JOURNAL OF LAPAROENDOSCOPIC SURGERYVolume 2, Number 4, 1992Mary Ann Liebelt, Inc., Publishers

Brief Technical Report

Laparoscopic Preperitoneal ProstheticInguinal Herniorrhaphy

IRVIN H. WILLIS, M.D., F.A.C.S. and HARRY SENDZISCHEW, M.D., F.A.C.S.

ABSTRACT

Laparoscopic minimally invasive surgical procedures are gaining popularity and becomingmore readily available. Presented here is an application of laparoscopy for the repair of groinhernias. Included are actual intraoperative photographs and descriptions of the techniquewith its rationale for the laparoscopic preperitoneal approach and the use of a prostheticmaterial.

INTRODUCTION

The repair of inguinal hernia is one of the most frequent operations performed today. Many approachesand techniques have evolved over the years. There have been, and still are, arguments as to what is the

best approach, the best method of repair, and with the best results and least morbidity. No one technique,however, seems to stand out as the ideal approach. Repairs vary from the methods of Bassini, to Ferguson, toHalstead, to Marcy, Laroche, Shouldice, Stoppa, McVay, Nyhus, Lichtenstein and others—a who's who ofhernia surgery. Now with the popularity and availability of laparoscopic surgical procedures, another optionis available. The authors feel that through the use of the laparoscope and by combining the features andaccepted principles of other varied approaches, a 'best of all worlds' solution may result. Herein, a suggestedtechnique for laparoscopic repair of the inguinal hernia is described and discussed.

MATERIALS AND METHODS

Under general anesthesia, after pneumoperitoneum has been created and with the patient in Trendelenburgposition, a # 10 trocar is placed at the umbilicus and a 45° laparoscope is placed to visualize the anatomy and

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1B 2BFIG. 1. A and B. The hernia defect and anatomic landmarks are clearly seen.

FIG. 2. A and B. The peritoneum has been dissected and peritoneal sac reduced, to reveal the musculo-fascial floor withits defects.

defects present (Fig. 1). Two # 12 trocars are then inserted under direct vision at the level of the umbilicus andlateral to the rectus muscle, one in the right and one in the left lateral abdomen. Reducers, graspers, andscissors connected to the Bovie are used and the peritoneum of the inguinal floor is incised on the top part ofthe defect. The peritoneal sac is reduced fully so that it does not snap back into the defect (Fig. 2). With a directhernia, the attenuated transversalis fascia in the defect is grasped and reduced out of the defect and pulled backinto the peritoneal cavity. The Autosuture Endo GIA 30-V (a disposable surgical stapler [United StatesSurgical Corp., Norwalk, CT]) is then inserted through the trocaron the side of the hernia, closed at the baseof the attenuated fascia, and fired (Fig. 3). The excess fascia is removed and the defect is thereby obliterated,creating an intact floor (Fig. 4). Pieces of Marlex mesh are then placed to reinforce the area from the pubictubercle area to Cooper's ligament to cover the transversus arch and over the internal ring area (Fig. 5). If anindirect hernia is present, the indirect sac is reduced fully, the canal obliterated with the necessary number ofMarlex mesh logs, and the entire floor area covered with a sheet of Marlex mesh, approximately 5 cm X 10cm to further reinforce the area. The peritoneum is then re-approximated with Autosuture Endoclips (adisposable applier [United States Surgical Corp., Norwalk, CT]), leaving the entire area reperitonealized. Thetrocars are removed under direct vision and pneumoperitoneum evacuated. The skin openings are approxi-mated with staples and band-aids are applied.

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3B 4BFIG. 3. A and B. The attenuated transversalis fascia is grasped and pulled back into the peritoneal cavity and theEndo GIA 30-V is applied at its base.FIG. 4. A and B. Appearance of the inguinal floor showing the defect obliterated with the staple line, creating an intactfloor.

