Laparoscopic inguinal hernia repair (LIHR) was reported in 1982, although at that time Dr. Ger performed direct clamp closure of the hernia sac without preperitoneal reinforcement with a patch. The laparoscopic hernia repair that we currently use started in the early 1990s and was first reported by Arregui in 1991 with the transabdominal preperitoneal prosthetic (TAPP) procedure. In 1992, Fitzgibbongs performed the first intraperitoneal onlay mesh (IPOM) repair. In 1993, Phillips, Mckernan and Law each performed total extraperitoneal patch repair.
1. Significance of the emergence of laparoscopic hernia repair
Laparoscopic hernia repair has been controversial up to now, but the controversy seems to be getting less and less. A growing number of RCTs show that laparoscopic hernia repair has faster postoperative recovery, lower recurrence rates, and lower rates of pain and discomfort compared with open hernia repair, as well as the advantages of small incisions, aesthetics, and exploration of contralateral hernias, cryptic hernias, and femoral hernias.
The development of laparoscopic hernia repair has also led to a rapid expansion of preperitoneal repair. Because before laparoscopic hernia repair was performed, “the surgeon knew almost nothing about the posterior wall of the inguinal canal, which was hidden from the surgeon’s view” (W. J. LYTLE, 1945). Most surgeons find it difficult to visualize what a PHS patch or Kugel patch is like when placed in front of the peritoneum, so they find the preperitoneal technique difficult. However, since the advent of laparoscopic techniques, it has become possible to see clearly the structures of the preperitoneum and thus to have a visual and correct understanding of its anatomy. Even if most physicians do not perform laparoscopic hernia repair, this knowledge of the preperitoneal anatomy is of great help to them in performing open posterior approach preperitoneal repair.
At present, there are also reports of robots doing TAPP at home and abroad. In addition to being expensive, robotic surgery highlights many advantages, such as three-dimensional picture and the ability to bend the operating rod in an articulated way with abnormal flexibility.
2. Surgical steps of TAPP.
①Poke hole location.
The umbilical hole (10mm) is generally chosen as the observation hole, and a 5mm operating hole is punched at the outer edge of each of the two layers of the rectus abdominis muscle slightly below the umbilical plane. In case of unilateral hernia, the operating hole on the healthy side can also be moved to 5 cm below the umbilicus.
② Incision of the peritoneum.
After entering the abdominal cavity, five ligaments should be identified first: ① middle umbilical ligament: located in the midline, it is the residual trace of umbilical ureter occlusion; ② medial umbilical ligament: it is a peritoneal fold covering the surface of the occluded umbilical artery, located on both sides of the middle umbilical ligament, and the bladder is located between the two medial umbilical ligaments; ③ lateral umbilical ligament: it is a peritoneal fold covering the surface of the inferior abdominal wall artery, located on the lateral side of the medial umbilical ligament. Usually, the peritoneum is cut in an arc of 3 cm at the superior edge of the hernia defect, and the medial side should not exceed the medial umbilical ligament to avoid damaging the bladder hazel, and the peritoneum in the middle should be cut to avoid damaging the inferior abdominal wall artery.
③ Separation of the hernia sac.
The hernia sac of hiatal hernia protrudes into the inner annulus and there is often some adipose tissue or “lipoma” outside the hernia sac, the larger “lipoma” should be removed, otherwise the “lipoma” will slide into the inguinal canal and cause recurrence similar to slip hernia. Otherwise, the “lipoma” may slip into the inguinal canal and cause a recurrence similar to a hiatal hernia. The hernia sac of hiatal hernia should be dissected as far as possible, as residual hernia sacs increase the probability of seroma, but large hernia sacs with dense adhesions to the spermatic cord should be transected, as forced dissection can cause postoperative scrotal hematoma.
During laparoscopic surgery, the spermatic cord must be fully “perietalized”, i.e., the hernia sac is fully free from the posterior spermatic vessels and vas deferens by 6 to 8 cm, which is a very important step, otherwise the patch will cover the hernia sac and cause recurrence of hiatal hernia. It is also important to note that in male patients, the vas deferens is on the medial lower side of the hernia sac and the testicular arterioles on the lateral lower side, so do not cause injury by rough separation when stripping the hernia sac.
