Laparoscopic Transabdominal Preperitoneal
Herniorrhaphy
Robert J. Fitzgibbons, Jr, MD
The overwhelming success of laparoscopic cholecystec-
tomy resulted in the retraining of general surgeons so
that they became experienced and facile in the principles
of therapeutic laparoscopy. Soon many surgeons began to
apply their newly developed skills in laparoscopy to
other commonly performed general surgical operations
in hopes of achieving the same benefits as were realized
with laparoscopic cholecystectomy. Inguinal herniorrha-
phy was no exception. The two commonly performed
laparoscopic herniorrhaphies, the transabdominal preperi-
toneal (TAPP) and the totally extraperitoneal (TEP), are
modeled after the conventional preperitoneal operations
popularized by Stoppa, Reeves, Nyhus I and others. The
major difference is that the preperitoneal space is entered
through three trocar sites rather than a large conven-
tional incision. The ensuing radical dissection of the
preperitoneal space with the placement of a large prosthe-
sis is similar to the conventional preperitonea! operation.
Laparoscopic inguinal hernia repair has the following
potential advantages: (1) less postoperative discomfort/
pain; (2) reduced recovery time, allowing earlier return
to full activity; (3) easier repair of a recurrent hernia
because the repair is performed in tissue that has not
been previously dissected; (4) the ability to treat bilateral
hernias; (5) the performance of a simultaneous diagnos-
tic laparoscopy; (6) the highest possible ligation of the
hernia sac; (7) and an improved cosmesis. Numerous
single center, multicenter, and comparative studies have
proven that an inguinal hernia can be repaired using the
laparoscopic method (Tables 1-3). The question that
must be answered now is should an inguinal hernia be
repaired using the laparoscopic method. Skepticism ex-
ists among many surgeons concerning the benefits of
laparoscopic herniorrhaphy because the severity of pos-
sible complications and the precise indications are a
matter of considerable debate.
An extensive discussion of the advantages and disad-
From the Department of Surgery, Creighton University School of Medicine,
Omaha, NE.
Address reprint requests to Robert J. Fitzgibbons, Jr, MD, Department of
Surgery, Creighton University School of Medicine, 601 North 30th St, Suite 3740,
Omaha, NE 68131.
Copyright 9 1999 by WB. Saunders Company
1524-153X/99/0102-0006510.00/0
Operative Techniques in General Surgery, Vol 1, No 2 (December), 1999: pp 169-184
vantages of the laparoscopic approach compared with the
conventional operation is beyond the scope of this
article. The question cannot be answered definitively
until the results of several randomized, prospective
comparative trials that are now either ongoing, or in
development, are completed. The purpose of this review
is to describe the technical details of the TAPP procedure.
Anatomical Considerations
A thorough knowledge of the anatomy of the groin from
an opposite perspective to what is normally taught, that
is, proceeding from deeper structures to more superficial,
is critical to a successful laparoscopic inguinal herniorrha-
phy. A laparoscopic view of a left direct hernia can be
seen in Figure 1. The most important anatomical land-
marks are the medial umbilical ligament, the inferior
epigastric vessels, and the internal ring. The vas deferens
and the internal spermatic vessels converge at the inter-
nal ring to form the cord structures. Cooper's ligament
and the symphysis pubis are not always visible laparoscop-
ically but can easily be defined by palpation with
laparoscopic instruments. Figure 2A is a cadaver prepara-
tion of the right groin with the peritoneum and preperito-
neal fatty tissue stripped away. The inferior epigastric
vessels, the symphysis pubis, the Cooper's ligament, the
vas deferens, and the internal spermatic vessels are
important landmarks to be exposed during the course of
a laparoscopic TAPP procedure, and, therefore, knowl-
edge of their location is crucial for the laparoscopic
surgeon intent on performing this type of repair. Also of
importance are the anastomotic pubic branches, because
troublesome bleeding will ensue if they are damaged
during the dissection of Cooper's ligament. A structure
that is not routinely exposed during a laparoscopic TAPP
herniorrhaphy but nevertheless must be appreciated, is
the iliopubic tract because this marks the inferior bound-
ary for staple placement when affixing the prosthesis
lateral to the internal spermatic vessels. The genitofemo-
ral nerve and the lateral femoral cutaneous nerve exit the
pelvis close to the inferior surface of the iliopubic tract.
Figure 2B is the same cadaver photograph with mesh
stapled in place in a desirable position for performing a
laparoscopic preperitoneal herniorrhaphy. The reason
169
 170 Robert J. Fitzgibbons, Jr

