult; I use an open anterior approach.

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  Patients who have had extensive intra-abdominal or prior pelvic, retroperitoneal surgery should not have a laparoscopic procedure, particularly if they have never had an anterior repair.

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Anatomic Considerations

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  The debate over transabdominal preperitoneal versus totally extraperitoneal repair has been evaluated in multiple different series. Ultimately, each of these approaches when performed in skilled hands results in a safe and durable repair.

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  Patients who have had a prior plug and patch or retroperitoneal mesh placed from an anterior approach should be approached cautiously. These patients can have a severely scarred retroperitoneum, making the creation of the peritoneal flap very difficult. In such cases, a hole can result that should be repaired.

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Operative Steps ( Video 22.1 )