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Fix of inguinal hernia is one of the commonest surgical procedures performed worldwide. The life long risk for males is 27% as well as for women is 3%1. Since Bassini published his landmark paper about the manner of tissue repair in 1887, numerous modifications happen to be proposed. Shouldice four layers repair3 enjoyed extensive popularity before the idea of prosthetic material was introduced. Even today in Canada, about 25% of inguinal hernia repairs are done through the Shouldice technique because it is cost effective4. Tissue repair may be the commonest type of hernia repair within the developing world for the same reason.

There's been a revolution in surgical procedures for groin hernia repairs after the introduction of prosthetic material by Usher in 1958. Open Pre-peritoneal mesh repair by Stoppa was found to significantly reduce recurrence rate for multi-recurrent groin hernias. However, it was associated with significant postoperative pain and morbidity. The idea of Tension Free Open Mesh Repair was initially described by Lichtenstein in 19897.

Ger documented the first laparoscopic hernia repair in 1982 by approximating the internal ring with stainless steel clips. The laparoscopic trans-abdominal preperitoneal repair would be a innovative concept within the hernia surgery and was announced by Arregui and Dion in the early 1990s. Laparoscopic groin hernia repair can be achieved by TAPP approach as well as Total Extra Peritoneal (TEP) approach. Both approaches of laparoscopic hernia repair replicate the concept of Stoppa by placing large mesh within the pre-peritoneal space to cover 1 / 2 of the abdominal wall and all the vulnerable areas myopectineal orifice of Fruchad including area of internal ring, Hasselbach’s triangle and the femoral ring. The benefits of laparoscopic repair include the same reduced incidence of recurrence noticed using the Stoppa technique using the advantages of lesser pain, reduced discomfort, short hospital stay and earlier resumption of normal daily activities.

Both techniques are secure, effective and also have the same advantages. Though TAPP a much better view from the inguinal anatomy is achieved and also the procedure also offers a brief learning curve. TAPP allows evaluation of opposite side too. In patients with irreducible hernial contents, you'll be able to slow up the contents under vision producing the procedure simpler and easier.

Patient Selection

Within the initial the main learning curve, patient selection is important. Indirect hernial sacs are closely applied to the cord structures and are more regularly complete, making dissection difficult. Left sided hernias tend to be more difficult to dissect than the right sided ones. Bilateral hernia repair throughout the learning curve may significantly boost the operating time. Recurrent hernias and irreducible hernias should be fixed only after expertise is gained in repair of simple hernias. Direct or small indirect primary hernias in slim and thin subjects are the best. Indirect, left sided hernias, large, irreducible or complex hernias in obese patients would be best avoided during the learning curve. Laparoscopic inguinal hernia repair is an advanced laparoscopic procedure. The dissection is performed in the vicinity of major vessels and also the possibility of injury to adjoining viscera It is therefore required that the surgeon likely to undertake the repair must have experience of laparoscopic surgery. Laparoscopic anatomy from the inguinal area is totally not the same as what's seen throughout the anterior method. The surgeon needs to learn this anatomy. Familiarisation with this particular anatomy by employed in one performing laparoscopic hernia repair regularly is very helpful for proper orientation.

Anaesthesia and Position of the Patient

Laparoscopic TAPP hernia repair is performed under general anesthesia. In elderly patient, an in depth cardiorespiratory build up ought to be done prior to surgery for safe general anesthesia and pneumoperitoneum.

The patient is asked to pass through urine just before shifting to the operation theatre. If the patient is much more than sixty years old, has the signs of prostatic growth or post void residual volume is much more than 50 ml, it is advisable to place a Foley’s indwelling catheter prior to surgery. This may be removed 24 hours following the surgery. Perioperative prophylactic antibiotics are administered.

After induction of anesthesia, irreducible hernial contents, if any, are reduced before painting & draping is commenced.

