To date, the laparoscopic repair of inguino-femoral hernias has had a tumultuous beginning in the surgical arena. Laparoscopic repairs have had to compete with the current gold standard for anterior or conventional inguinal hernia repairs, the Liechtenstein repair. Initially, some of these laparoscopic repairs, such as the "plug and patch" (PAP) and "on lay technique" (IPOM ), failed to demonstrate good results and were abandoned. In 1996 and 1997, only two laparoscopic repairs have proven to be viable with early results comparable or superior to the Liechtenstein repair. These repairs are the Extraperitoneal Laparoscopic Repair (EXTRA) and the Trans-Abdominal Preperitoneal Repair (TAPP). 

It should be noted, the most ardent critique of the TAPP procedure is that it is an intra-abdominal procedure with significant potential morbidity. For this reason, the TEP procedure which avoids intra-abdominal access was developed. In our studies, the morbidity rate of both these laparoscopic repairs was minimal and/or similar to other open repairs with comparable early recurrence rates. The most persuasive argument for using this procedure is the same argument favoring all laparoscopic procedures: the postoperative benefits to the patients, i.e., less postoperative pain, decreased disability and small incisions. However, it continues to be a new procedure with limited long term follow-up and analysis.

During the early nineties, our surgical team developed an original TAPP repair. This original technique was modified on several occasions. Later, the TEP technique was introduced for patients who had previously undergone major lower abdominal surgery. As of August 1, 1999, 1700 repairs were performed. Our technique and results are herein reported.

INDICATIONS

All patients cleared for general anesthesia were candidates for this repair. Our youngest patient was fifteen years old and our oldest 87 years old. Previous intraabdominal surgical procedures were not a contraindication. The surgeon decides on a per case basis if an extensive, lengthy enterolysis is in the best interest of the patient or if a TEP technique should be used. It has been reported that the major indications of this technique are recurrent inguinal hernias and bilateral inguinal hernias. We recommended that all inguino-femoral hernias including single, unilateral defects be repaired via laparoscopy.

A TECHNICAL CONSIDERATION: UNDERSTANDING THE ANATOMY

The anatomy of the inguino-femoral region viewed via a telescope placed in  intra-abdominal position differs radically from the anatomy observed via an open or anterior approach. The laparoscopic surgeon needs to become familiar with the anatomical structure of this region. As all anatomical landmarks are covered with peritoneum, in the TAPP technique the peritoneum has to be first incised and a lower flap developed in order to expose the region adequately. In the TEP repair, the anatomical landmarks need to be meticulously exposed with blunt dissection. 

Our guidelines for the performance of a safe and secure laparoscopic inguinal hernia repair, mandate the following structures should be clearly and unequivocally identified: 

• Cooper's Ligament
• The Epigastric Vessels
• The Spermatic Cord or the Round Ligament 
• The Femoral Canal and the Iliac Vessels
• In addition, the laparoscopic anatomical distinction between direct, indirect inguinal and femoral hernias should be well understood. Before a surgeon attempts to perform a laparoscopic inguinal or femoral hernia repair, he should memorize and be very familiar with the following diagrams. 

Anatomy: Inguinal Region with Peritoneal Coverage   

Anatomy: Inguinal Region without Peritoneal Coverage     

THE TECHNIQUES

Click on the following buttons to access each techniques

	The TAPP Repair
	The TEP Repair

TECHNICAL NOTES

• Variation of the Prosthetic Mesh Placement: Although  various prosthetic Mesh-s were used to perform these repairs, we now routinely use a tailored 6"x 6" USSC SurgiPro* Mesh. As described earlier, we have used two different variations for the placement of this Mesh. Approximately 500 cases were done with the graft wrapped around the spermatic cord and more than 700 cases were on lay placement. To date, there has been no difference in outcome or recurrence rates with either of these variations. As of October 1996, we now preferentially use the on lay Mesh placement.

• Placement of Prosthetic Mesh: Some authors deploy the Mesh over the inguinal region without anchoring it with staples.  We believe the Mesh should be stapled (staples or tacks) securely to the fascia and Cooper's ligament. When using the Multifire EndoHernia* or Protack Instrument* we routinely use 25 to 30 staples to complete one standard, unilateral repair. Under no circumstances should the Mesh be placed and stapled under tension. Numerous studies claim no staples should be placed lateral to the Inferior Epigastric vessels, as it increases the risk of injuries to the Genito-femoral, the Femoro-cutaneous and the Ileo-inguinal nerve. We do not adhere to this concept. We have placed staples or tacks lateral to the Inferior Epigastric vessels without any increase in our incidence of postoperative permanent neuropathies when compared to other series. We believe the incidence of such complications only increase when applying abdominal wall counter pressure when stapling. 

• Inguinal Hernias Without a Definite Peritoneal Sac: In 1282 repairs, nine patients were found to have a direct inguinal hernia without any evidence of a peritoneal sac demonstrated at the time of laparoscopy. It is essential that during a TAPP repair even if a peritoneal sac is not demonstrated, a peritoneal incision be made and the entire inguinal area be explored without peritoneal covering. An inguinal hernia can be present without a definite peritoneal sac seen at the time of laparoscopy.

• Postoperative Management: All patients were instructed to return to unrestricted physical activities when discharged home. In addition, all were asked to walk at least a mile a day starting the day after surgery. They were also instructed to use Advil® (Ibuprofen) for pain control and Darvocet™ for severe pain. They were seen postoperatively in the office on postoperative day 7 and 30, then on an as needed basis. 

• Choice of Laparoscopic Techniques: The laparoscopic techniques are currently used in the following settings:

- Incarcerated Inguinal-Femoral Hernia: TAPP Repair,

- Inguino-Femoral Hernia / Patients with previous major lower abdominal surgery: TEP Repair,

- Massive Inguinal Hernias with scrotal extension: TEP Repair or Anterior Repair,

- Bilateral Inguinal Hernias: TAPP or TEP Repair.