Overview of Laparoscopic Inguinal Hernia Repair
Inguinal hernia repairs are among the most frequently performed operations worldwide. Normally, doctors diagnose inguinal hernias by taking a detailed medical history and conducting a physical exam, usually identifying a lump in the groin area.
When it comes to treating this condition, there are many alternatives. Some patients choose to monitor the condition without immediate surgery, a practice known as “watchful waiting”. Other options include the methods called “open primary repair”, and “open tension-free repairs”, where a mesh prosthetic is used to strengthen the repair. There’s also a laparoscopic repair, a type of minimally invasive surgery, which also typically involves the use of a mesh prosthetic.
Anatomy and Physiology of Laparoscopic Inguinal Hernia Repair
The inguinal canal is a part of the body that can sometimes be difficult to understand because of its intricate structure. It’s especially important for doctors to know all about it when they’re doing laparoscopic hernia repairs, which is a minimally invasive surgery to fix hernias in the groin area. Certain key features help the surgeons navigate the procedure including the inferior epigastric vessels, the pubic bone and Cooper’s ligament, vas deferens, cord structures, round ligament, and the iliopubic tract.
During this surgery, surgeons need to be aware of two regions known as the ‘triangle of doom’ and ‘triangle of pain’. The ‘triangle of doom’ is a region that contains the vas deferens (the tube that carries sperm), testicular vessels, and the peritoneal fold (a fold of membrane in the abdomen). Why is it important? This area houses the external iliac artery and vein, which are major blood vessels. On the other hand, the ‘triangle of pain’ is another region defined by the iliopubic tract (a band of connective tissue), testicular vessels, and the peritoneal fold. This section includes the lateral femoral cutaneous nerve, the femoral branch of the genitofemoral nerve, and the femoral nerve – all crucial nerves related to sensation and movement.
These names sound daunting, but they simply help surgeons to remember where to be extra careful. Since these triangles contain many important structures, surgeons are strongly advised not to fix the mesh too roughly in these areas. Doing so might cause severe injuries to the blood vessels or nerves that may result in chronic pain.
Why do People Need Laparoscopic Inguinal Hernia Repair
A laparoscopic inguinal hernia repair, which is a minimally invasive surgery, has become a good choice for fixing an inguinal hernia. An inguinal hernia occurs when part of your intestine or fat pushes through a weak spot in your lower abdominal wall, often in the groin area. Initially, this type of repair was mostly used for hernias that appeared on both sides of the groin (bilateral) or for hernias that came back after a previous repair (recurrent).
But as doctors have become more familiar and skilled with these laparoscopic methods, they’re now also using them to fix an initial hernia that’s just on one side of the groin (primary/unilateral hernia). This laparoscopic approach potentially has several advantages, such as letting you recover faster after the surgery and possibly giving you less chance of long-term pain in the groin.
When a Person Should Avoid Laparoscopic Inguinal Hernia Repair
Generally, the only reason a person might not be able to undergo laparoscopic inguinal hernia repair – a minimally invasive surgery to fix hernias in the groin – is if they can’t safely be put under general anesthesia (made unconscious for the procedure). This is usually due to other serious health problems.
In some cases, people who are at high risk from general anesthesia, or who only have a single hernia, might be better off having an open hernia repair. This is a more traditional surgery that is performed under local anesthesia, which just numbs the area instead of putting you to sleep.
There are a few other situations where it might be difficult to do a laparoscopic hernia repair. If the hernia is very large and extends into the scrotum, the surgery can be quite challenging, especially for surgeons who are still learning this procedure. Also, if a person is taking blood thinners (anticoagulation), it can be hard to manage any bleeding that happens after the surgery. This is especially true for laparoscopic surgery, because it’s harder to control bleeding in the space behind the abdominal cavity (retroperitoneal space) compared to an open operation.
Equipment used for Laparoscopic Inguinal Hernia Repair
This is a general list of what’s typically required for a surgery known as laparoscopic inguinal hernia repair. Specific instruments or tools can vary, based on the surgeon’s preference. Simply put, this procedure fixes an area of the lower abdomen where an organ or fatty tissue is bulging through a weak spot.
1. The need for laparoscopic equipment, which includes a specialized camera of either 5mm or 10mm size with a 30-degree angle. This helps the surgeon view the surgical area on a screen while performing the operation.
2. Three laparoscopic trocars, which are tools used to create small entry points for other instruments during the procedure. The sizes needed are two 5mm and one 10mm trocars.
3. The surgeon’s choice of laparoscopic scissors and grasper, both of which are used to manipulate tissues inside the body. If the surgeon plans on attaching the mesh or the peritoneum (the thin tissue that lines the abdomen) in a specific kind of hernia repair known as TAPP, then they’ll need laparoscopic needle drivers, which are tools for suturing.
4. The surgeon’s preferred mesh prosthetic, generally an uncoated polypropylene or polyester mesh of at least 10x12cm, and often larger. This mesh is used to support the weakened area in the abdomen.
5. A method to secure the mesh, chosen by the surgeon. Options include tackers (which can be absorbed by the body or not), glue, or suture (stitching).
6. Closure sutures to stitch up the opening in the fascia (the layer of connective tissues under the skin) as well as the skin.
