M inima lly I n vas i ve

A p p ro a c h e s t o I n g u i n a l
Hernias
Charlotte M. Horne, MD, Ajita S. Prabhu, MD

KEYWORDS
 Inguinal hernia  Minimally invasive repair  Transabdominal preperitoneal approach
 Total extraperitoneal approach  Robotic inguinal hernia repairs

KEY POINTS
 Both the transabdominal preperitoneal approach and the total extraperitoneal
approach to inguinal hernias provide an effective means of repairing inguinal hernias.
 The robotic platform can be used and may help to decrease immediate postoperative
pain; however, as this is a fairly new technique, more research will help further determine
long-term outcomes.
 In all methods of fixation, we ensure adequate fixation medially with tacks placed on
Cooper’s ligament.
 Awareness of the nerves and vessels helps to guide dissection as well as prevent
inadvertent injury during mesh fixation.

INTRODUCTION

Inguinal hernia repair is one of the most commonly performed operations by a

general surgeon.1 Historically, repair was conducted via an open approach; how-
ever, since the description of minimally invasive techniques two decades ago,
there has been a shift to a laparoscopic approach. Initial pitfalls of the laparo-
scopic approaches included high recurrence rates, as mesh reinforcement was
not routine, as well as postoperative pain due to tack placement. Now minimally
invasive inguinal hernia repair is associated with minimal morbidity, mortality, and
low recurrence rates. Laparoscopic repair has been associated with decreased
postoperative pain, earlier return to work, and improved cosmetic outcomes
when compared with an open apporach.2 Despite this, there is no definitive evi-
dence that suggests superiority to an open approach. The two main minimally
invasive approaches are a transabdominal preperitoneal approach (TAPP) or a

The author has nothing to disclose.

The Cleveland Clinic, Department of General Surgery, 9500 Euclid Avenue, Cleveland, OH
44113, USA
E-mail address: HORNEC@ccf.org

Surg Clin N Am 98 (2018) 637–649

https://doi.org/10.1016/j.suc.2018.02.008 surgical.theclinics.com
0039-6109/18/ª 2018 Elsevier Inc. All rights reserved.
638 Horne & Prabhu

total extraperitoneal approach (TEP). Extensive comparison of these 2 techniques

has been conducted, and there is yet to be definitive evidence to support a supe-
rior approach.3 We feel both techniques to be equally effective when performed
by an experienced surgeon and choice of approach is at the discretion of the
operating surgeon.
Advantages of a minimally invasive approach include the ability to address bilat-
eral hernias through the same incisions, as well as, in the setting of recurrent inguinal
hernia repair, these approaches can allow for dissection in virgin tissue planes. The
most challenging part of these procedures is appropriate identification of inguinal
anatomy. It is important to identify major neurovascular structures early and be
cognizant about their location through to the completion of the operation. Knowl-
edge of the anatomy also can guide dissection in a safe manner and limit postoper-
ative morbidity.

TRANSABDOMINAL PREPERITONEAL REPAIR

Patient Selection
Although most inguinal hernias can be approached from an intraperitoneal approach,
some relative contraindications include multiple previous abdominal operations as
well as the inability to tolerate general anesthesia. Recurrent and bilateral inguinal her-
nias may benefit from a laparoscopic approach. We routinely give our patients prophy-
lactic heparin and preoperative antibiotic prophylaxis before incision. A Foley is placed
preoperatively and removed at completion of the operation to minimize urinary reten-
tion postoperatively.

Patient Positioning and Port Placement

Patients are placed in the supine position. Access is gained at the umbilicus using a
Hassan technique. Once access is gained and the abdomen is insufflated, two
5-mm ports are placed slightly cephalad to the level of the umbilicus just lateral to
the rectus sheath bilaterally under direct visualization. If adhesiolysis is required, we
recommend that this be done sharply if possible.
The preferred dissection plane is the preperitoneal plane, which can be identified by
the presence of the transversalis muscle fibers superiorly. Recognizing entry into the
pretransversalis plane, which can be identified by the recuts muscle superiorly, is
essential, as transition to the preperitoneal plane must be done lateral to the inferior
epigastric vessels for proper mesh placement.