The individual lies supine with both of your arms tucked by the side, to make room for the surgeon and his assistant to face at shoulder level. The head end of the table is kept 150 low to facilitate creation of pneumo-peritoneum and shift the bowel from the operative field. The computer monitor lies at the foot end of the patient. The operating surgeon stands quietly opposite to hernia. The assistant, who supports the camera, stands assisting hernia. The scrub nurse positions herself to the left of the patient, standing to the left from the surgeon.

It is important to maintain complete asepsis. All instruments ought to be properly sterilized by gas sterilisation or disinfected by soaking in activated gluteraldehide for any minimum period of 40 minutes just before surgery. A 300 telescope provides better exposure of the operative field and something can change perspectives by rotating the telescope, thus further improve exposure, specifically in the region from the symphysis pubis and laterally for that posterior abdominal wall structure.

Pneumoperitoneum and Placements of Ports

The Veress needle can be used to produce pneumo-peritoneum. Patency from the needle and spring function must be checked prior to insertion. The preferred site of needle insertion may be the supra umbilical fold. The spring mechanism gives a click sound immediately on penetrating the parietal peritoneum. Insuffulation is commenced with a set pressure of 12 mm of Hg. A pressure reading through of under 7 mm of Hg shows that tip position in the cavity. A Higher pressure indicates the end position to be extra extraperitoneal or obstruction towards the flow by the omentum. All quadrants of the abdomen are inspected and percussed to check on for uniform pneumo-peritoneum. Insufflation is continued until a pressure of 12 mm Hg is reached, which requires about 2.5 to three liters of gas.

After satisfactory pneumoperitoneum, the Veress needle is taken away along with a 10mm port is positioned through the supra umbilical incision. During insertion, the abdominal wall is lifted up and stable with the left hand and also the trocar is directed for the hollow of the pelvis. A 300 telescope attached to the camera, is introduced and also the groin area is visualized. Two 5 mm ports are put as working ports for the right and left hand of the surgeon, one on both sides, at the degree of umbilicus within the midclavicular line. These ports should be placed under vision to prevent injury to the inferior epigastric vessels and underlying bowel.

The hernia defect is inspected and also the kind of hernia is confirmed by the position of defect in relation to the inferior epigastric vessels and cord structures. The spermatic vessels rise from laterally and the vas deferens originates from medially to meet in the internal ring. This forms an inverted V. The inferior epigastric vessels (IEV) can be seen coursing upwards from this point. An immediate hernia is medial to the IEV and therefore medial to the point where the vas deferens and spermatic vessels join to create an inverted. An indirect hernia is lateral towards the IEV and it is in the tip of the inverted V formed by the vas deferens and spermatic vessels. The actual cord structures are noticed to enter the inguinal canal through the defect within an indirect hernia. The low and medial margins of the indirect defect are always sharp while the upper and medial margins are indistinct. The type of hernia found during surgery doesn't change the steps from the procedure but guides the extent of medial or lateral dissection for any minimum overlap of 5 cms.

Contra-lateral, clinically occult hernia might be present and may be clearly seen on trans-peritoneal examination during TAPP repair, as the opposite side can not be examined without dissection throughout a TEP repair. 30 % of patients with a primary unilateral hernia may subsequently develop a hernia of the opposite side as well. Detection of the clinically occult contra-lateral hernia and its simultaneous repair without any extra cut is an advantage of the TAPP repair and can assist in reduce the incidence of subsequent contra lateral hernia. This possibility of sub-clinical contra-lateral hernia should be discussed using the patient before surgery and permission for repair, if neccessary, should be obtained.

OPERATIVE STEPS

Step 1- Incising the Peritoneum

After inserting the telescope, all of the anatomical landmarks normally seen before peritoneal reflection are identified as described in the earlier chapter. These include the median umbilical ligament in the midline fold raised by obliterated urachus and also the medial umbilical ligaments on each side obliterated umbilical arteries ending within the hypogastric artery on both sides.