why placing staples below the level of the iliopubic tract
lateral to the internal spermatic vessels frequently results
in troublesome neuralgia is obvious. Two other nerves,
the ilioinguinal and the iliohypogastric, although lying in
a more superficial plane between the external and
internal oblique muscles, may also be injured if staples
are placed too deeply, especially when using a vigorous
bimanual technique (see Fig 3). Finally, the laparoscopic
surgeon should be aware of the location of the external
iliac vessels and the femoral nerve. Although these
structures would generally be considered outside the
normal field of dissection, injuries to them are particu-
larly debilitating.
Patient Selection
All adult patients with inguinal hernias who are candi-
dates for general anesthesia can be considered candidates
for the laparoscopic TAPP inguinal hernia repair. At the
present time, however, it is not clear that there are
sufficient advantages for patients with uncomplicated
inguinal hernias to outweigh the major disadvantages of
the procedure, which include (1) a laparoscopic accident,
(2) bowel obstruction secondary to adhesions or an
internal or a ventral hernia, and (3) increased cost.
Currently, we do not recommend laparoscopy for every
hernia (ie, unilateral and nonrecurrent). However, cer-
tain types, such as those that are recurrent, bilateral, or
otherwise complicated are particularly suited for the
laparoscopic approach. Absolute contraindications in-
clude any sign of intra-abdominal infection or coagulop-
athy. Relative contraindications include intra-abdominal
adhesions from previous surgery, ascites, or previous
"space of Retzius" surgery because of the increased risk of
bladder injury. Severe underlying medical illness is also a
relative contraindication because of the added risk of
general anesthesia. These patients are better suited for a
conventional operation under local anesthesia. An incar-
cerated sliding scrotal hernia is a relative contraindica-
tion, especially when it involves the sigmoid colon,
because of the high risk of perforation during the
dissection.

T a b l e 1. N o n c o m p a r a t i v e Trials of L a p a r o s c o p i c Inguinal H e r n i a R e p a i r (LIHR)

Hernias recurrent Recurrence Length of

at enrollment Hernia rate follow-up
Authors Year Technique (%) (n) (%) (mos)
Corbitt 1a 1991 TAPP 12 100 0 18
Arregui et al 2 1992 TAPP, extra 14 147 1.3 NA
Hawasli 3 1992 TAPP, mushroom plug and patch 10 143 1.4 7
Begin 4 1993 Extra 53 200 0.5 18
Fitzgibbons et al 5 1993 TAPP, extra, IPOM 14.5 867 4.5 34
Geis et al 6 1993 TAPP 11 450 0.6 30
Himpens 7 1993 TAPP 17 100 2 NA
Newman et ai 8 1993 TAPP 14 102 NA 1
Quilici et al 9 1993 TAPP 5 173 0 NA
Wheeler 1~ 1993 TAPP, mesh plus plug 5 135 0 18
Felix et a111 1994 TAPP, single or double buttress 13 205 0 21
Paget 12 1994 TAPP 15 222 1.8 18
Panton and Panton ~3 1994 TAPP 18 106 0 12
Rubio TM 1994 IPOM NA 120 48 0
Felix et aP 5 1995 Extra, balloon, CO2 8 382 0.3 9
Felix et a115 1995 TAPP 14 733 0.3 24
Ferzli and KieP 6 1995 Extra, balloon, CO2, blunt 11 326 1.6 22
Kald et a117 1995 TAPP 17 200 3.5 24
Kavic 18 1995 TAPP 10 244 1 34
Phillips et aP 9 1995 Variety 1.6 3229 1.6 22
Ramshaw et al 2~ 1995 TAPP 14 290 2.1 NA
Ramshaw et al 2~ 1995 TEP 16 118 0.5 NA
Voeller et al 2~ 1995 Extra, balloon, CO2 12 365 0 15
Batorfi et a[ 22 1997 TAPP 32 160 3.1 NA
Litwin et a123 1997 TAPP NA 632 0 14
Schmidt and Anta124 1997 TEP 0 20 0 10
Sievers et a125 1997 TAPP NA 776 3.9 NA
Barry et a126 1998 TAPP NA 206 3.0 29
Bittner et 8.127 1998 TAPP 0 3,400 0.5 NA
Cohen et a128 1998 TEP 33 144 0 40
Felix et a129 1998 TAPP/TEP NA 7,661 0.4 36
Ferzli et al 3~ 1998 TEP NA 237 3.2 NA
Hussein et a131 1998 TEP NA 803 1.5 24
Kiruparan and Pettit 32 1998 TAPP NA 215 1.4 30
Sayad et a133 1998 TAPP/TEP 0 11,222 2.7 NA
Toouli et a134 1998 TAPP NA 58 7 15

