preperitoneal dissection and to place the two accessory cannulas on either side of the umbilicus, as in

the TAPP procedure, instead of in the midline.

Figure 72-28. Typical operative setup and cannula site selection for a transabdominal preperitoneal (TAPP) laparoscopic inguinal

herniorrhaphy.

Figure 72-29. Important structures that must be identified after a preperitoneal dissection: inferior epigastric vessels, Cooper

ligament, spermatic vessels, vas deferens, iliopubic tract, genitofemoral nerve, femoral nerve, lateral femoral cutaneous nerve,

ilioinguinal nerve, iliacus muscle, and psoas major muscle.

The presumed advantages of the TEP procedure are that the inherent complications of entering the

peritoneal cavity, such as intra-abdominal organ injury or postoperative bowel obstruction secondary to

adhesions or trocar site herniation, are avoided. However, the operative space is limited, and

considerable experience is required to become familiar with the anatomy from this perspective. In

addition, it is not yet clear whether inadvertent breaches in the peritoneal cavity that are difficult to

1947

visualize because of the direction of the optics might negate the potential benefits of this approach.

Intraperitoneal Onlay Mesh Repair. The TAPP and the TEP herniorrhaphies are better considered

minimal access procedures rather than minimally invasive because of the extensive dissection required

in the preperitoneal space. The IPOM procedure was developed to be a truly minimally invasive

operation. By placing the prosthesis one layer deep to the preperitoneal space directly onto the

peritoneum, one can eliminate the need for a radical preperitoneal dissection. Initial laparoscopy and

accessory cannula placement are the same as in the TAPP procedure. A large piece of prosthetic material

is introduced into the peritoneal cavity and secured in place with staples, tacks, or sutures. An attempt

is made to use the same landmarks described previously for the TAPP procedure. The main concern is

development of the complications of intraperitoneal placement of a prosthesis in contact with intraabdominal organs. The procedure is regaining some popularity because of the development of the

adhesion barrier prosthetics for ventral hernia repair.

Special Considerations: Pediatric Hernias

Given the high incidence of indirect inguinal hernias due to a patent processus vaginalis in pediatric

patients, hernia repairs are completed using a high ligation technique. Concerns exist with the use of

mesh in adolescents with respect to effect on fertility, long-term groin pain, and infection risk.76,77

Postpubertal males have a similar anatomy to the adult population with a larger inguinal ring diameter

and variations on transverse fascia defects. It is unclear as to which age/size does a child become an

adult with respect to principles of hernia repair. Longitudinal studies comparing different hernia repair

techniques in adolescents are needed before we can determine optimal treatment for adolescents

especially those with weak inguinal floors and direct hernias.

Femoral Hernias

Femoral hernias are much rarer and account for 2% to 4% of groin hernia repairs and can present a

challenge to even the most experienced surgeon. As such, femoral hernias are more common in women

and often present with an acute episode of incarceration, intestinal obstruction, or strangulation, so that

emergency surgery is necessary. It can be difficult to reduce the hernia at surgery, and it is not

uncommon to have to divide the inguinal ligament to obtain greater freedom to perform this reduction.

Femoral hernias can be repaired from a lower approach, in which a vertical incision is made over the

femoral triangle in the upper thigh. The hernia is approached from below the inguinal ligament and

reduced, and then the defect is closed by suturing the inguinal ligament to the Cooper ligament from

below. An alternative is to insert a rolled plug of mesh into the defect and suture the periphery to the

inguinal ligament and Cooper ligament.66 The repair can also be carried out from above via an inguinal

approach, as in the McVay repair. The posterior floor of the inguinal canal is dissected out, and the

Cooper ligament is repaired after the hernia has been reduced. A third type of femoral hernia repair is

the preperitoneal repair. Access to the preperitoneal space is gained through an abdominal incision or

laparoscopy. A recent study based on the Swedish national register revealed that preperitoneal mesh

techniques (both laparoscopic and open) are a better choice for women with femoral hernias.78 As

effective as the Lichtenstein operation is for men, it may not be the best choice for woman. This is

because the Lichtenstein operation, unless modified, only addresses an inguinal hernia and not a femoral

hernia. On the other hand, the preperitoneal herniorrhaphies result in coverage of the entire

myopectineal orifice and thus both femoral and inguinal hernias are treated. Indeed, in the Swedish

study a much higher femoral recurrence rate was observed in women compared to men especially after

the repair of a direct inguinal hernia. This is significant because direct hernias are almost unheard of in

women providing strong evidence that the femoral hernia was actually missed at the index operation.52