Items in the hernial sac, if any, are decreased with the help of atraumatic bowel forceps. In case of irreducible hernias, the bowel contents have to be handled carefully. In case of omentum, a tear ought to be avoided as it might cause bleeding. The structures within the posterior abdominal wall are identified after decrease in the contents, specifically the external iliac artery and vein within the triangle of doom. The external iliac artery is mostly identified by its pulsations while the vein is generally noticed more clearly using its bluish hue medial towards the pulsations.

The peritoneal incision is begun at a point that is midway between the groin crease and also the umbilicus. An external landmark can be used to find the point of commencement of peritoneal incision that is midway between the inguinal ligament and also the umbilicus, generally about 8 cms above the interior ring. Incision about the peritoneum is definitely produced from the right to the left, i.e. from lateral to medial on the right side and medial to lateral on the left side. The peritoneum is acquired having a Maryland dissector within the left hand at the site of intended incision and pulled firmly inwards to lift it from the underlying transversus muscle. With scissors in the right hand, the peritoneum is incised. Co2 gushes into the space and makes further dissection easier. The incision should be generous to provide good watch of structures behind the peritoneal flap as well as for placing 15 cms mesh without folds. It extends previously mentioned the anterior superior iliac spine to the medial umbilical ligament.. Extending it medially beyond the medial umbilical ligament will increase the likelihood of injury to the urinary bladder, particularly if the urinary bladder isn't empty.

Step 2 - Raising the Peritoneal Flap

The right plane of dissection from the peritoneal flap from the transversus muscle is anterior towards the pre-peritoneal fascia with the loose areolar tissue, stripping all the fascia and fat using the peritoneum so the fibers of the tranversus muscle are bare. The flap is raised by both blunt and sharp dissection. Generally the plane is avascular but any small vessel is carefully cauterized before division. Care ought to be come to avoid injury to the IEVs while raising the peritoneum medial towards the internal ring. The IEVs really are a extremely important landmark in laparoscopic inguinal hernia surgery. These vessels should always be left connected to the muscle and really should do not be included in the flap otherwise they may come in the clear way of dissection and may get injured.

Your plane of dissection is easier on the medial side and blunt dissection is sufficient since the areolar tissue is loose and the peritoneum is not adherent towards the rectus muscle. This the main dissection might be done first. On the medial side, continued caudal dissection will identify the shiny Cooper’s Ligament and the pubic bone. Laterally, the peritoneum is slightly adherent to the transversus muscle and sharp dissection might be required, particularly about the left side. Care should be taken to not enter into the transversus muscle, which might bleed if injured. The flap is raised from cephalic to caudal direction. It's simpler to raise only the lower flap rather than raise less and a maximum flap.

Step 3 - Dissection of Medial peritoneum and Direct Sac

Dissection is continued medially to the pubic symphysis to visualize the Cave of Retzius. The medial dissection is going across the midline to the opposite side for some centimeters, particularly for a direct hernia so that the mesh can be put with a good overlap over the defect. A direct defect is encountered medially above the cooper’s ligament. Inside a direct hernia the hernial sac includes peritoneal out pouching with a variable quantity of extra-peritoneal fat which may sometimes be very large. The direct sac can be simply separated from pseudosac. The pseudosac is essentially thinned out fascia transversalis, identified by its glistening appearance and belongs to the parietal wall. One must stay posterior to the pseudosac otherwise, troublesome bleeding may be encountered. In case of large direct hernias, after lowering the sac, the dome from the pseudosac could be fixed towards the pubic bone by stapler to avoid postoperative hematoma or seroma formation.

Step 4 - Lateral Dissection

Following the medial dissection, the flap is raised Lateral to the internal ring till the anterior superior iliac spine and carried posteriorly within the psoas muscle. Care is taken in this dissection to prevent problems for the nerves overlying the psoas muscle namely lateral cutaneous nerve of the thigh laterally and the femoral branch from the genito-femoral nerve medially.