The hernia sac is located within the rectus hernia triangle, and the hernia sac and preperitoneal adipose tissue must be completely separated from the rectus hernia triangle and the pubic tuberosity and pubic comb ligament must be exposed posteriorly. The first layer of the transversus abdominis fascia at the site of the hernia is significantly thickened and is called a “pseudohernia sac”, which should not be mistaken for a hernia sac and forcibly removed.
The hernia sac of femoral hernia is located within the femoral ring, with the skeletal pubic fascia anteriorly, the pubic comb ligament posteriorly, and the trap ligament medially, and these three structures must be fully dissected and exposed so that the femoral hernia is not missed during surgery.
④ Separation of the anterior peritoneal space:
The separation of the anterior peritoneal space is from the internal to the pubic symphysis, from the external to the psoas major and the anterior superior skeletal spine, from the upper to at least 3 cm above the symphysis muscle, from the lower to 3 cm below the pubic comb ligament, and from the lower to 6-8 cm below the “pelvic walling” of the spermatic cord to ensure that a 13 cm × 9 cm patch can be implanted.
⑤ Laying and fixation of the patch:
A 10 cm x 15 cm patch is usually used, with appropriate trimming according to the patient’s condition. A small patch is an important cause of postoperative recurrence. Fixation of the patch can be done with a hernia fixator or sutures. The patch should be fixed to the rectus abdominis muscle, pubic comb ligament, and joint muscle, with coverage and fixation to the pubic tuberosity being particularly important because the vast majority of recurrences occur within the rectus hernia triangle adjacent to the pubic tuberosity. Bilateral hernias should be adequately dissected so that the preperitoneal space on both sides is connected and the medial side of the patch crosses and overlaps at the pubic symphysis. Damage to the inferior abdominal wall artery should be avoided when stapling above the patch and avoiding the crown of death, danger triangle, and pain triangle areas when stapling below. The patch is usually laid flat on the spermatic cord and spread as flat as possible; a curled patch can cause postoperative recurrence. A small cut can also be made to wrap the patch around the spermatic cord before fixation, which corresponds to an internal circumferential orifice shaping while strengthening the posterior wall of the inguinal canal. Since stapling of the patch may cause postoperative pain, fibrin glue is now used abroad to glue the patch.
(vi) Closure of the peritoneum:
The peritoneum can be closed by stapling or suturing. The peritoneum should be closed sufficiently to avoid contact between the patch and the abdominal contents, otherwise it may cause postoperative intestinal obstruction or even intestinal leakage.
3. Surgical steps of TEP.
①Poke hole location.
There are several options, which can be the same as the aforementioned poking holes for TAPP, or three holes can be equally divided in the lower abdominal midline below the umbilicus. Each of these approaches has advantages and disadvantages.
② Access and establishment of the anterior peritoneal space.
It is important to make the first poke hole about 1 cm below the umbilicus. A 12-mm transverse skin incision is first made, to be slightly offset. The subcutaneous fat is divided to reveal the anterior rectus abdominis sheath. The anterior rectus abdominis sheath is lifted and a transverse incision is made, leaving a 0 gauge viejo line over the incised anterior sheath. The rectus abdominis muscle is separated longitudinally to expose the posterior rectus abdominis sheath. A debrided 10 mm poke card is placed along the posterior sheath. A 30-degree scope is pushed straight through until the correct level of the anterior peritoneal space is revealed. The separation is continued forward to the pubic tuberosity and the Cooper’s ligament is shown. The second and third poke cards are then placed under direct vision, respectively.
(iii) Separation of the hernia sac: same as TAPP.
(iv) Separation of the anterior peritoneal space: same as TAPP.
⑤Flattening and fixation of the patch: same as TAPP.
⑥Deflation, withdrawal of the poke card, and end of surgery.
4. Several surgical techniques for laparoscopic hernia repair.
① Be sure to access the correct surgical level.
If the transverse abdominal fascia is divided into three layers, the correct level for laparoscopic hernia repair should be between the second layer of the transverse abdominal fascia and the peritoneum, that is, between the preperitoneal fat and the peritoneum (if you are used to two layers of the transverse abdominal fascia, the correct level should be “between the superficial layer of the transverse abdominal fascia and the peritoneum”). This is because the preperitoneal capillary network and the inferior abdominal wall arteries are essentially in the preperitoneal fat layer, respectively.