Abbreviations: NA, information not available; IPOM, intraperitoneal onlay mesh procedure.
Laparoscopic TAPP Herniorrhaphy 171

T a b l e 2. Early L a p a r o s c o p i c V e r s u s C o n v e n t i o n a l H e r n i o r r h a p h y : C o m p a r a t i v e Trials

Type of
Authors Study Intervention Results
Stoker et a135 Prospective, randomized TAPP vs Nylon darn 6 vs 18 pain tablets
Pain analogue score 1.8 vs 3.1
Return to activity 14 vs 28 days
T Cost
Cornell and Kerlakian 36 Prospective vs historical TAPP vs (not stated) Earlier return to activity 92% vs 29% at 14 days
Earlier return to work 73% vs 14% in 3 weeks
I Pain
T Cost
Brooks 37 Prospective, nonrandomized TAPP vs tension-free (plug) Earlier return to work
No difference in pain medication
1"Cost
Millikan et a138 Prospective, nonrandomized TAPP vs variety l Time off work
I Pain medication
l Complications
Hospital days better
1"Cost
Wilson et a139 Prospective, nonrandomized TAPP vs Lichtenstein Earlier return to activity (7 vs 14 days)
Earlier return to work (10 vs 21 days)
No difference in analgesic requirements or pain scale
Payne et ai 4~ Prospective, randomized TAPP vs Lichtenstein Return to work 9 vs 17 days
Improved SLR at I week
1"Cost
Vogt et a141 Prospective, randomized IPOM vs tension-free Oral narcotics (5 vs 16 doses)
1" Return to normal activity (7.5 vs 18.5)
Cost not mentioned
Lawrence et a142 Prospective, randomized TAPP vs Nylon darn SF-36, pain analogue scores better early
No difference in return to work
T Complication rate
1"Cost
Better quality of life
Barkun et a143 Prospective, randomized TAPP vs various I Postoperative narcotics
Better quality of life at I month
T Satisfaction with LH
1"Cost
Wright et a144 Prospective, randomized Extra vs Lichtenstein and Stoppa's repair l Pain scores (63 vs 35)
1 Analgesia doses (2.5 vs 2.0)
I Wound complications
Liem et a145 Prospective, randomized TAPP vs Lichtenstein I Incidence of wound abscesses (0 vs 6, P = .03)
1"Resumption of normal activity (6 vs 10 days)
1"Return to work (14 vs 21 days)
1" Resumption of athletic activities (24 vs 36)
I Recurrence rate (3% vs 6%, P = .05)

Abbreviations: 1, decrease in; 1", increase in; vs, versus; SLR, straight leg-raising; SF-36, Short Form Health Status Survey-36; LH, laparoscopic
herniorrhaphy.
Reprinted with permission from the MRC Laparoscopic Groin Hernia Trial Group: Laparoscopic versus open repair of groin hernias: A randomised.
Lancet 354:185-190, 1999.