Step 5 - Dissection of Indirect Hernial Sac and peritoneum within the cord structures

Dissection of indirect hernial sac is easily the most demanding part of laparoscopic inguinal hernia repair and it is best done after the medial and lateral dissection continues to be completed. In traditional hernias, the sac becomes densely adherent to the cord structures. The hernial sac is anterior and lateral to the cord structures. Dissection from the sac is performed close to the peritoneum. With a grasper within the left hand, the sac is pulled to the left and also the cord structures are dissected away from the sac with the right-handed instrument. A small indirect hernial sac can be easily dissected out to the peritoneal cavity. In the event of large/ scrotal indirect hernias, complete dissection from the sac might not be advisable as likelihood of problems for the cord structures are increased. In this situation the sac is circumferentially dissected so that a window is done between your sac and the cord structures and then sac might be divided after traction beyond the external ring. The distal part remains in situ but you ought to make sure that there is no bleeding in the cut end from the distal sac.

After reducing the sac, the dissection is continued proximally by stripping the peritoneum with both blunt and sharp dissection over the cord structures to expose and skeletonise the vas and gonadal vessels. Any lipoma linked to the gonadal vessels can also be dissected and drawn inwards. No dissection ought to be done deep towards the cord structures in the triangle of doom to avoid injury to the great vessels.

Step 6 - Preparation and site from the Mesh

Haemostasis should be secured prior to the mesh is placed and any blood/serum sucked out. If your prominent vein sometimes appears coursing horizontally within the Cooper’s ligament, it ought to be cauterized, else it may be a source of troublesome bleeding once the mesh is being fixed to the Cooper’s ligament with stapler. A polypropylene mesh of 15cm X 12 cm is employed for repair on both sides. Three corners from the mesh are rounded off except the low lateral corner for orientation. Upper half of the mesh is rolled and secured in that position with 2-0 vicryl suture in the center. The mesh has become rolled totally and introduced into the operating field through the 10 mm umbilical port by taking out the telescope. The telescope is then reinserted. The mesh is taken to the region of dissection and the lower the main mesh is unrolled. The low medial part of the mesh is positioned against the Cooper’s ligament. The medial border of the mesh should reach the midline as well as in direct hernia must go over towards the opposite side for a wide overlap. Look out of property from the prolene mesh, by virtue of its large pore size, is extremely helpful in proper positioning of the mesh. The mesh is fixed towards the Cooper’s ligament at two points with stapler. The anchoring suture has become cut away and also the remaining half of the mesh is unrolled. It's spread within the anterior abdominal wall, to cover the deficiency widely. Staples are applied over the medial and upper border from the mesh to anchor it to the underlying muscles. Generally Three or four staples are sufficient; one about the medial border and two on the upper border one on each side of the IEV. No staple should be put on the low and lateral areas of the mesh below the ileo-pubic tract to avoid problems for the nerves triangle of pain. In case of bilateral hernia repair, the meshes should overlap one another within the midline and are fixed to one another with stapler so they function as one mesh..

Step 7 - Reperitonealisation

Following keeping the mesh, the peritoneal flap is closed within the mesh to avoid bowel and omental adhesions. This can be done either with staplers or with sutures. It might be helpful to decrease the intra-peritoneal pressure to under 8 mm of Hg for better approximation from the peritoneum. The approximation begins laterally and continued medially. The lower cut edge of the peritoneum is lifted and stapled to the upper peritoneum with overlapping (Fig 23). Generally three or 4 staples are required. Sutured repair of peritoneum is better than stapler to avoid herniation of bowels with the gaps and could cause obstruction.

All co2 gas is evacuated to empty the abdominal cavity and also the scrotum. The ports are removed after lifting the anterior abdominal wall. The sheath of 10 mm port is closed with vicryl suture. Skin cuts are closed with subcuticular monofilament sutures or with glue. A suspensory bandage can be used for scrotal support.

