Figure 72-25. Shouldice repair.

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Figure 72-26. McVay (Cooper ligament) repair.

As population-based studies began to supplant personal series, it became obvious that the recurrence

rate for tissue repairs with the exception of the Shouldice repair approached 10% to 15% in the general

surgical practice.64 In the 1990s, widespread adoption of the routine use of prosthesis (usually a mesh

material) as popularized by Lichtenstein has resulted in the near elimination of the Bassini approach in

the United States with recurrence rates decreasing by 50% to 75%.65 The Lichtenstein operation or open

mesh herniorrhaphy, which is considered the “gold standard” operation for inguinal hernias with a

recurrence rate of 1% to 1.6% (Fig. 72-27).66 The initial dissection is identical to the tissue repairs

described. Once the sac has been dealt with, a 15 × 11-cm sheet of polypropylene mesh is used, the

medial end of which is rounded to the shape of the medial corner of the inguinal canal. This medial end

is sutured to the anterior rectus sheath 2 cm medial to the pubic tubercle. In deference to nerve

entrapment, most surgeons now use an absorbable suture, something considered heresy in the past. The

same suture is then continued laterally in a running locking fashion securing the inferior edge of the

prosthesis to either side of the pubic tubercle and the shelving edge of the inguinal ligament. The

periosteum of the bone is avoided to prevent osteitis pubis. The suture is continued to attach the lower

edge of the prosthesis to the shelving edge of the inguinal ligament up to a point just lateral to the

internal ring. If a femoral hernia is present, the posterior surface of the mesh is sutured to the Cooper

ligament after the inferior edge has been attached to the inguinal ligament. Alternatively, the inferior

edge of the prosthesis is sewn directly to Cooper ligament medially and then transitioned to the inguinal

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ligament over the femoral vessels. Both techniques close the femoral canal. A slit is cut in the lateral

end of the mesh to produce a narrow (one-third width) tail below and a wider (two-thirds width) tail

above. The spermatic cord is positioned between the two tails. The wider tail is placed over the narrow

one and a so-called shutter valve stitch placed just lateral to the cord including the inferior surface of

the superior tail, the inferior surface of the inferior tail, and the inguinal ligament. The tails are then

tucked under the external oblique aponeurosis to the level of the anterior superior iliac spine. The

external oblique aponeurosis is closed to re-create the external ring. The wound is closed in layers.

Figure 72-27. The Lichtenstein hernioplasty, showing placement of the mesh.

A popular modification of the Lichtenstein operation has been termed the plug-and-patch repair. As

the name implies, a plug usually constructed from polypropylene is inserted in the defect and secured

with interrupted sutures to either the internal ring (for an indirect hernia) or the neck of the defect (for

a direct hernia). The patch is then placed over the plug to cover the inguinal floor as in the Lichtenstein.

One might argue that this operation is nothing more than a Lichtenstein on top of a plug, and in fact the

term “plugstenstein” has been used to describe it. However, the difference with a plug-and-patch repair

is that only one or two sutures – or, sometimes, no sutures – are used to secure the flat prosthesis to the

underlying inguinal floor. This results in an operation that is fast and very easy to teach. However,

based on trials comparing the plug and patch to the Lichtenstein technique, no benefit with respect to

recurrence rate and/or chronic pain has been demonstrated.62

Preperitoneal Approach

The preperitoneal space is situated between the transversalis fascia and the peritoneum. The final

common denominator in all groin hernias is failure of the transversalis fascia to retain the intraabdominal contents. Repairs performed in this space make the distinction between direct, indirect, and

femoral irrelevant because the repair is accomplished behind the defective transversalis fascia,

addressing the entire myopectineal orifice.

For a conventional, open operation, the preperitoneal space can be entered via a lower midline

incision or a transverse incision placed slightly higher than usual. The rectus muscle is retracted

medially and the preperitoneal space entered. A large prosthesis is used that extends far beyond the

margins of the myopectineal orifice and envelops the visceral sac. The mesh is held in place by intraabdominal pressure, which pushes outward toward the undersurface of the transversalis fascia. If the

hernial sac is large, it is amputated or inverted beneath a purse-string suture to smooth the external

surface of the visceral sac. The distal peritoneal sac is left in place, undissected, and attached to the

cord. With a sliding indirect hernia, the sac is easily dissected away from the cord. Proponents of this

technique feel that polyester is better suited than other prostheses because of its pliability. For a

bilateral repair, one large chevron-shaped mesh can be used for both sides. One disadvantage of this

technique is the need for a larger incision and substantial amount of dissection and the associated pain.

Laparoscopic hernia repairs avoid the disadvantages of a large incision while providing the advantages

of preperitoneal repair.