T a b l e 3. A S u m m a r y of M o r e R e c e n t C o m p a r a t i v e , P r o s p e c t i v e , R a n d o m i z e d Trials of L a p a r o s c o p i c (LIHR) a n d C o n v e n t i o n a l
Inguinal H e r n i a R e p a i r (CIHR)

Hernias LH vs OH Follow-Up
Authors Year (n) Intervention Recurrence (mos)
Champault et a147 1997 100 vs 100 TEP vs Stoppa 6.0% vs 1.0% 36
Liem et al 4s 1997 487 vs 507 TEP vs anterior repair 3.0% vs 6.0% 24
Sarli et a151 1997 64 vs 66 TAPP vs Lichtenstein 0 vs 0 36
Aitola et a146 1998 24 vs 25 TAPP vs Lichtenstein 13% vs 8.0% 18
Dirksen et a148 1998 114 vs 103 TAPP vs Bassini 7 vs 22 24
Khoury 49 1998 169 vs 146 TEP vs mesh plug 2.5% vs 3.0% 36
Paganini et al 5~ 1998 52 vs 56 TAPP vs Lichtenstein 1 vs 0 28
Tanphiphat et a152 1998 60 vs 60 TAPP vs Bassini-modify 1 vs 0 32
Wellwood 53 1998 200 vs 200 TAPP vs Lichtenstein 0 vs 0 3
Beets et al s4 1999 56 vs 52 TAPP vs PMR 7 vs 1 34
Lucas and Arregui 55 1999 292 vs NA TAPP/TEP 2 vs NA
Juul and Christensen 56 1999 138 vs 130 TAPP vs Shouldice 4 vs 3 12

Abbreviations: LH, laparoscopic herniorrhaphy; NA, not available; OH, open herniorrhaphy; PMR, preperitoneal mesh repair.
172 Robert J. Fitzgibbons, Jr

1 The left-inguinal floor as viewed with the laparoscope. The landmarks, which should
routinely he identified at this point, are the inferior epigastric vessels, the internal inguinal
ring, the cord structures, and the medial umbilical ligament. In this photomicrograph, the
vas deferens and Cooper's ligament can also be appreciated through the peritoneum.
(Reprinted with permission from Fitzgibbons RJ Jr, Filipi CJ, Ryberg AA: Transperitoneal
approach to inguinal hernia, in Toouli J, Gossot D, Hunter JG (eds): Endosurgery. New
York, NY, Churchill Livingstone, 1996, pp 961-975.)
Laparoscopic TAPP Herniorrhaphy 173

2 (A) Photograph of a cadaver preparation (right side) showing the preperitoneal space after
removal of the peritoneum and preperitoneal adipose tissue (the urachial remnant has been resected
and the bladder retracted posteriorly). (B) Polypropylene mesh placed as if one were performing a
TAPP herniorrhaphy Note tile proximity of certain nerves to locations where a surgeon might want to fix
mesh. A lack of appreciation for this anatomical configuration was responsible for the excessive number of
neuralgias in the developmental stages of the TAPP procedure. RM, rectus abdominis muscle; IE, inferior
epigastric vessels; AP, anterior pubic branch and fliopubic vein; AA, aponeurotic arch of the transversus
abdominis muscle; TS, transversalis fascia sling; U, ureter; CL, Cooper's ligament; UA, umbilical artery;
PB, anastomotic pubic branches; RE retropubic vein; IV, external iliac vein; IA, external iliac artery; ES,
external spermatic vessels; VD, vas deferens; IP, iliopubic tract; IPA, iliopectineal arch; DC, deep
circumflex iliac vessels; GN, genitofemoral nerve; GB, genital branch of the genitofemoral nerve; FB,
femoral branch of the genitofemoral nerve; FN, femoral nerve; LC, lateral femoral cutaneous nerve; IL,
ilioinguinal nerve; IM, iliacus muscle; PM, psoas major muscle; IS, internal spermatic (testicular)
vessels; LV, iliolumbar vessels; B, bladder (retracted posteriorly). Thick arrow, deep inguinal ring; thin
arrow, femoral ring. (Reprinted with permission from Annibali R, Quinn T, Fitzgibbons RJ Jr: Surgical
anatomy of the inguinal region and lower abdominal wall: The laparoscopic perspective, in Bendavid R
(ed): Prostheses and Abdominal Wall Hernias. Austin, TX, RG Landes, Co, 1994, pp 82-103.)
174 Robert J. Fitzgibbons, Jr

3 Bimanual technique for placing staples during a laparoscopic herniorrhaphy. It is

particularly important when stapling lateral to the internal spermatic vessels because injury to
the femoral branch of the genitofemoral nerve or the lateral cutaneous nerve of the thigh can be
prevented if the surgeon feels the entire head of the stapler or tacker with the nondominant hand.
Care needs to be taken to avoid using this maneuver too vigorously because excessively deep
stapling can result in injuries to the flioinguinal and the iliohypogastric nerves. In addition, the
skin can actually be caught in a staple or tack, creating an unsightly and sometimes painful
dimple.