Initial Dissection
Initial dissection begins at the medial umbilical fold. An incision is made in the perito-
neum just lateral to the fold using scissors with cautery. This incision is should be
made as close as possible to the umbilicus to create a space to accommodate an
appropriate-sized piece of mesh. Next, further lateral dissection lengthens the perito-
neal flap. When carrying out the dissection laterally, it is important to maintain the
plane high on the abdominal wall. Creation of the peritoneal flap is complete when
the flap is lateral to the inferior epigastric vessels and the anterior superior iliac spine
(ASIS) has been reached (Fig. 1).
After the peritoneal flap is created, dissection is begun at the medial aspect to iden-
tity the pubic tubercle and Cooper ligament. This is successfully completed bluntly
due to the lack of significant structures medial to the inferior epigastric vessels.
Once the pubis has been reached, further dissection is completed medial to the
epigastric vessels, to fully expose the Cooper ligament.
 MIS Approaches to Inguinal Hernias 639

Fig. 1. Dissection is started just lateral to the medial umbilical fold. One grasper is used to
pull the incised peritoneal flap to assist in dissection. (From Rosen MJ. Transabdominal pre-
peritoneal inguinal hernia repair. In: Atlas of abdominal wall reconstruction. 2nd edition.
Elsevier; 2017. p. 418; with permission.)

Lateral Dissection
Next, attention is turned to the lateral aspect (Fig. 2). This should occur immediately on
the peritoneal flap to maintain hemostasis. Working laterally to medially, dissection is car-
ried toward the inferior epigastric muscles. To facilitate dissection, appropriate tension
must be maintained on the peritoneal flap. Filmy adhesions are pushed gently to develop
the lateral plane. The lateral extent of dissection is reached when the curve of the abdom-
inal wall begins to take a downward trajectory. It is in this dissection plane the testicular
vessels and vas deferens will be encountered. The peritoneum can be bluntly dissected
off the spermatic cord. It is imperative that the structures of the spermatic cord are
identified and fully mobilized to conclude the lateral dissection. This can be checked
by pulling on the peritoneal flap and ensuring that the cord structures do not move
with it. In women, we routinely divide the round ligament, to facilitate further dissection.

Fig. 2. Lateral dissection allows for identification of the spermatic cord and vas deferens. All
moves should occur in a medial to lateral fashion to avoid injury to the inferior epigastric
vessels. (From Rosen MJ. Transabdominal preperitoneal inguinal hernia repair. In: Atlas of
abdominal wall reconstruction. 2nd edition. Elsevier; 2017. p. 420; with permission.)
640 Horne & Prabhu

Hernia Reduction
After the spermatic cord has been identified, the presence of a direct, indirect, or com-
bined hernia defect can be determined. Direct hernias can be reduced by retraction of
the hernia with countertraction against the transversalis fascia. To confirm the entirety
of the hernia sac has been reduced, the Cooper ligament should be visualized from its
medial aspect to the epigastric vessels. Indirect hernias are reduced best by, first,
mobilizing the cord structures off the hernia sac. Next, by applying lateral retraction,
the indirect hernia can be successfully reduced. Often, if you are unable to reduce
the hernia, further dissection of the hernia sac off the spermatic cord needs to be
completed. Cord lipomas should be resected if present to prevent perception of recur-
rence. This should be done with cautery, as often there is a blood vessel supplying the
lipoma.

Mesh Selection and Fixation

We routinely use a 12  15-cm piece of heavyweight polypropylene mesh to
ensure adequate coverage of the hernia defect. Although anatomically shaped
meshes can be used, we find that these are more expensive and do not provide
superior results. We choose to use a heavyweight mesh, as this has been shown
to be equivalent to lightweight mesh in terms of recurrence and postoperative
pain.4 Maintaining a high lateral dissection during the creation of the peritoneal
flap creates a space that accommodates this size of mesh. As the most likely loca-
tion for recurrence is at the medial aspect, we ensure adequate fixation of the
mesh by placing 2 ProTacks directly on the pubis and Cooper ligament and
another tack placed high and medial (Fig. 3). The mesh is secured laterally by
another tack placed lateral to the epigastric vessels above the iliopubic tract.
Placing the tack here avoids the impaling nerves. Controversy exists as to the
optimal securement of the mesh, with current methods including tackers,
glue, and sutures. It is our opinion that appropriate placement of tacks with aware-
ness to location of the pathways of the nerves, can help minimize chronic pain
postoperatively.
After the mesh is secured, the peritoneal flap is reapproximated to the abdominal
wall, again using the ProTacker. Holes made during dissection should be closed at
this point.