DISCUSSION

The laparoscope is an excellent tool in the use of repair of inguinal hernia. It is imperative for any goodrepair of inguinal hernia that the surgeon be knowledgeable and familiar with the anatomy of the region. Theuse of the laparoscope allows one to see a truly exciting picture of the anatomy of the inguinal area—live,in-vivo, in color, and magnified. One certainly can gain a new and clearer appreciation of the concept ofhernia, and consequently its treatment.

The preperitoneal approach via the laparoscope is appropriate, as it avoids cutting through the inguinalcanal and floor area from anterior to posterior, as in a traditional approach, thereby possibly unnecessarilydestroying the floor of the canal to get back to the defect in the posterior wall. Mobilization and mutilation ofthe cord and nerves on the way are also avoided. ' The preperitoneal approach takes the surgeon directly to thesite of the problem.

Prosthetic material, specifically Marlex mesh, has been used for over 30 years and is well known to be an

excellent material that is not rejected by the patient, is incorporated into the patient's own tissues to strengthenweakened areas, and acts as a continuing barrier to further hernia defect formation.2

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FIG. 5. A and B. Marlex mesh logs are placed in the indirect canal to obliterate and fill this space. The floor area iscovered with a sheet of Marlex mesh to further reinforce the area. Not shown here is a 5 cm x 10 cm screen of Marlexmesh which is placed over the entire floor covering the internal ring area to pubic tubercle, over transversus arch to

Cooper's ligament.

In the case of an indirect inguinal hernia, the sac is dissected out of the canal completely and the canal isplugged with mesh, completely filling and obliterating the indirect defect.3 The plugs also serve to reinforcethe floor from the anterior side of the transversalis fascia. A flat screen of mesh is placed over the entire area

to further cover the internal ring area and reinforce the entire floor. With a direct hernia, the attenuatedtransversalis fascia of the defect is approximated with the Autosuture Endo GIA 30-V staple gun to obliteratethe defect in the floor. The area is then covered with a Marlex mesh screen to further reinforce the area. Themesh pieces are all placed directly in contact with the musculo-fascial defects in question, and the defects are

filled, closed, and covered without tension.4 When the peritoneum is approximated, no mesh is exposed to theperitoneal cavity as a possible site of adhesions.

With the use of the laparoscope for hernia repairs, with no large incisions in the groin and no muscle incised,there has been minimal pain found, immediate ambulation and intake of nutrition, and early return to fullactivity and work in a matter of days—instead of a 4 to 6 week painful convalescent period.5 Patients can

immediately resume full activity without restrictions.The laparoscopic approach is applicable to all groin hernias including recurrent, femoral, and incarcerated

hernias where bowel viability may be evaluated. Another advantage with the laparoscope is that anexploratory laparoscopy can be done for diagnostic purposes as well as easily visualize other areas for

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unexpected or uncertain hernias. If other hernias, such as bilateral are found, they can be repaired at the same

operative setting, possibly saving the patient from having to undergo another procedure.The technique of laparoscopic preperitoneal prosthetic inguinal herniorrhaphy is believed to be a safe,

quick, effective procedure applicable to the repair of all inguinal hernias.

REFERENCES

1. Ger R: The laparoscopic management of groin hernias. Contemporary Surgery 1991 ;39:15-19.2. Nyhus LM, Polcak R, Bumbect K. Donahue PE: The preperitoneal approach and prosthetic buttress repair for recurrent

hernia. Ann Surg 1988;208:733-737.3. Schultz L, Graber J, Pietrafitta J, Kickok D: Laser laparoscopic herniorrhaphy: A clinical trial, preliminary results. J

Laparoendosc Surg 1990;1:44-45.4. Shulman AG, AmidPK, Lichtenstein IL: The plug repair of 1402 recurrent inguinal hernias. Arch Surg 1990:125:265-

267.

5. CorbittJrJD: Laparoscopic herniorrhaphy. Surg Laparosc & Endose 1991;1:23-25.

Address reprint requests to:Irvin H. Willis, M.D., F.A.C.S.

Diplomate American Board of SurgeryMedical Staff Office Pavilion4302 Alton Road Suite 630

Miami Beach, FL 33140

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