TAPP Versus TEP
One of the major criticisms of the laparoscopic TAPP
procedure is the need to enter the peritoneal cavity. The
result is the possibility of a laparoscopic accident, result-
ing in injury to an intra-abdominal organ or intestinal
obstruction secondary to adhesive complications or ven-
tral herniation. The TEP operation was developed to
address this concern (see article on the TEP procedure by
guest editor and author, C. Daniel Smith, MD, within this
issue.) Technically, it is not a laparoscopic operation
because the peritoneal cavity is never entered. However,
because laparoscopic instrumentation is used, it is classi-
fied as a "laparoscopic" herniorrhaphy. The TEP proce-
dure is more demanding than the TAPP because of the
limited working space. Most authorities believe that the
laparoscopic surgeon should be comfortable with the
TAPP herniorrhaphy before attempting a TEE The author
tends to recommend the TEP procedure for smaller,
simpler hernias, whereas patients with large hernias,
those with previous lower abdominal incisions, or any
other complicating situation usually undergo a TAPP
herniorrhaphy.
Operating Room Set-Up
The operating room set-up used for the TAPP procedure
is shown in Figure 4. The operation is usually performed
under general anesthesia with the patient supine. Arms
should be tucked at the side of the patient because
outstretched arms may compromise the ability of the
surgeon to obtain an optimum angle for fixing the
prosthesis. A Foley catheter is placed to establish bladder
decompression only if the patient does not void immedi-
ately before entering the operating room. A single video
monitor is placed at the foot of the operating table. An
Laparoscopic TAPP Herniorrhaphy 175

ANESTHESIOLOGIST
I Anesthesia 1
Equipment
CAMERAOPERATOR
(OPTIONAL)
SURGEON

0 tj/ FIRST ASSISTANT

SCRUBNURSE

Instrument
9 i

Table
I VideoMonitor
Hydrodissector I and Insufflator Electorcautery I

4 Typical setup for the laparoscopic TAPP procedure. The surgeon stands on the
opposite side of the table from the hernia. Three cannulae are inserted: one at the
umbilicus, and the other two at the same level but lateral to either rectus sheath. A
single video monitor is positioned at the patient's foot.

a n g l e d laparoscope is essential to provide adequate
visualization of the inguinal region because it is some-
w h a t anterior (see Figure 5). The surgeon stands On the
opposite side of the table from the hernia. The first
assistant stands opposite the surgeon. The first assistant
usually acts as the camera operator because there is n o t
e n o u g h r o o m for a third person between the two p r i m a r y
surgeons and the head of the table. This assumes the
primary surgeon will use a t w o - h a n d e d technique. Alter-
natively, some surgeons prefer to use a o n e - h a n d e d
approach so that they can control the optics themselves
because proper visualization is so critical to a successful
laparoscopic herniorrhaphy. This is strictly a matter of
personal preference.

5 A 0 ~ telescope is shown on the top and a 30 ~ on the bottom. The 0 ~

device significantly restricts vision and should be avoided if at all possible.
176 Robert J. Fitzgibbons, Jr

SURGICAL TECHNIQUE

6 Except in unusual circumstances, only three cannulae are required. The

umbilical cannula (10 to 12 mm) is inserted first and used to introduce the
laparoscope. The author prefers placement of the initial cannula using an
open technique. It is absolutely imperative that the abdominal cavity is
entered safely, avoiding laparoscopic injuries, because this complication
would not exist with a conventional herniorrhaphy. After completing a
routine diagnostic surveillance laparoscopy, the patient is placed in the
Trendelenburg position to allow the bowel to fall away from the pelvis,
allowing for good visualization and access to the inguinal floor. Two
additional cannulae are placed just lateral to the rectus muscles at the level of
the umbilicus (see figure). These can both be 5 mm if the stapling or tacking
device is the same diameter. If the surgeon prefers a larger stapling device, it
can either be placed through the umbilical cannula, providing a 5-mm
telescope is available for observation of the fixation. A simpler solution is to
make the lateral cannulae opposite the hernia large enough to accommodate
the fixation device. Adhesions are taken down as necessary. Both inguinal
regions are inspected and the median umbilical ligament (remnant of the
urachus), the medial umbilical ligament (remnant of the umbilical artery),
and the lateral umbilical fold (peritoneal reflection over the inferior epigastric
artery) are identified. The internal inguinal ring and cord structures are
immediately evident. Commonly, the inferior epigastric vessels and the vas
deferens can be seen through the intact peritoneum as shown in Figure 1.
Laparoscopic TAPP Herniorrhaphy 177