Fig. 3. Two tacks are placed on the Cooper ligament, with 2 other tacks placed high medially
and high laterally. Left panel indicates intra-operative appearance. Right panel is a pictorial
reference. (From Rosen MJ. Transabdominal preperitoneal inguinal hernia repair. In: Atlas of
abdominal wall reconstruction. 2nd edition. Elsevier; 2017. p. 428; with permission.)
 MIS Approaches to Inguinal Hernias 641

Laparoscopic ports are removed under direct visualization and the fascia at the um-
bilical port is closed using a figure of 8 stitch. The Foley catheter is removed at
completion of the operation. Patients are discharged the day of surgery after they
have voided. Patients are not routinely given lifting restrictions postoperatively and
are counseled to increase their activity as they are able to tolerate.
Pearls and Pitfalls
 Maintaining the peritoneal dissection high on the abdominal wall during creation
of the peritoneal flap laterally helps to provide a space large enough to accom-
modate an appropriate-sized piece of mesh.
 Moves should be carried out in a lateral to medial dissection when clearing the
Cooper ligament and medial to lateral fashion during lateral dissection to prevent
injury to the inferior epigastric vessels.
 Large indirect hernia sacs can be ligated and incompletely reduced if complete
reduction causes significant risk to the contents of the spermatic cord. This
puts these patients at higher risk for postoperative seroma and this should be
carefully monitored.
 Counter pressure should be applied on the abdominal wall while tacks are being
placed to ensure tacks are not inadvertently placed below the iliopubic tract,
which may result in a nerve injury.

LAPAROSCOPIC TOTALLY EXTRAPERITONEAL HERNIA REPAIRS

Preoperative Planning
Like TAPP hernia repairs, a TEP approach can be used in most inguinal hernia repairs.
Relative contraindications to this approach include previous surgery in the retroperito-
neum, certain types of previous inguinal hernia repair, significant history of prior lower
abdominal surgery, and inability to tolerate general anesthesia. It is also imperative
that operative notes from previous hernia repairs are obtained, as this may dictate
the most appropriate way to approach the hernia. Use of a previous patch and plug
or hernia system can result in a technically difficult TEP and these may benefit from
an open repair.
In-depth knowledge of inguinal anatomy is essential for a safe, effective, and
efficient repair. Principal spaces that will be developed are the space of Retzius medi-
ally and the space of Bogros laterally. Once these spaces have been identified
and dissected, the myopectineal orifice is identified and the hernia defect can be
appreciated.
Patient Positioning
The patients undergo induction of general anesthesia, first-generation cephalosporins
are given 1 hour before incision, unless patient allergies dictate otherwise, and a Foley
catheter is placed perioperatively. We routinely place a Foley to limit postoperative uri-
nary retention and facilitate identification of a bladder injury; however, it is reasonable
to have the patient void just before the operation. Patients are placed in the supine po-
sition with arms tucked at the side. The operating surgeon stands on the side contra-
lateral to the hernia, with the assistant on the opposite side of the patient.
Incision and Initial Dissection
A 10-mm incision is made just lateral to the umbilicus on the side opposite of the her-
nia. In the setting of bilateral hernia repair, the incision should be made opposite the
side of the larger hernia. This allows for improved visualization as well as an increased
amount of space to work in. The anterior fascia is identified and divided either sharply
642 Horne & Prabhu