Several newer, less invasive preperitoneal techniques have been developed to place a mesh in the

preperitoneal space. For example, in the Kugel procedure, a small incision is made over the deep

inguinal ring and the preperitoneal space is developed bluntly followed by the use of a prosthesis with

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an incorporated reinforcing ring. This ring can be deformed to allow the prosthesis to be introduced into

the preperitoneal space and then the ring causes it to spring back to its original shape, providing wide

overlap of the myopectineal orifice.67 The procedure works well in experienced hands but because it is

partially blind, considerable training is required. In addition, in earlier designs, the peripheral memory

recoil ring was made of polyethylene terephthalate which had a tendency to fracture over time

occasionally resulting in injury to nearby viscera.68 Another approach is to take advantage of both the

preperitoneal space and the conventional anterior space using a bilayered prosthesis in which a cylinder

of prosthetic material connects the two layers through the hernia defect or the internal ring.69 One such

prosthetic is the Prolene Hernia System (PHS) where both an onlay and sublay mesh is placed. Trials

comparing PHS to the Lichtenstein technique have not shown any difference with respect to recurrence

rate and chronic pain.62 The objection to this system is that both the conventional anterior and the

preperitoneal spaces are dissected making the repair of a recurrence more difficult.

Laparoscopic Approach

The terminology to describe a laparoscopic inguinal herniorrhaphy can be confusing. A laparoscopic

preperitoneal hernia repair, in which a laparoscopy is performed and the preperitoneal space is entered

with a second incision in the peritoneum, is called a transabdominal preperitoneal repair, or TAPP repair.

An inguinal hernia repair in which prosthetic material is placed intraperitoneally over the defect under

laparoscopic guidance is referred to as an intraperitoneal onlay mesh repair, or IPOM repair. The third

general type of laparoscopic approach is the totally extraperitoneal laparoscopic repair, or TEP repair.

Laparoscopy, by definition, implies that the peritoneal cavity has been entered. To refer to this

technique as extraperitoneal therefore represents a contradiction in terms. However, because a

laparoscope and related instruments are used, it is fitting to discuss the extraperitoneal approach along

with the other laparoscopic inguinal herniorrhaphies.

The TAPP and the TEP laparoscopic inguinal herniorrhaphies are the most popular. Both are modeled

after the conventional preperitoneal operations. The major difference is that the preperitoneal space is

entered through three trocar sites rather than through a large conventional incision. The ensuing radical

dissection of the preperitoneal space with placement of a large prosthesis is similar to the conventional

preperitoneal operation.

Laparoscopic Versus Conventional Herniorrhaphy. Randomized controlled trials as well as a metaanalysis of pooled data from these trials have shown that on average, patients undergoing laparoscopic

herniorrhaphy have less pain initially than open, tension-free herniorrhaphy and return to normal

activities sooner with a lower incidence of wound infection and hematoma and less chronic

pain/numbness.61,70 The difference is even greater when the comparison is made to nonprosthetic

repairs. For recurrent hernias after conventional open repair, laparoscopic inguinal hernia repair results

in lesser postoperative pain and faster convalescence. However, the potential advantages of

laparoscopic hernia repair must be interpreted in light of the disadvantages, which include significantly

longer operative time and complications related to the laparoscopy such as bowel perforation or major

vascular injury, potential adhesive complications at sites where the peritoneum has been breached or

prosthetic material has been placed, the need for a general anesthetic, and increased cost because of the

expensive equipment. On the other hand, the conventional operation can be performed under local

anesthesia on an outpatient basis, with minimal risk of intra-abdominal injury, and the cost is less. A

long steep learning curve exists for laparoscopic hernia repairs, especially TEP, and an unacceptably

high recurrence rate may be seen when this procedure is performed by inexperienced surgeons without

appropriate training and mentoring. A recent meta-analysis including 27 randomized trials as well as an

additional cohort study revealed a statistically significant higher risk of recurrence of primary hernias

after laparoscopic repair as compared with open repair. The clinical significance of this is questioned

because the absolute numbers were not impressive, that is, reoperation rates in the cohort study, 4.1%

versus 2.1%.71,72 The operation is particularly difficult if a previous operation has been done in the

preperitoneal space (e.g., the index hernia repair or a prostatectomy) because of scaring with significant

risk for bladder or vascular injury. Despite the expected advantages, the choice between laparoscopy

and other techniques still depends on local expertise availability. Only dedicated centers are able to

routinely offer laparoscopy for a recurrent inguinal hernia.