7 The peritoneum is incised (using scissors) approximately 2 cm above the superior

edge of the hernia defect. Occasionally, the median umbilical ligament is divided if it
appears to compromise exposure. The peritoneal flap extends from the median umbilical
ligament to the anterior superior ifiac spine. The flap is mobilized inferiorly using blunt
and sharp dissection.

8 The inferior epigastric vessels are exposed using gentle blunt dissection. Next, the
pubic symphysis and lower portion of the rectus abdominis muscle need to be identified.
178 Robert J. Fitzgibbons, Jr

9 Cooper~s ligament is then dissected to its junction with the femoral vein. The
iliopubic tract is identified, and dissection is continued inferiorly with care taken to avoid
injuring the femoral branch of the genitofemoral and lateral femoral cutaneous nerves,
which enter the lower extremity just below the iliopubic tract. Finally, skeletonizing the
cord structures from the peritoneum completes the dissection. (Reprinted with permis-
sion from Fitzgibbons RJ Jr, Filipi CJ, Ryberg AA: Transperitoneal approach to inguinal
hernia, in Toouli J, Gossot D, Hunter JG (eds): Endosurgery. New York, NY, Churchill
Livingstone, 1996, pp 961-975.)
Laparoscopic TAPP Herniorrhaphy 179

10 For a direct hernia, the sac and preperitoneal fat are reduced from the hernia orifice
by gentle traction, separating the peritoneal sac from the thinned-out transversalis fascia,
which lines the abdominal wall portion of the hernia defect. This characteristic layer is
sometimes referred to as the "pseudosac." It is important that this layer be teased away from
the hernia sac and allowed to retract back into the defect, because needless bleeding will be
the result of an attempt to resect it. Some surgeons feel that the pseudosac should be tacked
or stapled to Cooper's ligament to decrease the incidence of seroma with large direct
hernias. For indirect hernias, there are two options. A small sac is easily mobilized from the
cord structures and reduced back into the peritoneal cavi~ A large sac may be difficult to
mobilize because of dense adhesions between the sac and the cord structures caused by
chronicity of the hernia, resulting in undue trauma to the cord if an attempt is made to
remove the sac in its entirety. In this situation, the sac can be divided just distal to the
internal ring leaving the distal sac in situ, with dissection of the proximal sac away from the
cord structures. The division of the sac is most easily accomplished by opening the sac on
the side opposite the cord structures. The division of the sac can then be performed from
the inside. (Reprinted with permission from Fitzgibbons RJ Jr, Filipi CJ, Ryberg AA:
Transperitoneal approach to inguinal hernia, in Toouli J, Gossot D, Hunter JG (eds):
Endosurgery. New York, NY, Churchill Livingstone, 1996, pp 961-975.)
180 Robert J. Fitzgibbons, Jr

1 1 The mesh has been fixed in place and trimmed to fit perfectly in the preperitoneal
space. (Reprinted with permission from Camps JNA, Nguyen NXNA, Annibali RNA, et al:
Laparoscopic inguinal herniorrhaphy: Current techniques, in Arregui MR, Fitzgibbons RJ
Jr, McKernan JB, et al (eds): Principles of Laparoscopic Surge~ New York, NY,
Springer-Verlag, 1995, pp 400-408.)

