Department of Surgery, St. Alphonsus Regional Medical Center, and Treasure Valley Hospital, Boise, ID 83706 USA

Between the dates 1-1-92 and 1-1-98, 500 consecutive herniated groins in 408 consecutive patients were repaired using LIHR. The patients were all males, ranging in age from 18 to 85 years of age. Almost all had routine, first time, or recurrent hernias. Two patients had multiply recurrent hernias. As the series progressed, the technique was modified and refined. The first 72 cases were performed via the transabdominal approach. Because the author became aware of anecdotal reports of small intestinal obstruction after LIHR, the technique was changed to the totally extraperitoneal approach. The remaining 428 groins were all repaired using this technique. A single disposable Hassan-type 12mm cannula was used for each case (Ethicon – model 512B). A 4" x 6" piece of polypropylene mesh was used for each groin. A laparoscopic stapler was used to fix the mesh in place (Ethicon – model EMS). No other disposable supplies were utilized. Two sutures of 2/0 Ethibond were used to fix the Hassan cannula in place, and close the umbilical fascia, and one suture of 4/0 Vycril was used to close all the skin incisions. Three Band-Aids were used as dressings.

Patients are placed supine with both arms placed on armboards in the crucifixion position. A Foley catheter is placed in all patients after the induction of anesthesia. All abdominal hair from the mid-epigastrium to the base if the penis and from one anterior superior iliac spine to the other is removed. The skin of this same area is then prepped with povidone iodine and the patients are draped in the usual sterile fashion. The surgeon positions himself at the patient’s side, across from the side involved with the hernia. A 2-3 cm curvilinear incision is made at a point 1 cm below the inferior aspect of the umbilicus. Cautery dissection is carried down entering the rectus sheath of the affected side. A Hassan-type cannula is fixed to the fascia with two 2/0 Ethibond sutures and positioned posterior to the rectus muscle and anterior to the posterior rectus sheath. A laparoscope is introduced to confirm that the setup has been correctly placed. Then and only then is insufflation commenced. The patient is now repositioned in Trendelenberg. Using the laparoscope as a blunt dissecting tool, this space is then developed in an inferior direction, extending below the end of the posterior rectus sheath, all the way to the pubic bone. Care is taken to keep the plane of dissection posterior to the muscles and anterior to the peritoneum. Next, a nondisposable 10mm cannula is placed in the suprapubic midline, and another cannula of this type is placed midway between the first two, both through 1 – 2 cm transverse incisions. Using both 5mm and 10mm blunt graspers of a type used in laparoscopic cholecystectomy, this extraperitoneal plane is developed laterally to a point just lateral to and superior to the anterior, superior iliac spine on the affected side. The retropubic space is exposed for a distance of 3 cm from the superior aspect of the pubic bone. If present, a direct hernia is pulled back into the abdomen as it is progressively dissected from its attachments to the surrounding tissues in the inguinal canal. In any event, Cooper’s ligament is completely exposed from the pubic bone over to the point where the iliac vessels cross it, and the dissection proceeds posteriorly down to a point just exposing the obturator nerve, artery, and vein as they enter the obturator foramen. From the point of origin of the inferior epigastric artery, the posterior peritoneum is dissected from lateral to medial completely uncovering the iliac artery over to a point about where it is crossed by the ureter. The peritoneum is dissected off the iliac artery, but all fibroadipose tissue over this vessel is left in place. In this way there is no direct contact between the iliac artery, and the subsequently placed mesh, which will overly it. The vas deferens is encountered during this part of the dissection, and its web-like attachments are disrupted as well. From the posterior aspect of the internal ring, the posterior peritoneum is dissected off of the testicular artery and vein in a superior (cephalad) direction for a distance of about 2 - 3 inches. The posterior dissection thus ends along a diagonal line, parallel to the inguinal ligament, that begins at the point where the ureter crosses the iliac artery, and ends about 3 cm superior and 2cm posterior to the anterior, superior iliac spine. An indirect hernia, if present is pulled back into the abdomen before the posterior dissection over the testicular vessels is commenced, progressively freeing it from its attachments to the surrounding tissues of the inguinal canal as it comes. Great care is taken to separate the posterior wall of the hernia sac from the vas deferens, and the testicular vessels as this dissection progresses. No attempt is made to excise the sac.

Let us now assume we are standing on the patient’s left, and we are repairing the right groin. A 4" x 6" piece of polypropylene mesh is trimmed to exactly 3.5" x 5.5". This size is a good fit for 97% of adult males, with only a few cases requiring a smaller piece. No cases required a piece larger than 4" x 6". The corners of the mesh are slightly rounded with a scissors. The mesh will be placed parallel to a line connecting the upper end of the symphysis pubis to the anterior, superior iliac spine. This will result in the upper left corner of the mesh extending across the midline of the anterior abdominal wall above the pubis. This upper left corner of the mesh is therefore aggressively trimmed to conform to the patient’s midline. The mesh is then introduced into the abdomen and positioned so that the left end is at the pubic symphysis and the right end is at or near the anterior, superior iliac spine. The posterior border of the mesh is positioned so that it covers over Cooper’s ligament and extends 3–4 cm posterior to it. In no case is the mesh allowed to rest so far infero-posterior in the pelvis that it overlies the obturator nerve. Otherwise, postoperative paresthesias might result. Two staples are used to fix the mesh to Cooper’s ligament. About 6 – 8 staples are then place along the perimeter to temporarily hold it in place. One or two are placed at the superior aspect of the pubic bone, and proceeding cephalad and then laterally, it is progressively stapled in place. No staples are placed posterior to the anterior, superior iliac spine to avoid injury to any of the nerves traversing this region (cutaneous nerves of the anterior thigh and lateral hip regions). From a point on Cooper’s ligament, all along the infero-posterior edge of the mesh, to a point at the anterior, superior iliac spine, no staples are placed. These are the areas where nerve injury can occur and staples in this location are not essential to the durability of the repair.