Patient and Procedure Selection. Assuming equivalence for recurrence and complication rates

between laparoscopic and open tension-free hernia repair for a given surgeon, all adult patients with

inguinal hernias who are candidates for general anesthesia can be considered candidates for laparoscopic

inguinal hernia repair. Certain hernia types, such as those that are recurrent, bilateral, or otherwise

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complicated, are particularly suited for the laparoscopic approach.73,74 In addition, women may be

better served with a laparoscopic operation because the femoral space is addressed, which should

eliminate the excessive incidence of femoral recurrence observed with conventional operations such as

the Lichtenstein.52 Contraindications to laparoscopic inguinal hernia repairs include intra-abdominal

infection and coagulopathy. Relative contraindications for laparoscopic inguinal hernia repair include

intra-abdominal adhesions from previous surgery, ascites, or previous retropubic space surgery, because

of the increased risk for bladder injury. Severe underlying medical illness is also a relative

contraindication because of the added risk of general anesthesia and these patients are better suited for

a conventional operation under local anesthesia. An incarcerated sliding scrotal hernia is a relative

contraindication, especially when it involves the sigmoid colon, because of the high risk for perforation

during the dissection.

Operative Techniques

Transabdominal Preperitoneal Repair. The procedure is begun with a thorough diagnostic

laparoscopy done through an umbilical cannula to rule out unrelated pathology and carefully inspect

both myopectineal orifices. Two additional cannulas are placed just lateral to the rectus sheath on either

side of the umbilicus (Fig. 72-28). For a unilateral hernia, a transverse incision is begun at the lateral

side of the medial umbilical ligament and extended to open its lateral leaf to the anterior superior iliac

spine. If the medial umbilical ligament appears to compromise exposure, it can be divided.

Electrocautery is used to minimize bleeding from the remnants of the embryologic umbilical artery. A

radical dissection of the preperitoneal space is then performed with mostly blunt dissection and

generous use of electrocautery, as bleeding in this area is particularly troublesome if it interferes with

illumination. The ipsilateral and contralateral pubic tubercles, inferior epigastric vessels, Cooper

ligament, and iliopubic tract are identified (Fig. 72-29). The cord structures are mobilized, and the

peritoneal flap is dissected several centimeters proximal to the bifurcation of the vas deferens and the

internal spermatic vessels. Recurrences have been attributed to inadequate mobilization of the

peritoneal flap, which does not allow the prosthesis to lie flat in this area. If small, an indirect sac is

mobilized away from the cord structures and reduced. If large, the sac is divided at a convenient point

distal to the internal ring and only the proximal portion is mobilized. A direct sac readily reduces during

the preperitoneal dissection. An easily visible layer of fatty tissue separates the thinned out transversalis

fascia lining the defect and the peritoneum.

A large piece of polypropylene mesh (at least 14 × 11 cm) is placed in the preperitoneal space to

cover the contralateral pubic tubercle medially and extending onto the anterior abdominal wall

superiorly at least 2 cm above the hernia defect, to the anterior superior iliac spine laterally, and over

the Cooper ligament inferiorly. Most surgeons prefer to fasten the prosthesis with staples, tacks, or

glue, but there is increasing evidence that fixation is not necessary when a large prosthesis is used that

widely overlaps the entire myopectineal orifice. Staples or tacks are never placed below the iliopubic

tract when lateral to the internal spermatic vessel because of the danger of damage to the important

nerves in this area. The last step is to cover the prosthesis by closing the peritoneum with sutures, tacks,

staples, or glue.75 The goal is to isolate the prosthesis from the abdominal viscera rather than to always

achieve precise approximation of the peritoneal edges. This is because gaps can form if the peritoneum

is closed under tension allowing bowel to migrate into the preperitoneal space. A better option is to

secure the inferior peritoneal flap to the transversalis fascia above the prosthesis and leave the superior

flap alone.

For bilateral inguinal hernias, the same peritoneal incision and preperitoneal dissections are used. The

symphysis pubis is completely exposed so that both preperitoneal dissections communicate with each

other. This exposure allows the placement of one large prosthesis (at least 25 × 8 cm) that essentially

covers the entire lower pelvis. By not incising the peritoneum between the two medial umbilical

ligaments, one avoids the theoretical complication of dividing a patent urachus.

Totally Extraperitoneal Repair. An incision is made at the umbilicus, as if one were planning to

perform open laparoscopy. The rectus sheath is opened on one side and the rectus muscle is retracted

laterally. Blunt dissection is then begun in the space between the rectus muscle and the posterior rectus

sheath. Once the space is large enough, two additional cannulas are placed in the midline, one

approximately 5 cm above the symphysis pubis and the other midway between the umbilicus and the

symphysis pubis. The dissection of the preperitoneal space is completed under direct vision. The rest of

the operation is identical to the TAPP procedure described previously except that peritoneal closure is

not necessary. Popular alternatives are to use a water- or air-filled balloon dissector to perform the

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