Postoperative Care

Oral liquids may be started four hours following the surgery. When the patient tolerates liquids, soft diet may be started thereafter. Sitting upright in the bed and early movements and activity should be encouraged. The patient should walk to the toilet to pass through urine. This helps to motivate the patient for early ambulation. Good analgesic coverage with injection diclofenac, given intramuscularly, at night and morning hours on the next day helps in early ambulation and recovery. The individual can be discharged after 24 hours on oral analgesics. Before discharge, the scrotum ought to be examined for any swelling, to eliminate haematoma formation. He's advised to resume full range of normal activities, including driving, in 5 to Seven days.

Complications

Laparoscopic hernioplasty is definitely an advanced laparoscopic surgery. Operative technique and experience determines the frequency of complications, time of recovery, and regularity. A proper technique is essential to achieve good results.

1. Intra operative complications
   1. The urinary bladder should be emptied before surgery either by self-voiding or by catheterization. A complete bladder can make large amount of difficulties during medial dissection as well as becomes vulnerable to injury. The bladder may sometimes become full intra-operatively when the anaesthetist infuses fluid rapidly or even the procedure becomes prolonged. In such a situation, it is preferable to insert a catheter intra-operatively rather than struggle with a full bladder.
   2. Bowel Injury: the individual ought to be inside a head low position to maneuver the bowels away from the operating field. During TAPP repair, as with all pelvic surgeries, chance of thermal injury to the bowel exists. The insulation from the instruments should be checked, use of electrical power ought to be kept to minimum even though moving the hand instrument, the foot ought to be from the cautery pedal to avoid accidental thermal problems for intra-peritoneal structures.
   3. Bleeding: Inferior epigastric or gonadal vessels may cause bleeding during dissection. Gentle careful dissection will avoid bleeding. Mostly, bleeding might be controlled with monopolar cautery or clips. Probably the most disastrous of all is the iliac vessel injury (in the Triangle of Doom), which requires an emergency conversion.
2. Post Operative Complications
   1. Seroma or Hematoma Formation: Seroma formation is a very common complication after laparoscopic hernia surgery. The incidence is incorporated in the range of 5 - 25%.15 Seromas generally form at the end of one week and are a cause of significant distress towards the patient, since they seem like a recurrence. If the possibility of seroma formation is discussed with the patient before surgery, it is going a long way in alleviating their distress. They are common after large hernia and direct hernia repair. Seroma formation is much more common throughout the learning phase and decreases with increasing experience. Gentle careful dissection and perfect haemostasis will decrease the incidence. The pseudosac can be tacked towards the pubic bone with 2 or 3 tacks in large direct hernia to avoid seroma formation. The scrotum ought to be completely deflated in the completion of surgery, prior to the ports are taken out. If seroma is anticipated, scrotal support ought to be employed for the first 7 to 10 days to prevent their formation. Seromas mostly resolve by Four to six weeks. The individual needs to be reassured concerning the spontaneous resolution of the swelling. Whether it does not resolve in 8 weeks, it might be aspirated under aseptic precautions.
   2. Urinary Retention: The incidence of urinary retention after laparoscopic hernia repair is about 1.Three to five.8%18. It is almost always precipitated in elderly subjects, particularly if symptoms of prostatism can be found. These patients would be best catheterized just before surgery and also the catheter removed on the morning after the surgery.
   3. Neuralgia: This complication is reported to be between 0.5 - 4.6%15 depending on the manner of repair. Comprehending the anatomy and location from the nerves lateral towards the internal ring and avoiding stapling in the region of the nerves has decreased the incidence. No staples are applied for fixation from the mesh lateral towards the cord and below the ileo-pubic tract, in the region the triangle of pain. An over-all rule would be that the stapler should be fired only when the tip from the stapler can be felt by another hand on the anterior abdominal wall. When the tip of the stapler cannot be felt using the other hand, it is too posterior and is in wrong position.
   4. Port site Hernia: Hernia can occur in the 10mm port sites. The sheath of 10 mm port ought to always be closed with vicryl suture.
   5. Mesh infection: Infection of the mesh is a serious complication after any hernia repair. Thorough aseptic precautions during handling from the mesh are important. The hand instruments and ports ought to be properly sterilized. The mesh should not come in direct connection with the skin. Changing gloves before handling the mesh is a wise precaution.
   6. Recurrences: In TAPP, the incidence of recurrence is 0.7 to at least one.85%. Recurrence after laparoscopic repair is definitely a technical failure.

