Laparoscopic Inguinal Hernia Repair

A pneumoperitoneum is created in the usual fashion (sub-umbilical position). The first trocar is inserted [11-5mm Versaport™]  in sub-umbilical position. 

The intra-abdominal cavity is visualized with the Telescope and intra-abdominal findings are reported [intra-abdominal pathology and inguinal hernia defects and sacs].          

If an asymptomatic hernia sac is identified on the contralateral side, our protocol mandates its repair, even though at this time we are unsure of its exact clinical significance.      

The two additional 5 mm VersaPort ™ Trocars are inserted under direct vision.

 

The repair is initiated. The laparoscope is pointed toward the afflicted inguinal canal. The peritoneal defect or hernia is identified. The Lateral Umbilical Ligament is located as well as the Inferior Epigastric Artery and Vein. A peritoneal incision is made using scissors or the EndoShear* Instrument. The incision is extended from the lateral aspect of the inguinal region to the Lateral Umbilical Ligament.

For obese patients, this ligament may have to be transected  in order to obtain additional exposure. The operator should be meticulous in making this incision as high as possible to maximize the exposure of the region.

 

With blunt dissection, Cooper's Ligament is exposed as well as the Inferior Epigastric Vessels and the Spermatic Cord. The iliac vessels are not dissected but their positions is clearly identified. It is essential to expose the uncovered abdominal wall meticulously (without peritoneum) and remove all fatty layers.

 

The indirect inguinal hernia sac should be dissected  carefully  from the Spermatic Cord. The most difficult hernia sacs to dissect are large, indirect inguinal sacs where iatrogenic injuries to the spermatic cord can occur. For this reason it is essential to expose and know at all times where the spermatic cord is located. Direct hernia sacs are easily dissected.

Caution: Be attentive not to injure the Vas Deferens.

Particular care should also be taken not to dissect lateral and inferior to Cooper's ligament, as the Iliac Artery and Vein will enter the femoral canal at this site. 

 

The 6x6 i Mesh is rolled like a cigarette and inserted uncut via the 11-5mm Versaport™ Trocar  into the intra-abdominal cavity and deployed over the inguinal region. The Mesh is attached or secured to Cooper's Ligament, around and lateral to the Inferior Epigastric Vessels using tacks delivered via the Protack® Instrument.

Caution: Be attentive not to place staples or tacks over the inguinal vessels.

The Protack® Instrument is dramatically different from the classical Multifire EndoHernia* stapler. The tacks are inserted by rotating; these tacks are more secure than the endostaples, and in most cases, we use 25 to 30 tacks (one disposable instrument) to perform one repair. Again, the operator should be meticulous to avoid the iliac vessels and to place tacks lateral to the inguinal ring.

Caution: Be attentive not to grossly place staples of tacks over visible nerve branches.

 

The operator should check the Mesh is well anchored to the surrounding structures. Using a closed grasper, pressure is applied with the end or tip of the grasper directly at the center of the covered direct and indirect defect. The Mesh should not migrate and remain in place.

 

The peritoneum is closed meticulously and no defect between the peritoneum and the abdominal wall should be left open. In addition, it should cover the entire Mesh.

The closure should be initiated on the lateral aspect of the repair. The peritoneal flap is held by a grasper and pulled over the upper peritoneal layer. Tacks are used to close the peritoneal flap. The epigastric vessels should be meticulously visualized prior to stapling around them.

Caution: Be attentive not to place staples or tacks over the Epigastric vessels.

The trocars are removed under direct vision. The fascia of the sub-umbilical trocar site is closed as needed.