Laparoscopic Inguinal Hernia Repair

Peritoneal defects generated by during a TEP repair must be repaired. This defects can generate delayed small bowel obstructions and other significant complications. For these reasons they need to be clearly identified and immediately repaired.

These defects can be repaired using SURGICON™ 5mm Clips, an ENDOLOOP or a 5 mm USSC ENDOCLIP™ . The edges of the defects are approximated with one graspers and clipped closed with clip applier. This repair is safe and has been proven to hold well.

If the operator is not certain all defects have been appropriately closed, a completion laparoscopy can be easily performed at the end of the TEP repair.

The Epigastric vessels are dangerous vascular structures. The laparoscopic surgeon should at all time know their location. All bleeding complications with or without re-exploration have been secondary to an intra-operative injury to the Epigastric vessels. 

For these reasons, we have set forth rigid operative guidelines with which one should always comply. They are as follows:

1. Whenever feasible, always insert the lateral trocars using trans-illumination.

2. Always locate the Epigastric vessels before making the peritoneal incision.

3. Always know the position of the Epigastric vessels during the entire hernia repair.

4. When anchoring the Mesh, always staple or place tacks on each side of the Epigastric vessels.

5. When closing the peritoneum [TAPP Repairs], always staple or place tacks on each side of the epigatric vessels.

6. When an injury to the Epigastric vein or artery is suspected, ligation of the epigastric vessels should be performed.

7. During a TEP repair, if the dilating balloon has migrated the Epigastric vessels inferiorly [on the inferior aspect of the repair or the peritoneum], they should ligated and cut them immediately.

8. If a patient, become hypo-tensive or tachycardic during his immediate recovery, always suspect an Epigastric vessels injury.

Immediate, minimal post-operative bleeding [without hypotension or tachycardia] should prompt the surgeon to admit the patient to the surgical service. A stable hematoma restricted to the inguinal region and scrotum does not require re-exploration. Serial CBC and observation should be obtained.

Immediate, severe post-operative bleeding [with hypotension and/or tachycardia] requires an aggressive management. The patient will be immediately transferred to a monitored unit. Serial [every 3 hours] CBC will be ordered as well as a Type and Hold for 4 Packed Red Blood Units. If the hypotension does not respond to intra-venous fluid , re-exploration should be contemplated. An injury to the Epigastric vessels is almost always the etiology. If the hemodynamic indices of the patient respond to intravenous fluid hydration, observation is warranted with transfusion if the Hemoglabin level drops below 8mg/ml. Continuously dropping hemoglobin level, will require re-exploration.

Injuries to the neural structure in the inguino-femoral area are reported to happen during a laparoscopic repair. Some authors claim that using a Mesh without any means of fixation [tacks] eliminates this complication. There are however no long term studies available with this technical variation.

However in our latest analysis of 2500 repairs, the occurrence of permanent, post-operative neuralgia was negligible even when placing tacks lateral to the spermatic cord or inguinal rings. Temporary, short term neuropathy do commonly occur  but do not impair the recovery of the patient but subside within a few days.

Injuries to the lateral cutaneous nerve and to the genital branch of the genito-femoral nerve can be minimized by using simple maneuvers.

1. Do not use abdominal wall counter pressure when placing a tack,

2. Dissect the abdominal wall meticulously and try to identify obvious neural branches,

3. Do not place and tack the Mesh under tension,

4. Make all patients exercise starting the day after the procedure [minimal exercise: a 1 to 3 miles, daily walk].