12 The peritoneal flap is pulled over the mesh and stapled in order to isolate the
prosthesis from intra-abdominal viscera.
Laparoscopic TAPP Herniorrhaphy
On completion of the dissection, a large piece of mesh, at
least 6 by 11 cm, is placed over the myopectineal orifice
so that it completely covers the direct, indirect, and
femoral spaces. The mesh can either be simply laid over
the cord structures, or a slit can be made in the mesh to
wrap the mesh around the cord structures. Most surgeons
now avoid the slit in the prosthesis because recurrences
have been noted through these slits even when they have
been repaired around the cord. The use of a large
prosthesis allows the intra-abdominal pressure to act
uniformly over a large area, thus preventing its hernia-
tion through one point (ie, the hernial defect). The
medial edge is stapled or tacked to the contralateral pubic
tubercle and the symphysis pubis. The medial, inferior
border is secured to Cooper's ligament. Next, the mesh is
stapled along the superior border to the posterior rectus
sheath and transversalis fascia, at least 2 cm above the
hernia defect. To further decrease the incidence of
neuralgia, staples are placed horizontally for the superior
border of the prosthesis to correspond to the direction of
the ilioinguinal and iliohypogastric nerves. 'They are
placed vertically when stapling laterally because this is
the direction of the lateral cutaneous nerve of the thigh
and the femoral branch of the genitofemoral nerve. It is
again emphasized that, to avoid neuralgias involving the
lateral cutaneous nerve of the thigh or the femoral
branch of the genitofemoral nerve, staples or tacks
should never be placed below the iliopubic tract when
lateral to the internal spermatic vessels. A useful maneu-
ver during fixation is to palpate the head of the stapler
through the abdominal wall with the nondominant hand.
This ensures that stapling is done above the iliopubic
tract (see Fig 3). A point just medial to the anterior-
superior iliac spine is the preferred location for the lateral
edge of the prosthesis, completing coverage of the
myopectineal orifice with a wide overlap. After the
complete fixation, redundant mesh on the inferior border
can be trimmed in situ to tailor it to the preperitoneal
space (see Fig 11). The purpose of trimming the mesh is
to prevent "roll-up" of the inferior border when closing
the peritoneum.
See Figure 12 for peritoneal closing. We do not feel
that linear approximation of the peritoneum is necessary
for all patients, especially if the result is tenting of the
peritoneum caused by excessive tension required to
approximate the two edges. The tenting effect may leave
a space between the peritoneal flap and the prosthesis, a
potential area into which the bowel might migrate,
resulting in bowel obstruction. Occasionally, it is neces-
sary to simply cover the prosthesis with the inferior flap,
leaving exposed the transversalis fascia. Excessive gaps
between the staples should also be avoided because the
bowel may herniate between these gaps, or may adhere to
the exposed mesh. In either situation, small bowel
181
obstruction may result. Decreasing the pneumoperito-
neum before closing the peritoneal flap may aid the
closure.
To reduce postoperative discomfort, a long-acting local
anesthetic is injected into the preperitoneal space before
completing the closure of the peritoneum and prior to
deflating the abdomen. Similarly, local anesthetic is used
in all trocar sites. Cannula sites greater than 5 m m should
be closed at the fascial level. Otherwise, an excessive rate
of trocar-site herniation will be observed (see 13). Direct
suture is difficult, especially in obese patients, but there
are a variety of reusable or disposable devices available to
facilitate fascial closure. Finally, the pneumoperitoneum
is released and the skin of all trocar sites is closed with
absorbable, intracuticular sutures.
Bilateral hernias can be repaired using one long
transverse-peritoneal incision extending from one ante-
rior-superior iliac spine to another. We prefer to use the
same peritoneal incision and preperitoneal dissection
used for a unilateral hernia on either side, preserving the
peritoneum between the medial-umbilical ligaments.
The symphysis pubis is completely dissected so that both
preperitoneal dissections communicate with each other.
This allows the placement of one large prosthesis (usu-
ally 8 by 30 cm or larger) essentially covering the entire
lower pelvis, similar to Dr Stoppa's procedure performed
conventionally, By not incising the peritoneum between
the two medial-umbilical ligaments, one avoids the
theoretical complication of dividing a patent urachus.
Some surgeons prefer two separate pieces of mesh to
avoid placing the mesh in front of the bladder. Also, it is
easier to manipulate two pieces separately and tailor
them more accurately to fit the preperitoneal space on
either side.
Postoperative Care and Follow-up
Most patients are discharged home the day of the
operation. Patients who have persistent nausea, vomit-
ing, or pain that is not well controlled with oral medica-
tion are admitted for overnight observation. Light duty
work with lifting restriction as dictated by pain tolerance
can be resumed as soon as the patient desires. Patients
return for follow-up at 1 week, 6 weeks and then as
needed.
Complications A s s o c i a t e d
With Laparoscopic Herniorrhaphy
The potential advantages of laparoscopic herniorrhaphy
must be interpreted in the light of the disadvantages of a
laparoscopic approach. These include complications re-
lated to the laparoscopy such as bowel perforation or
182 Robert J. Fitzgibbons, Jr