Who is needed to perform Laparoscopic Inguinal Hernia Repair?
The operation can be done by a main surgeon along with an assistant or a resident (a doctor in training). Ideally, the main surgeon carries out the surgery using two special devices called trocars (small tubes through which surgical instruments are inserted), while the assistant handles the camera to monitor the surgery.
Preparing for Laparoscopic Inguinal Hernia Repair
Getting ready for a laparoscopic inguinal hernia surgery is similar to preparing for any other surgery. Before the operation, doctors usually give antibiotics and blood thinning medicines based on the hospital guidelines or doctor’s preference. This is done to prevent infections and to stop any excessive bleeding during the surgery.
During this procedure, the patient will be made to lie flat on their back (also known as supine) under general anesthesia, which means they will be asleep and won’t feel any pain. Both their arms will be kept tucked by their sides and will be well cushioned to ensure the patient’s comfort.
Some surgeons might use a medical device called a ‘foley catheter’ which is a thin, sterile tube used to drain urine from the bladder during surgery. However, this might not always be necessary and is decided based on the surgeon’s discretion. Some might use it routinely, while others may use it selectively or not at all.
How is Laparoscopic Inguinal Hernia Repair performed
Laparoscopic inguinal hernia repair is a type of minimally invasive surgery used to fix a hernia in the abdomen’s lower part. There are two main methods to perform this surgery: the Transabdominal Preperitoneal (TAPP) technique and the Totally Extraperitoneal (TEP) method. Both methods are similar, but they differ in one key aspect. In the TAPP approach, the surgeon cuts into the peritoneum – a thin lining inside the abdomen. This cut needs to be closed after a mesh has been placed to repair the hernia.
The positioning of the small surgical instruments (also known as ports) used in the surgery can vary between the two methods. For the TEP technique, the ports are usually placed in a line from the pubic bone to the belly button. On the other hand, in the TAPP method, three ports are positioned at the belly button level and the mid-clavicular line (an imaginary line running down from the middle of your collarbone) on both sides of the abdomen. Both techniques offer the flexibility to repair hernias on either side of your lower abdomen.
In the TEP method, the surgeon enters the preperitoneal space – an area between your abdominal wall and your peritoneum – at the belly button level. This space isn’t breached during the operation. Meanwhile, in the TAPP method, the surgeon creates and closes a type of flap in the peritoneum that starts at the medial umbilical ligament (a structure near your belly button) and is cut towards the anterior superior iliac spine (a prominent part of your pelvis). It’s advised that surgeons close this flap after placing the mesh, which can be done with stitches or other surgical tools. This allows the mesh to be placed in the preperitoneal space, so it does not come into contact with your abdomen’s inner cavity or organs.
Regardless of whether the TAPP or TEP method is used, the procedure involves placing a large mesh implant over the entire myopectineal orifice (the area in your lower abdomen where hernias usually occur). This mesh provides coverage for direct, indirect, and femoral hernias – different types of lower abdominal hernias.
Possible Complications of Laparoscopic Inguinal Hernia Repair
The complications from inguinal hernia surgery, which involves fixing a weak spot in the lower belly, can occur during or after the operation. During laparoscopic surgery, which is a kind of minimally invasive surgery, complications can include injuring blood vessels and the bladder, or having trouble accessing the area to be operated on. However, these risks can be reduced by using a technique called TEP (totally extra-peritoneal) and by understanding the anatomy around the groin area well.
After the operation, the most common problems are the hernia coming back, or chronic (long-term) pain in the groin area. To help prevent these issues, surgeons place a large piece of a material called mesh over the entire weak area. This lower the chance of the hernia returning. To prevent chronic pain, surgeons take special care when fixing the mesh in place, especially in sensitive areas they refer to as the ‘triangle of pain’ and ‘doom’.
What Else Should I Know About Laparoscopic Inguinal Hernia Repair?
Inguinal hernia repair is a common surgery. There are two ways to do this: the traditional open surgery or a less invasive laparoscopic surgery. For both operations, the results are usually the same, as long as the surgeon is well trained and has gained enough experience in performing laparoscopic procedures.
Learning to perform laparoscopic surgery can take some time, often requiring a surgeon to complete between 50 and 250 procedures before he or she becomes proficient. Once the surgeon has become comfortable with the procedure, there can be benefits for the patient, including a faster recovery and potentially less long-term pain in the groin.
There are two types of laparoscopic techniques, called TAPP and TEP. The results are similar for both, so the surgeon can decide which one to use.
There’s still some debate about when it’s best to use laparoscopic surgery for fixing inguinal hernias, and it used to only be used for complicated cases. Now, however, it’s often the go-to method for all types of inguinal hernias, including simpler ones.
Another debate involves how to secure the mesh, a material used to help repair the hernia site. The options are no fixation, glue, tacks, or suturing it in place. Currently, guidelines suggest not fixing it in place unless the hernia is quite large.
Lastly, there’s a variety of mesh materials to choose from, commonly made of either polyester or polypropylene. There’s no definitive data to say which one is the best, so the decision is generally up to the surgeon. What’s important is that the mesh is big enough to cover the full area of the hernia.