If your level is too shallow, you will feel that looking for the level in the fat, with a larger bleeding out under the field of view, “the mountains and rivers of the motherland are red”, and even the subabdominal wall arteries are free underneath, which is very easy to misinjure.
If your level is deep, you are bound to damage the peritoneum, causing air leakage, peritoneal uplift, your operating space is reduced, sometimes forced to transit and do TAPP instead.
② The more nails you have when fixing a patch is not the better.
Many doctors who are just starting to do TAPP are afraid that poor patch fixation will cause patch displacement and hernia recurrence, so they desperately try to fix it with a staple gun or even staple it together in the pain triangle. There are also two types of nail guns that we commonly use today, one is EMS from Johnson & Johnson and the other is spiral nail from Tyco. Both are non-absorbable titanium materials. To hold a flat sheet in place without displacement, one nail is theoretically sufficient.
Considering that the anterior peritoneal space has a complex curvature, a patch with only one nail may not be displaced, but there is a possibility of rotation and folding, which can also cause incomplete coverage of the patch and recurrence of the hernia. Therefore, at least three nails are necessary, one nail on Cooper’s ligament to ensure that the patch can be embedded in the retropubic anterior peritoneal space, and the other two nails on the abdominal wall fascia layer 2-3 cm above the internal ring opening to fix the top of the patch and ensure that the patch will not rotate and fold extensively.
In clinical practice, we often have to close 3 to 5 staples depending on the patient’s condition (especially for straight hernia). 5 staples are often needed for TAPP, 3 on the left, middle and right of the upper part of the patch and 2 on Cooper’s ligament. 3 staples are usually sufficient for TEP.
(iii) Laparoscopic hernia repair is more invasive.
Although the postoperative scar is only three small holes in the abdominal wall, we have to be aware that the intraoperative free range is much larger than that of the developed procedure in order to establish the preperitoneal space. This makes it all the more important that we do not seek a greater extent during the freeing and that the separation is gentle to avoid unnecessary damage. It is important to find the correct level and properly treat the hernia sac to minimize the damage.
④ The erroneous view that “laparoscopic hernia repair” is necessarily better than open hernia repair should be corrected.
The overall advantages of laparoscopic hernia repair are not necessarily greater than those of open hernia repair, as reported in large RCT studies in various countries. Only in postoperative pain, foreign body sensation and abdominal wall compliance.
However, laparoscopic surgery gives us a clear and magnified view of the preperitoneal anatomy, which is very helpful in furthering our understanding of hernia and developing a good hernia procedure.
⑤ Careful separation of the “interconjunctival ligament” is necessary.
Probably the most difficult part of laparoscopic hernia repair for the surgeon is the separation and retraction of the hernia sac. It is difficult to see and appreciate the intercranial ligament during a developmental procedure. However, during TEP, the intercavernous ligament is still present at a high rate, especially in young patients younger than 40 years of age.
The intercisternal ligament appears microscopically as a very dense membranous structure that often travels at the junction of the Reitzus and Borgros spaces, sometimes turning transversely to the anterior superior iliac spine. The separation of the intercondylar ligament is often done with scissors, blunt separation is difficult, and the lower edge of the intercondylar ligament is fused with peritoneal adhesions, and too low a separation can cause rupture of the peritoneum and air leakage.
(6) The peritoneal reflex line of the separated anterior peritoneal space should be straight.
In TAPP, we often have to fix the patch with a staple gun and this problem is not yet prominent. However, in TEP, we often do not fix the patch for defects smaller than 4 cm, which requires us to be “meticulous” in establishing the preperitoneal gap, because too large a gap may cause postoperative displacement of the patch, despite the fixation effect of peritoneal pressure. Therefore, when establishing the peritoneal gap, it is best to make the peritoneal reflex line “straight” and not to make the anterior peritoneal gap too large, and secondly, to make it slightly smaller than the patch we have already trimmed, so that after the patch is placed, the peritoneal reflex line is slightly separated and the patch is “stuck” in the middle together with the anterior abdominal wall. “in the middle.