or with cautery, the rectus muscles are retracted laterally, and the posterior sheath is
exposed. We routinely use a 10-mm dissecting balloon trocar to develop our preper-
itoneal space; however, initial blunt dissection with the camera is feasible and can
result in moderate cost savings. The balloon trocar is directed toward the pubis and
subsequently inflated under direct visualization. The balloon should be inflated
completely if possible. The dissecting trocar is then exchanged for a 10-mm trocar.
To create the preperitoneal space without the dissecting balloon, the plane is first
gently developed with finger dissection. We next continue the dissection at the midline
to the pubis with a blunt laparoscopic probe. The trocar is then inserted in the preper-
itoneal plane and insufflated, which assists in further dissection of this space. To com-
plete the dissection, the laparoscopic camera can be used to create enough space so
subsequent ports can be placed. Care must be taken to avoid inadvertent injury to the
peritoneum, as this will result in insufflation of the abdominal cavity and make visual-
ization and subsequent dissection more difficult.
We then place two 5-mm trocars under direct visualization. Care must be taken to
ensure that the inferior-most trocar is at least 2 cm above the pubic symphysis to
ensure for adequate range of motion. The superior 5-mm trocar should be placed
as close to the 10-mm port as possible to increase the space between the 2 working
trocars to facilitate dissection as well as surgeon ergonomics.
As with an intra-abdominal approach, inguinal anatomy can again prove challenging
for even the experienced surgeon. Careful attention to location of the inferior epigas-
tric and iliac vessels is essential to ensure safe dissection. We start our initial dissec-
tion by clearing off the Cooper ligament (Fig. 4). This is a safe place to begin the
dissection because of the lack of important neurovascular structures. The Cooper lig-
ament is exposed using a laparoscopic Kittner through the superior port with dissec-
tion directed inferiorly to maintain the adequate plane.

Lateral Dissection
Next, we turn our attention laterally to expose the transversalis muscle. This dissection
will develop the space of Bogros, which is the lateral continuation of the space of
Retzius. Developing this plane allows for access into the myopectineal orifice and

Fig. 4. Medial dissection begins with identification of the Cooper ligament (bottom right)
and dissection directly on top of the ligament. Care must be taken here to avoid the corona
mortis. (From Rosen MJ. Transabdominal preperitoneal inguinal hernia repair. In: Atlas of
abdominal wall reconstruction. 2nd edition. Elsevier; 2017. p. 439; with permission.)
 MIS Approaches to Inguinal Hernias 643

further delineation of the hernia defect. To develop this space, we use laparoscopic
Kittners, with one applying gentle superior retraction against the transversalis fascia
and the other used to push the peritoneum inferiorly. Care must be taken to ensure
dissection is not carried out in a plane to cephalad, as this will develop a plane superior
to the transversalis fascia. The lateral extent of dissection is often encountered when it
becomes no longer technically feasible to progress more laterally due to the limits of
the instruments.
After lateral dissection is complete, dissection is turned medially toward the internal
ring. It is essential that the operator is cognizant of the iliac vessels, as these can be
closely associated with the cord structures. Upward traction against the abdominal
wall can facilitate entry into the preperitoneal plane. Dissection should be carried
down to the internal ring, to allow for full exposure of the spermatic cord.

Dissection of the Spermatic Cord

The next step is to create a window around the spermatic cord. We do this by first
identifying the vas deferens. Once the vas deferens is identified, this is retracted su-
periorly. Attachments are bluntly dissected until all the contents of the cord have
been identified. During this dissection, work should occur in a superior manner, as
the contents of the triangle of doom lie inferiorly. Constant upward retraction on the
abdominal wall and epigastric vessels facilitates dissection of structures off the sper-
matic cord (Fig. 5). After the spermatic cord is identified, determination of the pres-
ence of direct, indirect, or combination of both is present.
If a direct hernia is encountered, reduction can be facilitated by applying retraction
inferiorly while the other hand bluntly dissects attachments off the hernia sac. The goal
of the retraction and dissection should be to identify the distal-most portion or top of
the hernia sac. Once this has been identified, it can be held in one hand, with careful
inferiorly directed tension, while the other hand dissects the hernia free of surrounding
adhesions. The hernia has been completely reduced when the full extent of the direct
defect can be visualized.

Mesh Selection and Placement

We routinely use a 4  6-inch heavyweight polypropylene mesh, although a light-
weight mesh is another feasible option. Preshaped meshes can be used; however,
we do not routinely use these because of their cost.

