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Laparoscopic Inguinal Hernia Repair

  1. Introduction

Hernia is defined as an area of weakness or complete disruption of fibromuscular tissue of body wall causing protrusion of abdominal contents. Hernia in latin means “A Rupture”.

  1. Epidomology

Of all groin hernias, 95% are hernias are of inguinal region with the remainder being femoral hernia. Inguinal Hernia is 9 times more common in men than women. Although femoral hernias are found more in females, the inguinal hernia is still the most common hernia in women.

  1. Anatomy of Groin

Inguinal region has 2 rings, 2 boundaries & 2 borders.

  1. 2 Rings
  2. Internal Ring – A deep ring is formed by a normal defect in transversalis fascia through which spermatic cord in men & round ligament in women pass out into the abdomen from the extraperitoneal  plane.
  3. External / Superficial Ring – It is inferior and medial to the internal ring & represents an opening of aponeurosis of external oblique. Spermatic cord passes through external ring before entering the scrotum in males.
  4. Anterior boundary is the external oblique & posterior boundary is transversalis fascia with some contribution from aponeurosis of transverses abdominis muscle.
  5. Inferior border is imparted by inguinal & lacunar ligament. Inguinal ligament represent the interior extension of external oblique aponeurosis & extends from anterior superior Iliac spine to pubic tubercle.
  6. Superior border is formed by arching fibers of internal oblique.
  7. Transversus abdominis muscle & its fascia represent true floor of inguinal canal.
  8. Deep to floor there is inferior epigastric artery & vein, genitofemoral lateral femoral cutanesus nerve.
  1. Anatomical Classification
  1. Indirect Inguinal Hernia – Develops lateral to inferior epigastric vessels.
  2. Direct Inguinal Hernia – Develops medial to inferior epigastric vessel. Thus they are found in Hesselbachs Triangle.

Hesselbachs Triangle

  • Lateral border is by interior epigastric artery
  • Medial border is by lateral border of rectas sheath
  • Base by inguinal ligament

Etiology

  1. Primary etiology of indirect inguinal hernia appears to be patent processus vaginalis, which in essence represent a hernia sac. Not every person with petent processus vaginalis develops hernia. Some predisposing factors are pregnancy, COPD, abdominal ascitis patient undergone peritoneal dialysis, chronic constipation.
  2. More common in chronic smokers because cigarette causes connective tissue disruption.
  1. Clinical Manifestation
  • The most common presenting symptomatology for a groin hernia is a dull feeling of discomfort or heaviness in the groin region that is exacerbated by straining the abdominal musculature, lifting heavy object or defecating.
  • With a reducible hernia, the feeling of discomfort resolves as the pressure is releaved when the patient stops straining the abdominal muscles.
  • Pain often worse at the end of day.
  • An incarcerated hernia occurs when the hernia contents are trapped in hernia defect so that contents cannot be reduced.

Physical Examination

On physical examination a visible bulge can be seen at the hernia site which increases on increase in intraabdominal pressure like coughing.

  1. Treatment
  1. Treatment of all hernia regardless of their location or type is surgical repair.
  2. Groin repair can be done under local general or regional (spinal or epidural) anesthesia.
  3. Laparoscopic repair are generally done under general anaesthesia to provide complete muscle relaxation needed to achieve insufflation of the preperitoneal or peritoneal sac.
  4. There are three techniques in Laparoscopic Hernia Repair.

Transabdominal preperitoneal repair

  • This technique was the 1st Laparoscopic hernia repair to be performed.

Steps

  • Ports are entered through the umbilicus & then laterally on either side the rectus muscle.
  • Both inguinal regions inspected, median & medial umbilical ligament and lateral umbilical fold are identified.
  • Parietal layer of peritoneum incised superior to hernia defect & reflected interiorly exposing epigastric vessels, cooper’s ligament & public tuberule
  • In Direct Hernia
In Direct Hernia

In Indirect Hernia

Peritoneal sac is pulled back within peritoneal cavity

Peritoneal sac retracted of the cord structures & pulled back within peritoneal cavity

  • A large polypropylene mesh is placed between peritoneum & transversalis fascia that covers the inguinal floor, inguinal ring & femoral canal.
  • Mesh is tacked to public tuberule medially, Cooper’s ligament interiorly & artery superior iliac spine laterally
  • Peritoneal flap is closed over the mesh
  • Risk with this procedure is, mesh is in direct content with the bowel & significant concern has been raised about potential for intra – abdominal adhesions post-op.
  1. Total Extraperitoneal Approach

It is most popular method. This is performed entirely within the preperitoneal space & does not involve peritoneal cavity. Surgeon carefully develops a plane between peritoneum posteriorly & abdomen wall anteriorly & thus insufflates the preperitoneal sac.

Steps –

  • Incision is made interior to the umbilicus & ant. Rectus sheath on ipsilateral side is incised.
  • Rectus is retracted laterally & preperitoneal space is bluntly dissected to allow placement of a port to facilitate insufflations
  • Large prosthetic mesh is placed through laparoscopic port into the preperitoneal space & it is then postioned deep to the hernia defect.
  1. Intraperitoneal onlay mesh repair
  • It is simplified version of TAP repair
  • In this we enter the peritoneal cavity but we do not create a peritoneal flap.
  • Rather a large mesh is simple stapled directly to post. to peritoneum
  • Disadvantage – 1) Direct contact with bowel high chances of adhesions & possible erosion of the mesh into the bowel content. 2) In large hernia, the mesh & peritoneum may herniated through the defect together.
  • These days a anatomical 3D mesh is used to cover the defect. This doesn’t require a fixation device like tacker.

 

  1. Complications of laparoscopic hernia repair
  1. Recurrance – It is rare, but when it occurs is often secondary to deep infection undue tension on repair or tissue ischemia, patient who are over active in the immediate post-op setting.
  2. Seroma form in dead space remaining from wide dissection during hernia repair. Sometime in Laparoscopic Hernia Repair as the sac in as it is, filling of sac with seroma type fluid leads to pseudohernia.
  3. Infection – Mainly from skin
  4. Haematoma
  5. Neuralgia
  1. Often neuralgia will follow the known distribution of the regional nerves, including branch of genitofemoral nerve & lateral femorocutaneous nerves.
  2. In Laparoscopic Herniorraphy lateral femorocutaneous nerve is more commonly injured.
  3. Nerves can also be intentionally sacrificed with a result. There is depriration of sensation along nerve distribution mainly inner upper thigh & hemiscrotum.
  1. Bladder Injury
  2. Testicular Injury
  3. Vas Deferens Injury
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