13 Left-lower abdominal-quadrant trocar-site hernia involving the sigmoid colon. We

now recommend that all trocar sites greater than 5 mm in size be closed at the fascial level.

major vascular injury, potential adhesive complications Hernia Recurrence

at sites where the peritoneum has been breached or
Our group analyzed the videotapes of 13 patients eventu-
prosthetic material has been placed, the apparent need
ally suffering a recurrence after laparoscopic herniorrha-
(at least at the present time) for a general anesthetic, and
phy and identified several mechanisms as the cause of the
increased cost because of the expensive equipment
recurrence. These included: (1) incomplete dissection of
necessary. Table 4 summarizes possible complications of
the preperitoneal space, which leads to poor overall
laparoscopic herniorrhaphy by dividing them into three
assessment of the groin floor, missed hernias, insufficient
groups: (1) those related to the laparoscopy, (2) those
delineation of important landmarks, and inadequate
related to the patient (ie, general complications), and (3)
space for the inferior border of the prosthesis to lay flat
those related to the herniorrhaphy. Except for complica-
causing it to roll up; (2) a prosthesis that is too small,
tions unique to laparoscopy, the incidence of other
leading to incomplete coverage and overlap of all the
complications is similar for both the laparoscopic and
potential hernia sites of herniation through the myopec-
conventional procedures.
tineal orifice; (3) migration of the mesh prosthesis; (4)
mesh slitting, which may be the source of a future
recurrence; (5) folding or invagination of the mesh into
Table 4. Complications the defect; and (6) displacement of mesh by hematoma.
Related to Related to the Related to the We feel a thorough dissection of the preperitoneal space
Laparoscopy Patient Herniorrhaphy with identification of all the landmarks followed by
Bleeding Urinary Neurological fixation of a large size mesh that adequately covers and
Abdominal wall Ileus Cord and testicular overlaps the entire myopectineal orifice without slitting
Intra-abdominal Aspiration pneumonia hydrocele
Retroperitoneal Cardiovascular and Wound infection or folding is the best way to avoid recurrence. Slitting of
Visceral injury respiratory insuffi- Prosthetic infection the prosthesis remains controversial. Although we feel it
Bowel perforation ciency Seroma
Bladder perforation Nausea and vomiting Retroperitoneal hema- is unnecessary, some surgeons think it aids in fixation
Bowel obstruction toma and is acceptable providing the slit is adequately repaired
Trocar or peritoneal Foreign body reaction to
closure site hernia mesh
around the cord structures.
Adhesions
Diaphragmatic dysfunc- Conclusion
tion
Wound infection Laparoscopic inguinal herniorrhaphy will only be success-
Hypercapnia
ful if it is performed safely by well-trained surgeons. It is
Laparoscopic TAPP Herniorrhaphy
an excellent alternative to conventional herniorrhaphy in
selected circumstances. The best indications are: (1)
recurrent hernia after a conventional inguinal hernia
repair (CIHR), because the operation is performed in
normal, nonscarred tissue; (2) bilateral hernias, as both
sides can easily be repaired using the same small laparos-
copy incisions; and (3) the presence of an inguinal hernia
in a patient who requires a laparoscopy for another
procedure (ie, a laparoscopic cholecystectomy), assum-
ing the gram stain of the bile is negative. A more
contentious issue is the use of laparoscopic inguinal
hernia repair (LIHR) for the uncomplicated, unilateral
hernia. Large prospective, randomized trials will be
needed to definitvely settle the question of whether the
added risks and costs are worth the benefits. The
potential for severe, life-threatening complications is
greater with LIHR than CIHR, although the overall
incidence of complications between the two procedures
is similar. The question becomes does the benefit of LIHR
justify the increased risk of severe complications? We feel
it should be part of the armamentarium of surgeons
offering comprehensive hernia therapy.
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