The patient is now repositioned in the flat position, out of Trendelenberg. A grasper in the middle cannula is used to grasp the posterior peritoneum and elevate it and place it on top of (anterior to) the posterior mesh on the surface of the psoas muscle/testicular vessels. This is to insure that as this peritoneum descends, it will not start itself posterior to the mesh, lifting the mesh anteriorly, as it continues its descent downward, and end up going through the internal ring, completely undoing the repair. This simple maneuver is all that is required to avoid this, rather than making holes or slits in the mesh to place part of the mesh behind the testicular vessels. The insufflation tubing is then disconnected from the Hassan cannula and the insufflation is allowed to slowly escape, all the while observing the peritoneum and intraperitoneal content as they descend to insure that they fill the hollow of the mesh, pressing it against both the anterior and posterior abdominal walls. The crucial point here is to not allow the posterior mesh to be displaced anteriorly. Instruments and cannulae are then removed under direct vision and finally the laparoscope and its cannula, and all insufflation is evacuated. The umbilical fascia is then closed with two figure–of–eight sutures of 2/0 Ethibond, using the same sutures that were fixing the Hassan cannula. The skin incisions are then closed with interrupted buried dermal sutures of 4/0 Vycril. Each is infiltrated with several c.c.s of ¼% Sensorcaine with epinephrine for postoperative pain control. Band-Aids are applied. Patients are instructed to remove the Band-Aids on the first postoperative morning and shower without protecting the wounds. Further dressings are at the patient’s discretion. Patients are permitted to return to any type of physical activity of their choosing, without limitation, beginning on the first postoperative day. Specifically, no lifting restrictions are imposed. Patients are seen on the third postoperative day and again three weeks thereafter. Further visits are on an as–needed basis.

Studies have reported typical recurrence rates for conventional hernia repair of 10-15% [7, 8]. This is consistent with the fact that 15% of all hernia repairs are recurrent hernia repairs [9]. Happily, the author has little experience in repairing recurrence after the laparoscopic approach described herein. The single recurrence in this series occurred at about the 100th case. No reasonable method of traversing the previously dissected planes could be conjured up preoperatively at the time of the second repair. Therefore the repair was approached traditionally. This may be one of the few disadvantages of the laparoscopic approach, although if the rate of recurrence is kept this low, it is a relatively theoretic disadvantage. At surgery, this patient was found to have recurred because the posterior aspect of the mesh had been displaced anteriorly. In other words, the mesh was folded upon itself with both halves up against the anterior abdominal wall and the fold at the internal ring. Both the anterior abdominal peritoneum and the posterior abdominal peritoneum were posterior to the mesh, thus allowing free access of the peritoneum and intraperitoneal contents to the internal ring. An analysis of this failure resulted in changing the technique slightly to prevent its repetition and no such occurrence has been witnessed in the subsequent 400 cases. This could only occur at the end of the case, when the instruments are removed and the insufflation evacuated. Good laparoscopic technique mandates that the instruments and cannulae are removed under direct vision. This implies that insufflation is present as they are removed. As the insufflation is released and exits the abdomen, and the posterior peritoneum descends, if it catches the upper border of the posterior mesh and displaces it inferiorly and anteriorly, this may not be seen. The technique was modified in the following way. The laparoscope is kept in place through the umbilical port. The point on the peritoneum that corresponds to the posterior aspect of the internal ring is grasped with a 5-mm grasper through the middle port and elevated over the top of the posterior mesh. It is then placed down on top of the mesh and held in place at the internal ring while the suprapubic cannula is removed, and the insufflation tubing is disconnected from the umbilical cannula. As the gas exits the abdomen, the intraperitoneal contents are observed to descend and fill the peritoneum. They come to rest on top of the posterior peritoneum, as desired. The grasper, laparoscope and both cannulae are then slowly and carefully removed. If any resistance to their removal is met, the insufflation tubing is reconnected and the abdomen refilled to see what the problem might be. This technique has resulted in a recurrence free experience since it was adopted.

A frequent occurrence is the development of a seroma in the inguinal canal. This occurs because blood and serum from the preperitoneal dissection can accumulate in the first few hours after surgery and pass directly through the mesh, entering the potential space left in the inguinal canal as a result of having removed the hernia and placed it back in the abdomen. Further, blood and serum originating from the inguinal tissues themselves, as a result of dissecting the hernia free from them, can accumulate here as well. Such collections are usually small but can appear to be a recurrence initially. However, if one is not aggressive about re-exploring such a groin, one will find that the mass becomes smaller, firmer, and ultimately disappears completely with the passage of time. Most often the presence of a seroma is not even noticed by the patient. Seldom is it a source of symptoms.