SPORTS HERNIA/ATHLETIC PUBALGIA

The term sports hernia is confusing because, by definition, these patients do not actually have a hernia

but rather a weakness of the posterior inguinal floor. This condition has received considerable attention

in the lay press because of its prevalence in high-profile athletes involved in sports who require rapid

changes in direction of the hip area such as soccer, football, basketball, track and field, tennis, and

hockey. Alteration in the complex balance that must be maintained between the lower abdominal

muscles and the leg adductor muscles and tendons, all revolving around the area of the pubic bone, is

the final common denominator for many of the conditions that cause groin pain in up to 5% of athletes

1948

(Fig. 72-30).79 The first step in approaching these patients is to make sure that one is not dealing with a

cause outside of the groin with referred pain, such as lumbosacral radiculopathic pain, prostatitis, hip

disease, and a gastrointestinal cause. The differential diagnosis is listed in Table 72-8.

Figure 72-30. Complicated arrangement of muscle pulling in different directions that attach to the pubic bone.

DIAGNOSIS

Table 72-8 Conditions Other Than a Hernia Associated With Groin Pain

Some authorities prefer to refer to this condition as “athletic pubalgia,” as this conveys the concept

that the physical examination is inconclusive and the cause of groin pain is unclear. Imaging may be

performed by ultrasound, but cross-sectional imaging (CT or magnetic resonance imaging [MRI]) is the

most useful diagnostic modality in the absence of a highly experienced ultrasonographer.80 Compared to

CT, MRI provides excellent overall anatomic detail especially with the development of fast imaging

scanners that will allow dynamic imaging (i.e., performed during straining) with or without the

addition of intraperitoneal contrast agents.

1949

The initial treatment is conservative with forced inactivity, elastic immobilization bandages,

ice/massage, nonsteroidal anti-inflammatory analgesics, and occasional steroids (systemic and/or local).

Surgery is a last resort. Although lacking clear-cut anatomic justification, a mesh hernia repair similar to

either an anterior Lichtenstein or a TEP laparoscopic operation is the most popular procedure,

sometimes combined with a variety of muscle reattachment procedures and tenotomies. The best results

are obtained with a multidisciplinary approach including a surgeon, an orthopedist, a physical therapist,

and a sports medicine physician. Not surprisingly, the results are variable given the lack of objective

criteria to recommend operation but can be gratifying in some in this motivated group of patients.

Complications of Inguinal Hernia Repair

Complications Related to the Patient

Urinary Retention. The most common predisposing factor for urinary retention after a hernia repair is

the use of general or regional anesthesia.59 Meta-analyses of randomized controlled trials comparing

various hernia techniques performed under general anesthesia have not shown a difference in urinary

retention rates.81–84 Predisposing factors for urinary retention include overhydration with intravenous

fluid during surgery, use of opioid analgesics, older age, prostatic symptoms, and prolonged operative

time.85,86 Intermittent catheterization or temporary placement of an indwelling urinary catheter is

usually adequate therapy. Prophylactic and therapeutic use of alpha adrenergic blockers including

prazosin and tamsulosin have been shown in some studies as an effective strategy to prevent

postoperative urinary retention.87,88

Ileus. Ileus can be seen with either the conventional or the laparoscopic procedure but is more common

with the latter. Treatment is symptomatic, and spontaneous resolution is the rule. Nasogastric

decompression is occasionally needed.

Complications Related to the Herniorrhaphy

Recurrence. A lower risk for recurrence with the use of prosthetic material for the repair of an inguinal

hernia has been clearly proven by meta-analysis.89 Recurrence rates of 2% or less are now routinely

reported from specialty centers performing either laparoscopic or conventional TFRs. Although the

recurrence rate for hernia repairs is less than 1% at the Shouldice Clinic, others have not been able to

duplicate this outstanding record with this or any of the other nonprosthetic repairs.90 Complications

during the first month after surgery; operation for recurrence; and sutured repairs without mesh, with

either anterior or preperitoneal techniques, are associated with an increased recurrence rate. A

laparoscopic approach is also considered a risk for recurrence because of its higher potential for

technical failure, especially in the less experienced. This was felt to be the most likely reason for a

higher recurrence rate at 2 years in a Veterans Affairs study for the laparoscopic approach (10%)

