Bilateral hernias. Bilateral hernias can be repaired simultaneously without additional incisions or trocar sites. Patients undergoing another Laparoscopic Procedure. A patient with an inguinal hernia can safely undergo laparoscopic herniorrhaphy following the completion of the primary laparoscopic procedure. 

 

The primary procedure must not have created contamination by spillage of purulent materials. Placement of additional trocars may be required. Hernia repair should not be performed using trocars in suboptimal positions. Access and appropriate angles for dissection are critical for laparoscopic surgery.

 

The patient should be supine with arms tucked at the side. Extending the arms on arm boards may not allow enough room for the surgeon to comfortably operate. The Trendelenburg position allows the bowel to fall away the pelvis, providing excellent access. The surgeon stands on the opposite side of the table from the hernia. Placement of a Foley catheter is optional and depends on surgeon’s preference. Place a single video monitor at the foot of the operating table. Adjust the height of the monitor for comfortable viewing by both surgeon and assistants.

 

Place the first trocar at the umbilicus. optical system has improved so much in the last several years that a 5-mm telescope may be sufficient for visualization. however, this does make mesh introduction later in the procedure more difficult. therefore, many surgeons still prefer a 10-mm cannula. Place two additional trocars lateral to the rectus sheath on either side at the level of the umbilicus under direct vision;5-mm trocars are sufficient assuming no 10-mm instrument will be required.

 

An angled laparoscope provides the best visualization of the inguinal region, which is somewhat anterior. Inspect both inguinal regions. identify the median umbilical ligament, the medial umbilical ligament artery, and the lateral umbilical fold peritoneal reflection over the inferior epigastric artery. if the median umbilical ligament appears to compromise exposure, divide it.
 

Use laparoscopic scissors to incise the peritoneum along a line approximately 2cm above the superior edge of the hernia defect, extending from the median umbilical ligament to the anterior superior iliac spine. Mobilize the peritoneal flap inferiorly using blunt and sharp dissection. Expose the inferior epigastric vessels, and identify the pubic symphysis and lower portion of the rectus abdominis muscle. Dissect cooper’s ligament to its junction with the femoral vein.

 

Identify the iliopubic tract. Continue the dissection inferiorly, with care to avoid an injury to the femoral branch of the genitofemoral nerve and the lateral femoral cutaneous nerve, which usually enter the lower extremity just below the iliopubic tract. Complete the dissection by skeletonizing the cord structures. Direct hernia. reduce the sac and preperitoneal fat from the hernia orifice by gentle traction. A small sac is easily mobilized from the cord structures and reduced back into the peritoneal cavity. A large sac may be difficult to mobilize because of dense adhesions between the sac and the chord structures due to the chronically of the hernia. Undue trauma to the cord may result if an attempt is made to remove the sac in its entirety. In this situation, divide the sac just distal to the internal ring, leaving the distal sac in situ. This is most easily accomplished by opening the sac on the side opposite the cord structures and completing the division from inside. Dissect the proximal sac away from cord structures.
 

Place a large piece of mesh over the myopectinal orifice so that it completely covers the direct, indirect, and femoral spaces. The mesh can be simply laid over the cord structures; or, a silt can be made in the mesh to wrap around the cord structures. Most surgeons now avoid the silt in the prosthesis because recurrences have been noted through the slits even when they have been closed around the cord.

 

The large prosthesis allows the intra-abdominal pressure to act uniformly over a large area, thus preventing its herniation through the hernia defect in the abdominal wall. Although not all surgeons think that stapling or tacking is necessary, most feel that the practice may prevent migration or shrinkage in some patients. Begin stapling/ tacking along the superior border of the prosthesis.  Place staples horizontally along the superior border to minimize the chance of injury to the deeper ilioinguinal or iliohypogastric  nerves.

 

Place staples/tacks at least 2 cm above the hernia defect beginning medially above the contralateral pubic tubercle and extending laterally to the anterior superior iliac spine. Staple/tack the inferior border to cooper’s ligament medially. Again the opposite pubic tubercle marks the area to begin placing staples/tacks for the inferior broader and these are continued over the area of the ipsilateral pubic pubic tubercle to the femoral vein. Ddo not place staples/tacks directly into either pubic tubercle because chronic postoperative pain can result. Affix the medial and lateral borders using vertically placed staples or tasks. This is to the direction of the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve.

 

Lateral to the internal spermatic vessels, place all staples/tacks above the iliopubic tract. This avoids neuralgia from injury to the lateral cutaneous nerve of the thing or the femoral branch of the genitofemoral nerve.it is useful to palpate the head of the stapler by hand. This ensures that stapling is done above the iliopubic tact.

 

After stapling/tacking is complete, excise any redundant mesh. Close the peritoneal flap over the mesh with staples, tacks, or continuous 3/0  vicryl  suture. The goal should be to isolate the prosthesis from intraabdominal viscera. Occasionally, it is necessary to simply cover the mesh with the inferior flap, leaving exposed transversalis fascia. Avoid excess gaps between staples; bowl can have herniated or adhere to the mesh through these defects. It may be helpful to decrease the pneumoperitoneum prior to flap closure. Bilateral hernias can be repaired one long transverse peritoneal incision extending from one anterior superior iliac spine to the other.
 

Another option is to make two separate peritoneal incisions, preserving the peritoneum between the medial umbilical ligaments but still dissecting the preperitoneal space over the symphysis pubis. this has the theoretical advantage of avoiding damage to a patent urachus.
 

large single piece of mesh measuring 30 cm x7.5cm can be stapled/tacked from one anterior superior iliac spine to the other anterior superior iliac spine. Some surgeons prefer two separate pieces of mesh because of concern that placing the mesh across the bladder could interfere with bladder function. Also, it is technically easier to manipulate two pieces separately and tailor them more accurately to fit the preperitoneal space on either side.