A few keys points should always be remembered to keep the recurrence rate negligable

• The peritoneum ought to be stripped from the midline the medially to the anterior superior iliac spine laterally. Proximally the peritoneum should be stripped off the cord structures for a distance to avoid indirect recurrence. In direct hernia, the dissection should cross the midline.
• Mesh of 15 x 12cm is recommended, so the entire myopectineal orifice is included with wide overlap.
• The mesh should lie in the pre-peritoneal space without any folds, particularly in the corners. When the mesh gets folded, the pre peritoneal space ought to be dissected further.
• For Bilateral repair, the mesh of both sides should overlap within the center.
• The mesh ought to be fixed over the cooper’s ligament with minimum two staples. The polypropylene material has memory and after it's unrolled inside, it may again roll back and leave the defect uncovered. Fixing top of the margin of the mesh further decreases the chances of the mesh rolling back and may assist in obtaining a zero recurrence.

Outcome of TAPP repair

A single large series of 12678 cases of TAPP hernia repair showed a mean operating time of 40 min., a morbidity of two.9%, recurrence rate of 0.7% along with a disability from work with 14 days. Ten cases of urinary bladder injury, eleven cases of bowel injury and 2 cases of injury to the vas were reported. Many of them were reported throughout the learning curve. Mesh infection was reported in ten cases. Fourteen patients with seroma formation required reoperation.

In another series of 3017 cases of TAPP from two centers17 over seven years, the recurrence was 5% in initial 325 cases when the mesh size was 11cm x 6 cm. It had been then increased to 15cm x 10cm. and this decreases the recurrence to 0.16% for the rest of the cases on the follow-up of 45 months. The mean operating time was 40minutes and also the rate of seroma formation was 8% having a mean hospital stay of 0.9 nights. Thus, most of the cases have been done as a day care procedure. They had also reported 7 cases of bladder injury, of which 6 were recognized immediately and dealt with laparoscopically. Only four cases had mesh infection, which three were treated conservatively.

One Randomized Controlled Trial19 reported no statistical distinction between TAPP and TEP when considering duration of operation, haematoma formation, period of stay, time to return to usual activities and recurrence. Eight non-randomized studies suggest that TAPP is assigned to high risk of Port Site Hernia and visceral injuries whilst there appears to be more conversions with TEP. It has been pointed out; however, that placement of the mesh can't be checked while deflating the pneumoperitoneum.

The benefits of TAPP over TEP are as follows -

1. Acknowledgement of important landmarks and assessment of opposite hernial defects during dissection are easier.
2. In irreducible hernias, adhesions between the omentum, intestine and the sac are freed without injuring the structures and managed with fewer complications.
3. Sliding hernia can be recognized immediately and dissection performed easily.
4. Various other surgeries like cholecystectomy could be coupled with this process.

Laparoscopic hernia repair by the TAPP technique is a great operation for treating inguinal hernias. Precondition for excellent results may be the strict using a standardized technique. In experienced hands, all sorts of hernias, which includes large scrotal hernias and recurrent hernias after previous preperitoneal repair, could be operated with low morbidity and recurrence rates. However, to achieve favorable results, a strong educational enter in laparoscopy is encouraged.