compared to an open TFR (4% for the Lichtenstein repair).91

A consistent definition of a recurrent hernia does not exist because of the difficulty in differentiating a

lipoma of the cord, a seroma, or an expansile bulge of the internal oblique muscle from a true hernia

recurrence. It may be that reoperation rates as a surrogate provides the most accurate data.92 From a

clinical standpoint, a hernia should not be classified recurrent unless there is a visible bulge or there is

unequivocal evidence of a hernia by an imaging modality such as ultrasound, CT, or MRI. This is

especially important for patients who present with pain after their hernia repair because their pain is

likely due to a preoperative condition other than the hernia or a postinguinal herniorrhaphy pain

syndrome which might be exacerbated by further groin surgery. Femoral recurrences are seen after a

Lichtenstein repair because the femoral canal is not routinely closed with the classic technique.52

The general principle for managing recurrent hernias depends on the original repair. The logical

approach is to perform the herniorrhaphy in the space that has not been dissected. If the patient had a

previous conventional repair, then a preperitoneal repair is best chosen. On the other hand, if the index

operation was a preperitoneal one, then a repair that is performed in the conventional inguinal space is

best. The dissection of the preperitoneal space after a failed herniorrhaphy has been performed is

particularly challenging, with significant risk for vascular, neurologic, and bladder injury.

7 Postherniorrhaphy Groin Pain. Now that the recurrence rate has been brought down to a minimum

using modern hernioplasty techniques, chronic postoperative groin pain syndromes (persisting >3 to 6

months post surgery) have emerged as the biggest issue facing inguinal hernia surgeons (Algorithm 72-

3). Poobalan and colleagues published a critical review of inguinal herniorrhaphy studies between 1987

and 2000.93 The frequency of at least some long-term groin pain was as high as 53% at 1 year (range,

1950

0% to 53%). On average, moderate or severe postherniorrhaphy groin pain probably occurs in about

10% of patients. Several factors have been suggested to be related to the development and intensity of

postherniorrhaphy including psychological status, presence of preoperative pain at surgical site, nerve

injury, intraoperative nerve handling, surgical technique (open vs. laparoscopic), and acute

postoperative pain. Risk prediction model for persistent postoperative pain–based preoperative,

intraoperative, and postoperative factors can be helpful in predicting which patients will be more likely

to suffer from postherniorraphy pain.76

Algorithm 72-3. Management of groin pain after herniorraphy.

Perhaps the most important single determination for the chronic postherniorrhaphy pain patient is to

decide whether the pain is the same or different from that which brought the hernia to the attention of

the physician in the first place. There are a variety of conditions that cause groin pain (Table 72-8). CT,

ultrasonography, herniography, laparoscopy, and MRI all have their place in the evaluation of these

patients. MRI is perhaps the most beneficial because of its ability to differentiate between muscle tear,

osteitis pubis, bursitis, and stress fracture. Strain of the adductor muscle complex (adductor longus,

brevis, magnus, and gracilis muscles) is commonly overlooked in this group.

True postherniorrhaphy groin pain should be divided into two types: (a) nociceptive pain, which is

caused by tissue damage, is further subdivided into somatic and visceral pain, and (b) neuropathic pain

due to direct nerve damage. Somatic pain is the most common and is usually caused by damage to

ligaments, tendons, and muscles. Visceral pain refers to that which is related to a specific visceral

function such as urination or ejaculation (see dysejaculation syndrome, later). Neuropathic pain is much

less common but is important to recognize because surgical treatment is possible if the cause is

incorporation of a nerve in staples or suture material. The nerves that are usually involved are the

ilioinguinal nerve, the iliohypogastric nerve, both the genital and femoral branches of the genitofemoral

nerve, and the lateral cutaneous nerve of the thigh. The former two are especially prone to injury

during a conventional herniorrhaphy, whereas the latter are most likely damaged during laparoscopy. A

femoral nerve injury is extremely rare and is usually the result of a gross technical misadventure. Pain

and/or paraesthesia in their distribution characterize patients’ symptoms for the more common nerves.

There is significant overlap of these nerves, and therefore, it is commonly difficult to sort out exactly

which nerve is damaged. Both nociceptive and neuropathic pain is best treated initially with reassurance

and conservative treatment with anti-inflammatory medications and local nerve blocks because these

will frequently resolve spontaneously. An exception is the patient who complains of severe pain

1951