Fig. 5. First the hernia sac and cord structures are identified and isolated (left). Next, the
cord structures are dissected off the hernia sac (right). Upward retraction against the
abdominal wall can facilitate this dissection.
644 Horne & Prabhu

To facilitate the placement of the mesh, the medial aspect can be marked so it can
be easily identified. The mesh is then rolled and placed through the 10-mm port into
the preperitoneal space. The mesh is subsequently positioned at the pubis and is
tacked using a ProTacker to the Cooper ligament (Fig. 6). We routinely anchor the
mesh medially first, as this facilitates unrolling of the mesh in a narrow space. It is
imperative that appropriate midline coverage is achieved, as this is the most common
location of recurrence. Next, the mesh is unrolled laterally, and the superior aspect is
anchored to the superior aspect of the abdominal wall.
As with TAPP, other types of methods to secure the mesh in place have been inves-
tigated. These include absorbable tacks, glue, or even no fixation. We routinely use
titanium tacks, as there is some evidence to suggest that this is associated with
decreased chronic pain.5
We do not routinely explore both groins at the time of the index operation, because if
there is no concern for a contralateral hernia and they are asymptomatic, potential
operative exploration could result in postoperative morbidity. We do routinely explore
the contralateral groin if there is concern for a hernia on preoperative examination or a
large defect is noted intraoperatively.
After the mesh is anchored and hemostasis is achieved, the abdomen is desufflated
under direct visualization. This ensures that the mesh lays smoothly in the space. The
fascia is closed with a figure of 8 0-vicryl suture, the Foley is removed, and the patient
is awakened from general anesthesia. Patients are routinely discharged on the same
day after voiding in the post anesthesia care unit (PACU).

Pearls and Pitfalls

 As space is limited in the TEP, careful placement of ports to facilitate ease of
dissection is key. To achieve optimal space between the 2 working ports, we
place our inferior port first and then, using a finder, place the superior port as
close to the 10-mm port as possible without impaling the balloon of the balloon
port. Placement of the inferior port must be 2 cm above the pubis. If this port is
placed too inferiorly, dissection will be limited by the pubis.
 When placing the ports, especially with placement of the preperitoneal dis-
secting port, care must be taken to avoid penetrating the peritoneum, as insuf-
flation of the abdomen can make further dissection and visualization more
difficult.

Fig. 6. Two tacks are placed on the Cooper ligament (left) and then the mesh is unrolled and
tacked laterally (right). Palpation on the abdominal wall while tacking ensures tacks are
placed about the iliopubic tract.
 MIS Approaches to Inguinal Hernias 645

 The corona mortis often can be encountered during the dissection of the Cooper
ligament. Gentle dissection here with early identification of this vein and control
can prevent inadvertent vascular injury.
 Tacks should be placed superior to the iliopubic tract to avoid injury to nerve
structures. This can be ensured by palpation against the abdominal wall when
the tacks are fired.
 Early recognition of the inferior epigastric allows for prevention of an inadvertent
avulsion of these vessels. Once identified, they can be retracted superiorly
throughout the lateral dissection to aid in visualization and prevent vascular injury.

ROBOTIC TRANSABDOMINAL PREPERITONEAL INGUINAL HERNIA REPAIR

Introduction
As chronic groin pain remains the Achilles’ heel of the inguinal hernia repair, different
fixation techniques, including glue, various types of tacks, and suturing the mesh in
place present possible solutions to this problem. As intracorporeal suturing proves
to be technically challenging due to the limited range of motion of the trocars in a lapa-
roscopic transabdominal approach to hernia repair, use of the robotic platform in
these situations can help to overcome these ergonomic restrictions. Robotic inguinal
hernia repair presents a reasonable option to inguinal hernia repairs, and there are
some data to suggest improvement in immediate postoperative pain when compared
with a standard laparoscopic approach.6

Patient Selection
Like laparoscopic transabdominal and TEP approaches, relative contraindications to a
robotic approach include an extensive intra-abdominal surgical history, previous pel-
vic radiation, and a history of surgery in the retroperitoneum. We routinely obtain all
previous operative reports, as certain hernia repairs can lead to increased technical
difficulty of the repair. Also, patients must be healthy enough to tolerate general anes-
thesia for the duration of the operation.

Patient Positioning and Port Placement

Patients are placed supine on the operating table with arms tucked at their side. The
operative area is clipped and appropriate preoperative antibiotics are given before
incision. A vertical skin incision, large enough to accommodate a 12-mm balloon
port, is made 4 cm cephalad to the umbilicus. Dissection is carried down to the linea
alba, which is divided, and the abdomen is entered under direct visualization. We then
secure the anterior fascia using 0-vicryl sutures. A 12 mm balloon port is then inserted.
The abdomen is insufflated to 15 mm Hg and a brief inspection of the abdominal cavity
is completed. Next, two 8-mm ports are placed at the same level as the initial 12-mm
port, approximately 4 cm cephalad to the umbilicus, under direct visualization. We
ensure that there is approximately 8 cm between the ports, as this facilitates full range
of motion of the robotic arms. The patient is placed in mild reverse Trendelenburg and
the robot is docked. The robot is docked from above the patient, so in the setting of
bilateral hernia repairs, undocking and redocking are not required.
To facilitate progression through the operation, the mesh and required sutures are
placed in the abdomen through the 12 mm port before docking the robot. As the SI
robotic platform requires the camera to be removed and redocked when material is
entered through the 12-mm port, we prefer to place the required materials before
starting our dissection to minimize operative time. These are placed out of the surgical
field but in a place where they can be easily retrieved, such as in the pelvis.
646 Horne & Prabhu

OPERATIVE STEPS
Creation of the Peritoneal Flap
As in the TAPP, we start our dissection by first identifying the medial umbilical ligament,
the peritoneum is incised, and the peritoneal flap is created. We dissect in a medial to
lateral fashion, ensuring to stay high on the abdominal wall to create a space large
enough to incorporate the mesh. The lateral extent of the flap is reached when the
position cephalad but corresponding to the ASIS is encountered. The correct dissection
plane is the preperitoneal plane. To facilitate dissection in this place, superior traction
on the abdominal wall allows for appropriate tension to maintain this plane.
After the peritoneal flap is created, we start our dissection medially at the Cooper lig-
ament. Care must be taken when dissecting here to avoid the corona mortis. Dissection
is carried out in a medial to lateral fashion. Medial retraction on the peritoneal flap creates
the appropriate tension to facilitate further dissection out laterally. Filmy adhesions are
bluntly dissected off the peritoneal flap and dissection is completed once the peritoneum
is visualized taking a downward curve toward the retroperitoneum (Figs. 7 and 8).

Identification of Cord Structures and Hernia Reduction

Next, we identify the spermatic cord as well as its relation to the hernia sac. In the setting
of an indirect hernia, the contents of the cord are carefully dissected bluntly off the hernia
sac and the hernia sac is reduced in its entirety. We are careful not to skeletonize the
cord but do take down the peritoneal attachments bluntly to ensure there is enough
mobility at the base of the peritoneum to hold the mesh. The spermatic cord structures
are adequately dissected when they are not tethered to the underlying peritoneum. This
can be tested by pulling on the peritoneal flap and ensuring that the cord structures do
not move. Direct hernias are most easily reduced by appropriate upward retraction on
the transversalis fascia and then downward countertraction on the hernia sac (Fig. 9).

Mesh Choice and Placement

Once an adequate peritoneal flap has been created, and the sac has been reduced,
the mesh can now be appropriately positioned and secured. As with the laparoscopic
TAPP repairs, we use a 12  15-cm piece of heavyweight mesh because it is both
cost-effective and provides a durable repair. The mesh is secured at midline to the
Cooper ligament using a 0-Surgilon interrupted suture. Interrupted sutures are then
placed high medially and high laterally for further securement. Care must be taken
to avoid the deep inferior epigastric vessels and the iliopubic tract when suturing at
the medial and lateral aspects, respectively. The mesh is then inspected to ensure it
is secured with appropriate tension and enough medial coverage. Next, the peritoneal

Fig. 7. Medial dissection is carried immediately inferiorly to identify and clear off the
Cooper ligament, as seen here in the center.
 MIS Approaches to Inguinal Hernias 647

Fig. 8. The peritoneal flap is retracted medial and filmy adhesions are pushed superiorly for
the lateral dissection of the peritoneal flap. We can identify we are in the preperitoneal
plane by the transverse running muscles of the transversus abdominus.

flap is closed in a lateral to medial running fashion using a 3 to 0 absorbable V-Loc

suture. Tears in the peritoneum are fixed at this time as well (Figs. 10 and 11).
On completion of closure of the peritoneal flap, all needles are removed under direct
visualization, the 8-mm ports are removed under direct visualization, the abdomen is
desufflated, and the anterior fascia is closed in a figure of 8 fashion with an 0-Vicryl
suture (Fig. 12).
At completion of the case, the Foley catheter is removed, and patients are dis-
charged the same day, after voiding in the PACU. Patients are not given any lifting re-
strictions postoperatively and are normally limited from heavy activity due to pain.
Pearls and Pitfalls
 To facilitate suturing of the mesh in place, trocars should be placed 4 cm above
the level of the umbilicus. Optimal distance between trocars is 8 cm.
 We decrease the number of moves by placing all required mesh and sutures in
the abdomen before starting our dissection. These can be easily retrieved
when needed.
 Care must be taken to ensure to identify the inferior epigastrics when placing the
superior medial anchoring stitch to avoid impaling the epigastrics.
 Lateral anchoring sutures must be placed above the iliopubic tract, in order to
avoid injuries to the nerves. The iliopubic tract is the lateral border of the triangle
of pain.

Fig. 9. Medial retraction on the hernia sac facilitates dissection off the cord structures. This is
completed bluntly. As you can see, this is an indirect hernia, as it lies lateral to the epigastric
vessels, which can be seen superiorly.
648 Horne & Prabhu

Fig. 10. Medial anchoring of the mesh to the Cooper ligament.

Fig. 11. Superior medial and superior lateral fixation of the mesh. Care must be taken to
avoid the inferior epigastric vessels (circled) when placing the medial fixation suture.

Fig. 12. The peritoneal flap is closed using a running V-Loc suture. Holes made in the peri-
toneum are also closed at this time.
 MIS Approaches to Inguinal Hernias 649

SUMMARY

Both the TAPP and TEP approaches to inguinal hernias provide an effective means of
repairing inguinal hernias. The robotic platform can be used and may help to decrease
immediate postoperative pain; however, as this is a fairly new technique, more
research will help further determine long-term outcomes. In general, less is more
when it comes to anchoring the mesh. In all methods of fixation, we ensure adequate
fixation medially with tacks placed on the Cooper ligament. Subsequent tacks are
used sparingly, only to ensure mesh lies flat. In general, the biggest pitfall to these op-
erations is inadequate identification of important neurovascular structures. Awareness
of the nerves and vessels helps to guide dissection as well as prevent inadvertent
injury during mesh fixation.

REFERENCES

1. Barbaro A, Kanhere H, Bessell J, et al. Laparoscopic extraperitoneal repair versus

open inguinal hernia repair: 20-year follow up of a randomized controlled trial. Her-
nia 2017;21:723–7.
2. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparo-
scopic mesh repair of inguinal hernia. N Engl J Med 2004;350:1819–27.
3. Köckerling F, Bittner R, Jacob DA, et al. TEP versus TAPP: comparison of the peri-
operative outcome in 17,587 patients with a primary unilateral inguinal hernia. Surg
Endosc 2015;29:3750–60.
4. Koning G, de Vries J, Borm G, et al. Health status one year after transinguinal her-
nia repair and Lichtenstein’s method: an analysis alongside a randomized clinical
study. Hernia 2013;17:299–306.
5. Belyansky I, Tsirline V, Klima D, et al. Prospective, comparative study of postoper-
ative quality of life in TEP, TAPP and modified Lichetenstein repairs. Ann Surg
2011;254:709–15.
6. Waite K, Herman M, Doyle P. Comparison of robotic versus laparoscopic transab-
dominal preperitoneal (TAPP) inguinal hernia. J Robot Surg 2016;10:239–44.